Did China lie about COVID-19? – A story of human-to-human transmission – Part 2

[Note: A shorter, revised and on a few issues more up to date version of this piece has been published by Quillette as a four-part essay. The version on Quillette is more polished and a bit less polemical, but this one has more technical details on some issues, so which version you should read depends on what you’re looking for.]

On the other hand, there is evidence that Chinese officials withheld information that would have made it clear earlier that sustained human-to-human transmission was occurring. But as I will argue, even in that case, most of the claims people make are wildly exaggerated. A very useful account of the way in which the local health authorities delayed the publication of crucial information about human-to-human transmission was published on 5 February 2020 in China News Weekly. It was apparently deleted from their website almost immediately, but fortunately it was archived in various other places and eventually translated by China Change, a website created by Chinese human rights activists who live in the U.S. Another very useful source on that issue is the story that Associated Press recently published, which is particularly interesting to understand the role played by the national authorities in the delay. Moreover, unlike most of what is published about China these days, it’s actually balanced. The Wall Street Journal also published a piece on March 6 that is useful to establish a timeline of who knew what and when regarding human-to-human transmission. Any claim I make below for which I don’t provide a link is supported by at least one of those sources.

As we have seen, by early January, both the Wuhan Health Commission and the national health authorities had realized that a new virus closely related to SARS-CoV-1 had emerged in Wuhan and was responsible for a cluster of pneumonia over there. However, on several occasions during the first half of January, both the local authorities in Wuhan and the national authorities in Beijing made statements in which they denied that sustained human-to-human transmission was occurring. On January 5, the Wuhan Health Commission published a statement saying that the number of cases had risen to 59, but that “no clear evidence of human-to-human transmission has been found and no infections by medical personnel [had] been found”. After that, the Wuhan Health Commission made no public announcement about the status of the outbreak until January 11, when it announced that the number of cases had risen to 41 and that one person had died of the disease on January 9. This statement also said that “no health worker has been found to have contracted the disease and no clear human-to-human transmission has been established”. The period between January 6 and January 10, during which no new cases were announced, coincided with the convening of Wuhan’s “Two Sessions”, the annual meeting of the city’s party officials.

On January 15, the Wuhan Health Commission started to move slightly in the direction of acknowledging that human-to-human transmission was occurring, after it published a document stating that “no clear evidence of human-to-human transmission has been found, and the possibility of limited human-to-human transmission cannot be ruled out, but the risk of sustained human-to-human transmission is low”. Moreover, the same day, it also said in a public notice that one woman may have contracted the virus from her husband. This limited acknowledgment that human-to-human transmission could be occurring took place shortly after, on January 13, the first case outside was reported in Thailand. She was 61-year-old Chinese woman who had arrived in Thailand from Wuhan on January 8 and reported visiting Huanan Seafood Market on a regular basis before the onset of symptoms. On January 15, Li Qun, the head of the China CDC’s emergency center, also told Chinese state television that they had “reached the latest understanding that the risk of sustained human-to-human transmission [was] low”. As far as I know, since the official announcement of the identification of SARS-CoV-2 as the cause of the outbreak of pneumonia in Wuhan on January 9, this was the first time the national health authorities were communicating on the situation.

After that, as more cases started to appear outside China, things started to move faster. The Wuhan Health Commission had not announced any new cases since January 11, but this changed on January 17, when 4 new cases were announced. The period between January 12 and January 16 coincided with the convening of Hubei’s “Two Sessions”. On January 18, the Wuhan Health Commission announced 17 new cases, then 136 on January 19. The first case outside Wuhan, in the city of Guangdong, was also announced on January 19 by the National Health Commission. Finally, on January 20, the head of a team of experts — who as we shall see had been sent to Wuhan by the National Health Commission on January 19 — announced on television that human-to-human transmission was occurring and that 14 health care workers had been infected while caring for a single patient. Xi Jinping made his first public statement about the outbreak that night, saying it had to be taken seriously. At this point, the authorities started to act very quickly and it should have become clear to everyone, both in China and abroad, that the virus would probably spread and that a pandemic was likely.

By then, starting around January 10, the annual Chinese New Year migration had begun and millions of people had already moved across the country. Indeed, cases started to multiply in other Chinese cities and in various other countries around the time human-to-human transmission was publicly acknowledged, but this didn’t prevent the local authorities from going ahead with various public events that gathered thousands of people in Wuhan during that period. The National Health Commission started began to do a daily count of cases on January 21 and, on January 22, the Wuhan Health Commission started to require that people wear masks in public. In the evening of January 22, officials announced that Wuhan would be put under quarantine the next day at 10am, with no traffic being allowed in or out of the city. On January 24, several other cities in the province of Hubei were also placed under quarantine, while in Wuhan the authorities started building a quarantine center to treat patients with COVID-19. On the same day, most other provinces declared a level 1 public health alert, the highest emergency level. It’s also around that time that the number of cases started to rise very quickly and that various studies about the outbreak started to come out. This was just the beginning of a massive effort to suppress the epidemic that variously affected different parts of China and is still ongoing today.

As in the case of the identification of the virus, in order to determine whether it’s prima facie plausible that China suppressed information about human-to-human transmission, I think it’s useful to review how much time it took for the U.S. health authorities to publicly state that sustained human-to-human transmission was occurring at the beginning of the pandemic of swine influenza in 2009. So I went through the transcripts of every CDC press briefing during that period in order to establish the timeline and be able to compare it to China’s response in 2020. As noted above, back in 2009, the CDC published a report about the discovery of the virus in samples from 2 different children on April 21. At the time, it was still not sure that human-to-human transmission, let alone sustained human-to-human transmission, was even possible, although it noted that “the lack of known exposure to pigs in the two cases [increased] the possibility that human-to-human transmission of this new influenza virus [had] occurred”.

By 23 April 2009, the Interim Deputy Director for Science at the CDC was saying they believed that human-to-human transmission was occurring, but they “certainly [didn’t] know the extent of the problem”. On April 24, the Acting Director of the CDC was explaining that, since they were seeing cases without any connection between them, it suggested “there [had] been transmission from person to person through several cycles” (which is the definition of sustained human-to-human transmission), but he remained prudent. On April 27, the WHO raised its pandemic alert status to phase 4, meaning that sustained human-to-human transmission of the virus was occurring in at least one country. But even at this point, the Acting Director of the CDC was still prudent, explaining that although they had “only one case of documented by viral testing person to-person spread”, they were “seeing significant rates of respiratory infection among contacts”, which suggested to him that the virus was “acting like a flu virus” and was spreading from person to person. Thus, between the time the virus was first sequenced and the time the health authorities made it absolutely clear that sustained human-to-human transmission was occurring, it took 13 days. But the CDC had already indicated that it believed that human-to-human transmission was occurring 10 days after the virus was first sequenced and only 3 days after the discovery was announced.

In the case of SARS-CoV-2, on the other hand, it took 17 days after the virus was sequenced by the National Institute of Viral Disease Control and Prevention and 11 days after the discovery was announced. As I have argued above, the virus could probably have been identified as the cause of the outbreak of pneumonia in Wuhan a few days earlier if everything had gone right at the end of December, but this was almost certainly not the result of a conspiracy to cover up the discovery, so I think it’s fair to take January 3 and January 9 as starting points for the comparison. In any case, it doesn’t really matter, because no matter which starting points you take, it took China significantly longer to publicly state in unambiguous terms that human-to-human transmission was occurring and that it wasn’t a fringe phenomenon. So I think that, just on the basis of this comparison, we should already suspect that China wasn’t entirely forthcoming with information pertaining to human-to-human transmission during that period. Indeed, as I will now explain, there is actually evidence that China suppressed information that would have made it clear earlier that sustained human-to-human transmission was occurring, although it’s not always clear who between the local authorities and the national government is responsible and it’s more difficult than most people think to figure out exactly what the various actors knew at each point.

A lot of nonsense is being said on the topic and it’s important to correct the record. One particularly egregious instance of disinformation on that issue comes from a piece ironically called “The Comprehensive Timeline of China’s COVID-19 Lies” published by Jim Geraghty in the National Review:

According to a study in The Lancet, the symptom onset date of the first patient identified was “Dec 1, 2019 … 5 days after illness onset, his wife, a 53-year-old woman who had no known history of exposure to the market, also presented with pneumonia and was hospitalized in the isolation ward.” In other words, as early as the second week of December, Wuhan doctors were finding cases that indicated the virus was spreading from one human to another.

If this were right, it would be really bad, since it would mean that China already had evidence of human-to-human transmission at the beginning of December in 2019, yet the authorities continued to deny it was occurring until 20 January 2020.

However, you may have noticed the ellipsis in Geraghty’s quote of the Lancet study, here is what it looks like when you quote this passage in extenso:

The symptom onset date of the first patient identified was Dec 1, 2019. None of his family members developed fever or any respiratory symptoms. No epidemiological link was found between the first patient and later cases. The first fatal case, who had continuous exposure to the market, was admitted to hospital because of a 7-day history of fever, cough, and dyspnoea. 5 days after illness onset, his wife, a 53-year-old woman who had no known history of exposure to the market, also presented with pneumonia and was hospitalised in the isolation ward.

As you can see, once you read the full passage, the meaning is completely different. It’s not the wife of the first case who fell ill 5 days after him, despite having no known history of exposure to Huanan Seafood Market, but the wife of the first fatal case, who as we saw above died on January 9. As for the first case, as the study explicitly states, none of his family members developed any fever or respiratory symptoms. By the way, the same dishonest argument was repeated on the blog of the Chinese dissident who translated the Caixin article on the sequencing of the virus, in case you thought that dissident were always honest or trustworthy.

Had it not been for the misleading editing of this passage, I could have bought that this was just a honest mistake due to a quick reading, but this makes it much harder to believe. I don’t know whether Geraghty edited this passage himself or if he was just lazy and copied that from elsewhere without checking the study first, but at best he was careless and, in any case, someone was being deceptive here. I know several people at the National Review for whom I have a great deal of respect, so I have no doubt a correction will soon be added to Geraghty’s article, but it’s regrettable that such a misleading claim was published. However, this is not the only problem with this passage of Geraghty’s article, let alone with the rest of the article. Even if members of the first case’s family had developed symptoms, which as we have seen they did not, it still wouldn’t follow that China already knew or even suspected that human-to-human transmission was occurring by the second week of December. First, as the paper notes, December 1 is the date of the onset of symptoms, but none of the patients included in the study were hospitalized until December 16. But perhaps more importantly, the information in that study is the result of a retrospective epidemiological investigation, that was conducted in January after the Chinese realized the outbreak was caused by a new coronavirus. As we have seen, until late December, nobody in Wuhan had any idea that a new virus had already started to spread. A lot of people keep making that mistake and talk as if the Chinese already knew in December or even January things we have only learned much later.

Another story that has been widely repeated is Taiwan’s claim that it had warned the WHO about human-to-human transmission in late December, but that it was ignored. Here is what, for instance, the Financial Times wrote on March 20:

Taiwan has accused the World Health Organization of failing to communicate an early warning about transmission of the coronavirus between humans, slowing the global response to the pandemic.

 

Health officials in Taipei said they alerted the WHO at the end of December about the risk of human-to-human transmission of the new virus but said its concerns were not passed on to other countries.

 

…

 

Taiwan said its doctors had heard from mainland colleagues that medical staff were getting ill — a sign of human-to-human transmission. Taipei officials said they reported this to both International Health Regulations (IHR), a WHO framework for exchange of epidemic prevention and response data between 196 countries, and Chinese health authorities on December 31.

This sounds pretty bad and, since Taiwan made that claim, countless people have repeated it and accused both China and the WHO of having suppressed the truth, including Trump on April 17. The only problem is that it’s not true.

I knew that from the moment I read this article because, as I will argue shortly, it’s very unlikely that any health care workers had actually fallen ill because of the virus at the time. In fact, when I read that article, my first reaction was to wonder why, if Taiwan is telling the truth, it didn’t release the email in which it had allegedly warned the WHO about human-to-human transmission. Apparently, I wasn’t the only one, so after a few days and under pressure Taiwan was forced to release the email:

News resources today indicate that at least seven atypical pneumonia cases were reported in Wuhan, CHINA. Their health authorities replied to the media that the cases were believed not SARS; however the samples are still under examination, and cases have been isolated for treatment.

 

I would greatly appreciate it if you have relevant information to share with us.

 

Thank you very much in advance for your attention to this matter.

As you can see, there is no mention of human-to-human transmission whatsoever, nor does the email say anything about health care workers getting ill, so this was just a propaganda stunt on the part of Taiwan. Keep in mind that, at this point, although some people in China had already sequenced SARS-CoV-2, even the Chinese had not confirmed that it was responsible for the cluster of pneumonia in Wuhan. So the notion that Taiwan already knew not only that but also that human-to-human transmission was occurring is preposterous.

It’s true that, on December 31, the Taiwanese health authorities started screening passengers from Wuhan, but this doesn’t mean they knew that human-to-human transmission was possible and, as we shall see shortly, they did not and neither did the Chinese health authorities. They were just prudent and didn’t trust the Chinese, which served them well in this case, but this doesn’t mean Beijing was lying. I know this will come as a shock to many people, but China actually isn’t the only country that engages in propaganda. Worse, as this example illustrates, even democracies do so all the time. It’s amazing that, even though Taiwan’s claim has been debunked several days ago, people keep repeating that story. In defense of its earlier claim, Taiwan published a statement in which it explained that “public health professionals could discern from [the wording of the email] that there was a real possibility of human-to-human transmission”, because the email talked about “atypical pneumonia” and said that cases had been “isolated for treatment”. Anyone who claims that this ridiculous argument vindicates the strong accusation Taiwan initially made should be ashamed of themselves. In fact, the first statement published by the WHO about the outbreak, on January 5, explicitly says that “all patients are isolated” and talks about “cases of pneumonia of unknown etiology”. So if public health professionals could have discerned from the wording of Taiwan’s email that human-to-human transmission was likely, as Taiwan’s ridiculous statement claims, how come none of them did even after the WHO published a statement with the exact same wording? I don’t think you need me to spell it out for you.

In the statement the Taiwanese authorities published to argue that, despite all appearances to the contrary, they didn’t lie when they claimed to have informed the WHO about the risk of human-to-human transmission on December 31, they also made this claim:

In mid-January, the Taiwan CDC dispatched experts to Wuhan to gain a better understanding of the epidemic, the control measures taken there, and patients’ exposure history. Based on preliminary research, Taiwan determined that this form of pneumonia could indeed spread via human-to-human transmission.

But as one can readily verify, this is also a lie.

It’s true that, in mid-January, China allowed Taiwanese experts to visit Wuhan, who held a press conference on January 16 after their return. Here is the statement published by Taiwan’s CDC at the time:

On January 15, 2020, Taiwan CDC was notified by the Chinese Center for Disease Control and Prevention that the total number of cases of the novel coronavirus-associated pneumonia remained at 41, including 6 severe cases, 1 deaths, and 7 cases that had been discharged from the hospital. On the other hand, on January 16, 2020, Japan announced the first imported case of the Wuhan novel coronavirus. The case developed fever during his stay in Wuhan, but he did not visit the Huanan Seafood Market, which is linked to most cases. Nevertheless, it was possible that he came into close contact with patients of unexplained pneumonia. Taiwan CDC will continuously closely monitor the development of the case. Since confirmed cases that had not visited the Huanan Seafood Market have been subsequently reported in Thailand and Japan, limited human-to-human spread in Wuhan cannot be ruled out. [Emphasis is mine.] Additionally, as the source of infection is still under investigation, Taiwan CDC has raised the travel notice level for Wuhan City to Level 2: Alert, advising travelers planning to recently visit Wuhan and other neighboring areas in China to take personal precautions to ward off infection.

Does this sound to you like the Taiwanese health authorities had “determined that this form of pneumonia could indeed spread via human-to-human transmission” at the time? Please.

As we have seen, on January 15, the Wuhan Health Commission had publicly said the same thing after they realized a woman might have been infected by her husband. It’s quite possible that, during their visit in Wuhan, the Chinese hid information relevant to the possibility that human-to-human transmission was occurring from the Taiwanese experts, since as we shall see there is evidence that China knew more about this than it said at the time, but it doesn’t change the fact that Taiwan had not determined that human-to-human transmission was occurring by mid-January, let alone in late December. It’s completely transparent that Taiwan is lying and, if journalists were doing their job, it would get called out for that. However, not only is this not going to happen, but people are going to keep repeating Taiwan’s earlier claim, because they’re the “good guys”, so the truth doesn’t really matter. I have no problem with calling out China when it lies, but we should do the same with other countries instead of giving them a pass because we find their political system more palatable, otherwise we have no right to lecture China about the importance of telling the truth.

It’s more difficult than people think to figure out when exactly the Chinese health authorities reached the conclusion that sustained human-to-human transmission was occurring. People don’t seem to realize that it’s not so easy to show that human-to-human transmission is taking place when a new virus is identified. As I noted above, even after it had identified the virus responsible for the swine influenza pandemic in 2009, the American CDC remained very cautious for a while on this point. It has taken a bit longer for the Chinese health authorities to publicly state that sustained human-to-human transmission was occurring with SARS-CoV-2, but although there does seem to have been some deception on their part about this, it’s unclear to what extent it was due to the local or the national health authorities and it’s also very difficult to determine who knew what and when exactly they did. Moreover, even if the Chinese health authorities didn’t know that human-to-human transmission was occurring, it doesn’t mean they’re off the hook, because sometimes people don’t know something they ought to know. However, in assessing this question, we must be careful not to ascribe to the Chinese knowledge they couldn’t possibly have had at the time.

There are 2 fundamental points about human-to-human transmission that most people don’t seem to understand, which explains most of the nonsense they say when they accuse China of having known about human-to-human transmission for weeks but lied about it. First, human-to-human transmission is not a black-or-white type of thing, it’s on a continuum. Even the limited/sustained human-to-human transmission is a gross simplification, which is more confusing than useful in my opinion, although I use it because public health officials do and I have to in order to report characterize their statements at various points in time. In principle, if a virus can be transmitted from one person to another, then it can also be transmitted from that second person to a third. Perhaps they really have to try hard and spit in each other’s mouth or something, but it has to be possible, so the distinction is largely artificial. So there is no precise moment at which anyone can determine that sustained human-to-human transmission, as opposed to limited human-to-human transmission, is taking place, because there is no precise line that separates viruses for which only limited human-to-human transmission is possible from viruses for which sustained human-to-human transmission is possible. The fact that a virus can be transmitted from person to person doesn’t mean that it can result in a pandemic.

The second point is that not only is human-to-human transmission not a black-or-white type of thing, but neither is someone’s judgment about whether it’s occurring, because people make probabilistic judgments about this as they do about most other complicated questions. It’s not as if people wake up one day and suddenly decide that sustained human-to-human transmission was occurring. It’s always a gradual process during which people adjust their assessment of the probability that different kinds of human-to-human transmission are occurring as evidence comes in or fails to come in. Even if you have evidence that some human-to-human transmission is possible, it doesn’t mean that you will or even that you should conclude that a pandemic is a likely outcome. For instance, in the case of avian influenza viruses, both family clusters and infections of health care workers have been documented, but the CDC still deems sustained human-to-human transmission unlikely and doesn’t think that a pandemic of avian influenza will occur as long as those viruses don’t mutate. Thus, it doesn’t make sense to argue that, since China knew that some people had been infected by family members or that health care workers had been infected by patients by such-and-such a point in time, they must have also known that sustained human-to-human transmission was occurring by then, yet this exactly what people do all the time. Moreover, as we have already seen in the case of family transmission, the claims they make about when China had realized that such events had occurred are often not supported by the evidence. This is also the case for the claims they make about the infection of health care workers, so let’s turn to that issue.

As I just noted, when a new virus appears and people don’t know whether human-to-human transmission is possible, infections of health care workers is often a sign, although it’s hardly dispositive. Still, this question is important and a lot of people have therefore been talking about this, even if they are confused about what exactly can be concluded from that kind of evidence. According to a story published by the China Youth Daily on January 28, Lu Xiaohong, the director of gastroenterology at Wuhan Fifth Hospital, heard around December 25 that 2 hospitals in Wuhan had personnel who were suspected of having been infected with unexplained viral pneumonia and were placed in isolation. However, she doesn’t even name the 2 hospitals in question and, except for her vague testimony, I haven’t been able to find any evidence that any health care workers had developed symptoms at the time, so I think it’s almost certainly false. I’m not saying that she is necessarily lying, it’s possible that she misremembered the date when she heard that, which would be surprising since she made this claim more than a month after this allegedly happened. It’s not uncommon for people to retrospectively convince themselves they had understood what was going on before they actually did and, given the lack of corroborating evidence in this case (despite the fact that many journalists in both China and the rest of the world have talked with doctors in Wuhan), I think it’s likely what explains Lu’s testimony.

This conclusion is made even more plausible by the fact that, in addition to a lack of corroborating evidence, there is actually plenty of evidence that is hard to reconcile with her testimony. In particular, according to a study published in the New England Journal of Medecine in March, based on epidemiological investigations that started on January 3 after a surveillance mechanism for pneumonia of unknown etiology was established in Wuhan, no health care worker developed symptoms before January 1. Of course, this study is based on Chinese data and they could be false, but although various articles claim that health care workers started to get ill in late December, I have not been able to find the name of a single of them. Again, given how many journalists and foreign experts have talked to doctors in Wuhan about this, it would be surprising if some had in fact started to get ill before January. Moreover, given the timeline of the outbreak I have previously established, even if some health care workers had already fallen ill by December 25, it’s unlikely that anyone would have thought it was because a new virus had started to circulate in Wuhan, since as we have seen everything indicates that nobody in Wuhan realized that until a few days later.

As I already noted, it’s difficult to know exactly when the Chinese authorities figured out that sustained human-to-human transmission was occurring, but it seems clear that, by January 14, both the  local and national health authorities had reached the conclusion it was likely the case. Indeed, as the Associated Press revealed in the story I mentioned above explains, internal documents show that, on that day, the head of the National Health Commission told provincial health officials during a confidential teleconference that “the epidemic situation [was] still severe and complex, the most severe challenge since SARS in 2003, and [was] likely to develop into a major public health event”. Under a section titled “sober understanding of the situation”, the memo describing the conference obtained by the Associated Press said that “clustered cases suggest that human-to-human transmission is possible”. In response to this conference, the China’s CDC initiated the highest-level emergency response internally and the National Health Commission distributed a 63-page set of instructions to provincial health officials, which “ordered health officials nationwide to identify suspected cases, hospitals to open fever clinics, and doctors and nurses to don protective gear”. However, as we have seen above, despite a limited acknowledgement that human-to-human transmission might be taking place on January 15, they continued to talk in public as if sustained human-to-human transmission was unlikely until January 20.

I think this shows that, at least between January 14 and January 19, the national health authorities lied about human-to-human transmission. However, if you pay attention to the language used in the internal memo obtained by the Associated Press, it’s also clear that, at least on January 14, the national health authorities were still not entirely sure that human-to-human transmission was possible. The picture of what they knew at this juncture painted by this memo is hardly consistent with the widely repeated claim that China knew for a fact that human-to-human transmission was occurring weeks before it publicly acknowledged it. On the contrary, it suggests that, even as late as mid-January, the national health authorities were still not sure that human-to-human transmission was occurring. However, they still thought it was likely enough to assume that it was and prepare accordingly, yet didn’t say so and continued to minimize the risk in public. (As the Associated Press revealed in another story I already mentioned in the first part of this essay, they also stalled on providing the WHO with detailed epidemiological data, probably because they knew that once someone else had the data and could independently analyze them, they wouldn’t be able to control the narrative anymore.) As we shall see, this delay arguably had consequences, since those events unfolded during the Chinese New Year migration, so a lot of people left Wuhan and spread the virus elsewhere in China.

But this fact alone should be enough to put to rest the notion that, at the time, the Chinese government had already known exactly how contagious SARS-CoV-2 was since the beginning of January, let alone that it knew even before that, but said nothing and did nothing because it was engaged in some kind of cover up. What could possibly have been the point of that? It doesn’t make any sense. Do the people who make that sort of claim think that the Chinese government was trying to make sure that a deadly epidemic would spread over the whole country instead of being contained in Wuhan? Many of them seem to do, since I have run into countless people on social media who explicitly say that. The anti-China hysteria has reached such a level that people make claims that run against the most elementary common sense, but they don’t even realize that what they’re saying is completely absurd, because their hatred of China has destroyed their critical faculties, for those who had any in the first place. They depict the Chinese leaders as cartoon villains who do crazy/evil shit just for the sake of it, but nobody is actually like that. Of course, it’s not that Chinese leaders don’t do a lot of crazy/evil shit, such as putting hundreds of thousands of Uighurs in re-education camps, but they do it for a reason. What reason could they possibly have had to deliberately let a deadly virus spread throughout their country? Don’t get me wrong, I can come up with all sorts of theories to explain that, but the point is that they are all crazy.

A far more likely explanation is that, as the evidence strongly indicates, even the Chinese leaders weren’t sure about how bad this was, so they hesitated to say publicly that human-to-human transmission was occurring and take measures that would cripple the economy to contain the outbreak. We have seen governments in other countries do the same thing over and over again when they had to make decisions to fight the pandemic, even though unlike China they had the benefit of hindsight and they knew much more about what they were dealing with than the Chinese government could possibly have known in mid-January. Again, people talk as if the Chinese leaders were übermenschen with perfect foresight, who were not subject to the same limitations as other human beings. But at the risk of saying something shocking, they are not. The Chinese leaders are also human beings, who hesitate before making decisions that will affect hundreds of millions of people and possibly even put in jeopardy their own power. If people weren’t so hysterical about China, because they’re blinded by their ideological hostility toward the Chinese Communist Party, they would see that. The local authorities in Wuhan may have faced different incentives and as we shall see there is some evidence they temporized a little, but even they must have known that, if a deadly epidemic was allowed to spread over the whole country because they had suppressed information, they would pay a heavy price.

So what about the evidence that shows that the Chinese health authorities knew that human-to-human transmission was occurring before mid-January? Well, as I have already shown, in the case of the claim that China knew human-to-human transmission was occurring as early as December, the evidence is essentially non-existent. It’s harder to figure out how exactly the Chinese health authorities reached the conclusion that human-to-human transmission was likely by mid-January and even more so to determine to what extent the local health authorities knew more than the national health authorities. As the New England Journal of Medecine study I already mentioned above found, 45% of the cases who developed symptoms before January 1 had no known link to Huanan Seafood Market. In particular, according to a Lancet study I also mentioned before, the earliest confirmed case, whose symptoms onset was December 1, didn’t have any known connection to Huanan Seafood Market. Moreover, among the subsequent cases (as of January 22 when the data analyzed in the paper stops), only 8.5% had such a connection to the market. The authors conclude that human-to-human transmission occurred since mid-December, but it’s important to remember that, as I already explained, this is based on a retrospective epidemiological investigation conducted in January, so it doesn’t mean that the Chinese knew that at the time.

According to the New England Journal of Medecine study, the data were collected thanks to a monitoring system that was put in place after January 3, but it probably took a while before the picture that is painted in that paper started to emerge. I think many people don’t realize it, but this kind of epidemiological investigation takes a lot of time. To give you a sense of what is involved, here is how the methodology was described in the paper:

The earliest cases were identified through the “pneumonia of unknown etiology” surveillance mechanism. Pneumonia of unknown etiology is defined as an illness without a causative pathogen identified that fulfills the following criteria: fever (≥38°C), radiographic evidence of pneumonia, low or normal white-cell count or low lymphocyte count, and no symptomatic improvement after antimicrobial treatment for 3 to 5 days following standard clinical guidelines. In response to the identification of pneumonia cases and in an effort to increase the sensitivity for early detection, we developed a tailored surveillance protocol to identify potential cases on January 3, 2020, using the case definitions described below. Once a suspected case was identified, the joint field epidemiology team comprising members from the Chinese Center for Disease Control and Prevention (China CDC) together with provincial, local municipal CDCs and prefecture CDCs would be informed to initiate detailed field investigations and collect respiratory specimens for centralized testing at the National Institute for Viral Disease Control and Prevention, China CDC, in Beijing. A joint team comprising staff from China CDC and local CDCs conducted detailed field investigations for all suspected and confirmed 2019-nCoV cases.

 

Data were collected onto standardized forms through interviews of infected persons, relatives, close contacts, and health care workers. We collected information on the dates of illness onset, visits to clinical facilities, hospitalization, and clinical outcomes. Epidemiologic data were collected through interviews and field reports. Investigators interviewed each patient with infection and their relatives, where necessary, to determine exposure histories during the 2 weeks before the illness onset, including the dates, times, frequency, and patterns of exposures to any wild animals, especially those purportedly available in the Huanan Seafood Wholesale Market in Wuhan, or exposures to any relevant environments such as that specific market or other wet markets. Information about contact with others with similar symptoms was also included. All epidemiologic information collected during field investigations, including exposure history, timelines of events, and close contact identification, was cross-checked with information from multiple sources. Households and places known to have been visited by the patients in the 2 weeks before the onset of illness were also investigated to assess for possible animal and environmental exposures. Data were entered into a central database, in duplicate, and were verified with EpiData software (EpiData Association).

No matter how fast you try to go, something like this is going to take time, so it’s not as if as soon as the surveillance was put in place the Chinese instantly realized there was a pattern of people being infected after being in contact with sick people and without any connection to Huanan Seafood Market.

As the study also notes, the reagents necessary to laboratory-confirm cases by RT-PCR were not provided to Wuhan until January 11, so before that samples had to be sent to the National Institute for Viral Disease Control and Prevention in Beijing to be tested. You have to keep in mind that, at the time, the virus had just been sequenced over there and that researchers were still in the process of making sure it was responsible for the outbreak. As they explained in a paper I already mentioned, in the process, they had to develop and validate tests to detect SARS-CoV-2 in swabs that, for obvious reasons, didn’t previously exist. So when people claim that the Chinese health authorities must have already known that human-to-human transmission was occurring at the beginning of January because there were already patients with no history of visiting Huanan Seafood Market, they are saying that the Chinese must have had figured this out despite the fact that, for most of this period, they didn’t even have tests to confirm suspected cases! Again, people keep forgetting this, but it was still very early days and the Chinese had to do everything from scratch.

When I consider the timeline and how early it was, I don’t find it implausible at all that, as the memo obtained by the Associated Press suggests, the Chinese health authorities didn’t really start thinking sustained human-to-human transmission was likely until around January 14. They may have reached this conclusion a bit earlier, but almost certainly not much earlier, since again they were barely able to do PCR diagnostics before January 11. Of course, this information ultimately comes from Chinese researchers, so people will no doubt question it. But this timeline is totally consistent with what we know about the technical challenges involved in dealing with a new virus, and what we have seen in other countries that had the benefit of hindsight, so it would be completely irrational to reject this information because of that. We know that conducting epidemiological investigations, developing and validating laboratory tests and producing the necessary reagents take time, it’s not as if we had to the Chinese’s word for it. This timeline is also consistent with how long it took the American CDC to make clear that sustained human-to-human transmission was occurring after it identified the virus responsible for the swine influenza pandemic in 2009. As we have seen, it took the CDC 10 days after it first sequenced the virus and 3 days after it announced the discovery to make clear that it believed sustained human-to-human transmission was likely occurring, although even then it remained prudent. If the Chinese health authorities had publicly said what they privately said in the memo obtained by the Associated Press, it would have been more or less as fast in 2020, so I don’t see any reason to assume that they had reached that conclusion much earlier than that.

In the story where it talks about this memo, the Associated Press conjectures that, had the doctors who leaked information about the pneumonia cases that started to pile up in hospitals in late December not been publicly admonished, doctors would have been less reluctant to share the information they had. However, although I obviously think it was bad to reprimand those doctors, I don’t find that very plausible. First, the doctors were not reprimanded for sharing information with their hierarchy, but for sharing that information online. Moreover, as we have seen above, the health authorities seem to have set up a pretty thorough surveillance mechanism (with one important caveat I will discuss shortly), so I don’t think the issue is that people weren’t sending them information. Finally, as I argued above, you would have expected things to take roughly as much time just on account of the fact that conducting epidemiological investigations, developing and validating laboratory tests and producing the necessary reagents in sufficient quantities is not something that can be done overnight and presumably it wouldn’t have been faster if doctors had not been afraid to speak up.

One reason people often bring up to argue that China must have known earlier is the fact that health care workers quickly got infected, which should have been a sign that human-to-human transmission was possible. As we have seen, it doesn’t seem to be the case that any health care worker had already developed symptoms in December, but according to the New England Journal of Medecine Study, 7 of them did between January 1 and January 11. (Unfortunately, the paper doesn’t say when the onset of symptoms was for each of them, so we have no way to be more precise.) However, it’s ridiculous to conclude that, because of this, the Chinese health authorities must have known at the time that human-to-human transmission was occurring. First, as I keep repeating, the findings presented in that paper are the result of a retrospective epidemiological study that wasn’t published online until January 29. We don’t actually know when the Chinese found out those health care workers had developed symptoms, but keep in mind that, as I already noted, they barely had any tests during that period.

According to the Wall Street Journal, which cites health experts, the Chinese missed a lot of cases early on because they were only looking for “patients who had fever, direct Huanan Seafood Market exposure and chest scans ruling out regular bacterial pneumonia”. As a result, “they overlooked those who had come in close contact with such cases, and other patients who had no direct exposure to the market, milder symptoms or illnesses other than pneumonia”.  (The Associated Press gives the same explanation in the story I already mentioned.) This is totally consistent with the surveillance mechanism described in the New England Journal of Medecine, which gives the definition of suspected case that was used between January 3 and January 17 in the following passage:

A suspected NCIP case was defined as a pneumonia that either fulfilled all the following four criteria — fever, with or without recorded temperature; radiographic evidence of pneumonia; low or normal white-cell count or low lymphocyte count; and no reduction in symptoms after antimicrobial treatment for 3 days, following standard clinical guidelines — or fulfilled the abovementioned first three criteria and had an epidemiologic link to the Huanan Seafood Wholesale Market or contact with other patients with similar symptoms.

As you can see, if the Chinese were only looking for people that satisfied this definition, it’s not surprising they missed a lot of cases.

You might think that it’s because they were incompetent, but that would just be another example of  failing to appreciate that, at the time, the Chinese didn’t know what we now know and couldn’t possibly have known it. In particular, at the time, nobody knew that many people who have been infected by SARS-CoV-2 only have mild symptoms or even no symptoms at all. All the knew at the time was that it was very similar to SARS-CoV-1, which seems to kill around 10% of the people who are infected and usually result in very acute symptoms. So I think the Chinese can be forgiven if, after they realized the outbreak of pneumonia had been caused by a new coronavirus genetically very similar to SARS-CoV-1, it took them a while to understand that they shouldn’t only be looking for people with acute symptoms. Incidentally, the Wall Street Journal and many other people argue that, since patients were placed in isolation and many of them were sent to a hospital specialized in infectious diseases as early as December 30, the Chinese health authorities already knew that human-to-human transmission was possible. However, what I just explained shows why this argument is not even remotely convincing, since this is exactly what you would expect people who had just found out a new coronavirus very similar to SARS-CoV-1 was responsible for several unusual cases of pneumonia to do. It doesn’t mean they had any evidence that human-to-human transmission was occurring at the time. What do people think Chinese doctors were going to do with those patients, stack them on top of each other and lick their eyeballs? Again people are clearly not thinking straight about this.

In fact, this is exactly what Yuen Kwok-yung, a microbiologist specialized in infectious diseases who advised both the national government in Beijing and the authorities in Hong Kong, told Caixin when they asked him why Hong Kong declared the situation “serious” as early as January 4:

We did not know how serious the virus was at that time, nor did we know it was a new type of coronavirus, but because the virus appeared in the winter season and we were told it was related to SARS, we decided to be very cautious, and the Hong Kong government took our opinions seriously. As scientists we should never neglect “soft intelligence,” because this kind of information can sometimes be more timely than official warnings, like animals who can sense the coming of earthquakes and reacted ahead of time.

Again, this is just common sense, there is no need to assume that the Chinese already knew human-to-human transmission was possible at the time. However, when it comes to China, common sense tends to fly out the window pretty fast.

I’m unaware of any case of a health care worker who developed acute symptoms before January 12, when Li Wenliang, the ophthalmologist who been punished for leaking information about the virus on December 30, was placed in isolation with a fever and a cough. Moreover, he tested negative several times, before a test finally came back positive on February 1. (The first doctor died on January 25, but he was much older and apparently didn’t get infected until January 18. According to Ai Fen, she was informed that a nurse in her department was infected on January 11, but there is no indication that she had acute symptoms or even that it had been confirmed by a laboratory test.) So the focus on people with acute symptoms can explain why the Chinese might not have noticed that health care workers started to get sick in early January. Even if the Chinese health authorities had also been looking for people with mild symptoms at the outset of the surveillance, it would hardly be surprising if they had not noticed right away that 7 health care workers had fallen ill. According to this paper, in 2011, there were 7.9 health care workers per 1,000 in the urban areas of China. Thus, if we use that figure to estimate the number of health care workers in Wuhan, we end up with approximately 87,000 and 150,000 for the metropolitan area. It wouldn’t be shocking if the Chinese health authorities had not noticed right away that 7 of them were sick because they had been infected by SARS-CoV-2, especially if their symptoms were mild. There must have been a lot of health care workers who had a cough or even a fever in Wuhan at the time and the Chinese health authorities weren’t going to test them when they didn’t even have enough tests for severe cases. In fact, if you ask me, it wouldn’t be surprising if, in addition to the 7 cases that were eventually detected, there had been other health care workers who were infected around that time but were never diagnosed with COVID-19 because they only had mild symptoms.

So I don’t think anyone, not even the local health authorities, had reached the conclusion that human-to-human transmission was occurring during the first 10 days of January. Some people probably suspected human-to-human transmission was occurring at the time, but I doubt anyone had clear evidence at the time. There has been a lot of speculation that the local health authorities may have misled the national health authorities about that, but while I think it may have happened later, I don’t think it had already happened back then. Sometime between January 10 and January 14, the national health authorities came to believe that human-to-human transmission was probably occurring, but it’s impossible to know exactly when and whether the local health authorities had already figured it out before the national health authorities did. A team of experts was dispatched to Wuhan by the national health authorities on December 31, but they apparently failed to find clear signs of human-to-human transmission, which based on everything I have said above is entirely believable and even totally unsurprising.

A second team of experts was sent over there on January 8, but according to the Associated Press, they also failed to find to unearth any clear signs of human-to-human transmission. Wang Guangfa, the leader of that second team (who fell ill after his return to Beijing on January 16), later declared that he “always suspected it was human-to-human transmissible”, but this doesn’t mean that he’d found any clear evidence of that, despite the fact that some health care workers had already started to fell ill at the time. As I already explained, I think that’s because they were only looking for people with acute symptoms, which as I argued wasn’t crazy. To be sure, Li Wenliang was placed in isolation on January 12 with a fever and a cough (while the second team of experts was still in Wuhan), but again it’s important to remember that all the tests performed on him came back negative until February 1, so I don’t think we can conclude from this either that Wang Guangfa must have known at the time that human-to-human transmission was occurring or that information was kept from him by the local health authorities.

Meanwhile, in Hong Kong, Yuen Kwok-yung told Caixin that 6 members of a family of 7, including one who hadn’t traveled to Wuhan (unlike the others who had just returned from a trip over there), were admitted to Shenzhen Hospital on January 10 and that by January 12 his team had “basically confirmed” they’d all been infected by SARS-CoV-2 with rapid testing kits and informed the national health authorities. However, the “basically” seems to be doing a fair bit of work here, because according to the paper where this family cluster is described, not all members of that family had shown up at the hospital until January 15. Still, although they apparently weren’t done looking at this family back then, it’s possible that it was one of the clusters mentioned in the memo obtained by the Associated Press, which apparently convinced the national health authorities that human-to-human transmission was likely around that time. However, those cases were not publicly confirmed at the time, because on January 3 the National Health Commission had ordered the institutions not to publicly disclose any case until they had been independently confirmed by the national health authorities. Had those cases been publicly confirmed right away, it may have made people both in China and elsewhere realize that human-to-human transmission was likely sooner, but the desire by China’s national health authorities to have total control over the flow of information prevented that.

A third team of experts, led by Zhong Nanshan, was dispatched by the National Health Commission and arrived in Wuhan sometime between January 17 and January 19. (The first date is what Yuen Kwok-yung, who was a member of that team, told Caixin in the interview I mentioned above, but the story Caixin published in Chinese I also talked about before says the team arrived on January 19. Meanwhile, according to the Wall Street Journal, the team arrived on January 18. According to the New York Times, on the other hand, the team had completed the visit on January 19. For various reasons, I think the date given by Yuen Kwok-yung is more likely, but I can’t be sure.) As we have seen, at this point, the national health authorities had already determined that human-to-human transmission was likely, but apparently they still weren’t sure. This visit seems to be what cleared up whatever doubts they still had on the matter and eventually convinced them to put Wuhan in quarantine. According to Yuen Kwok-yung, the local health authorities were not entirely forthcoming with information during that visit and many of the people they talked to sounded like they’d been briefed about what to say, but when pressed they just couldn’t hide the information that convinced the team that human-to-human transmission was definitely occurring and led to Zhong Nanshan’s public statement to that effect on January 20. (The fact that a single patient had apparently infected 14 health care workers seemed to have played a particularly important role in their reaching that conclusion.) Of course, he could be lying, but the timeline suggested by this narrative is entirely consistent with the confidential memo seen by the Associated Press and the various considerations I have reviewed above, so I think it’s probably what happened.

So what should we make of all that? First, it’s clear that, between January 14 and January 20, the national health authorities made several public statements about human-to-human transmission that didn’t accurately reflect what they were privately saying. In other words, they were lying, but the lie probably wasn’t as blatant as people think. Indeed, even on January 14, when they took steps to prepare for a pandemic, confidential documents obtained by the Associated Press suggests they were still not entirely sure that sustained human-to-human transmission was possible. Their doubts were not entirely lifted until sometime between January 17 and January 20, after a third team of experts dispatched by the National Health Commission visited Wuhan. My guess is that, during the week that separated the confidential teleconference on January 14 and the announcement that human-to-human transmission was occurring on January 20, the local health authorities waited as long as possible to give the information they had on that issue to the national health authorities, possibly because Hubei’s communist party wanted to be able to hold its annual meetings undisturbed. One reason I think it’s likely is that, if they had noticed that 14 health care workers had been infected by a single patient by January 20, even if you take into account the lack of tests in Wuhan during that period, it seems doubtful that the local health authorities had not noticed that several health care workers had been infected by this patient earlier.