It is widely known that when the new coronavirus emerged in December 2019, the Chinese government downplayed the pandemic threat for several critical weeks. Less commonly known is those same authorities deliberately sacrificed health workers to maintain their lies.
The Chinese Communist Party’s (CCP) calculated cover-up enabled the coronavirus to go global. By silencing doctors, Beijing not only fueled this pandemic but also compromised the world’s ability to spot the next one.
Why the CCP decided to cover up the outbreak is unclear. It may have been a reluctance to cancel political meetings, a fear of public panic—especially around the Chinese New Year—the embarrassment of another pathogen being born on Chinese soil, or the simple instinct to squash bad news ingrained into officials in an authoritarian system.
Pandemics are like wars. The first casualty is truth.
Instead of notifying the World Health Organization (WHO) about the outbreak of atypical pneumonia and evidence of human spread, the authorities censored information, concealed the virus, and silenced doctors who tried to warn their colleagues. Hospital leaders refused to authorize masks or other personal protective equipment (PPE) on the grounds that it would cause panic. As patients infected health care workers and health care workers infected one another, hospital leaders insisted that spread among humans was impossible—that no staff members were infected—even altering diagnoses that suggested otherwise.
Beijing’s official line through Jan. 19, 2020 was that the outbreak began in late December 2019, that all cases had been infected by an unidentified animal source at the Huanan Seafood Wholesale Market, and that no health care workers were infected. But even when the government conceded human spread on Jan. 20, it reported only a fraction of the real numbers.
These falsehoods influenced the WHO’s decision not to immediately declare a Public Health Emergency of International Concern, a step it had previously taken over Ebola, Zika, and the H1N1 virus. It also informed the widespread belief that COVID-19 spread in a similar manner to influenza—by large droplets landing on surfaces and transferred by touching rather than through airborne microdroplets. That misdirection contributed to the early and persistent focus in the West on surface disinfection and hand hygiene rather than masks—considerably more effective.
The lack of information also meant some important early trends were missed. For example, most infected staff were in non-urgent specialties, such as ophthalmology, family medicine, and elective surgery. These specialties are not considered high risk, and patients were less likely to be sick or symptomatic—meaning health workers were less likely to wear masks than their colleagues in emergency respiratory medicine and intensive care units.
The delayed understanding of transmission dynamics cost the lives of unknown numbers of health care workers in China, contributed to the deaths of tens of thousands more abroad, and superpowered the pandemic.
The cover-up had various elements. First, like severe acute respiratory syndrome (SARS) in 2002, Chinese authorities did not notify the WHO, in violation of International Health Regulations, the global rules on pandemic threats. These rules stress that any threat that infects health care workers—positive proof of human spread—must be reported. Instead, as with SARS, the WHO learned about the new threat not from Beijing but from an open-source platform devised by doctors to rapidly disseminate information and counter governmental tendencies to suppress emerging threats.
Admittedly, uncertainty is the defining principle of any new pathogen. But by Dec. 27, 2019, Wuhan authorities knew the threat was serious. By then, the new coronavirus had been sequenced, several patients without links to the market had been identified, and at least one health care worker had been infected. Both SARS and Middle East respiratory syndrome (MERS), COVID-19’s older siblings, both caused atypical pneumonia, pandemics, and high infection rates among health care workers.
The doctors in Wuhan understood this threat and tried to warn one another. Providing health care workers with PPE would not necessarily have contradicted the official story about no human-to-human transmission. For an outbreak of atypical pneumonia during flu season, masks are the bare minimum. After SARS, PPE would be welcomed as a prudent protective measure rather than raise international eyebrows. But Chinese authorities, at pains to maintain their fiction, rejected this compromise.
Instead, authorities engaged in a pattern of demonstrable lying and covering up, threatening doctors involved in early warnings and restricting information. On Jan. 3, 2020, when China formally acknowledged the pneumonia outbreak, authorities told the WHO they had no idea what was causing it. In fact, by then, the new coronavirus had been sequenced several times—beginning with Vision Medicals on Dec. 27, 2019; BGI Genomics on Dec. 29, 2019; Wuhan Institute of Virology on Jan. 2, 2020; and China’s CDC on Jan. 3, 2020. On Jan. 5, a consortium led by professor Zhang Yongzhen at Fudan University in Shanghai sequenced it, deposited it in GenBank, the U.S. public database of DNA sequences, submitted it to Nature, and shared it with China’s National Health Commission (NHC).
Yet the Chinese government pretended it still didn’t have a clue. On Jan. 6, the NHC gave a national briefing on the pneumonia of unknown cause. On Jan. 9, in breaking news, the NHC announced that a novel coronavirus had been discovered on Jan. 7. But China didn’t share the sequence until Jan. 11—and only after Zhang permitted it to be posted on Virologica, an open platform.
On Jan. 1, 2020, the WHO formally asked China to verify the outbreak. Instead of replying within 24 hours as required, the Wuhan Public Security Bureau reported it had “taken measures” against eight “law breakers” and warned against “manufacturing, believing, or spreading rumors.” Belying later claims that the cover-up was limited to local authorities, Chinese state media publicized this intimidating warning widely.
The Chinese government’s cover-up led WHO experts to make deadly mistakes. On Jan. 5, the WHO passed on its minimal information from Beijing in a post entitled “Pneumonia of Unknown Cause.” WHO experts knew it lacked detail but not that it was a litany of lies. The seafood market as the source seemed plausible, given that SARS began at a wet market in Guangzhou. Yet compared with Guangzhou’s exotic wildlife, the Huanan market was mundane, more remarkable for being next to Wuhan’s high-speed train station.
On Jan. 11 and 12, Chinese authorities told the WHO there had been no new cases since Jan. 3, consistent with their claim that the wet market was the source of all cases, given that it had been closed since Jan. 1. Again, the government insisted there was no infection among health care workers or clear evidence of human spread. In fact, at least 20 health care workers already had confirmed COVID-19, and dozens more had been clinically diagnosed—among them Li Wenliang, a young ophthalmologist who would become famous for his tragic death following his early warnings. Well before he found an N95 mask on Jan. 10, he was infected by a glaucoma patient.
On Jan. 13, a senior NHC official informed an expert delegation from Hong Kong, Macau, and Taiwan that human-to-human transmission was occurring. Yet the next day, when the delegation visited Wuhan Jinyintan Hospital, medical staff treating patients on the isolation ward, described as the “dirty zone,” were not wearing masks or goggles.
The same day, Chinese health officials apprised the government that human spread was most likely occurring. At the WHO’s daily news conference, a WHO virologist said that limited human spread, potentially among families, was possible, adding “but it is very clear right now that we have no sustained human-to-human transmission.” It is unclear whether WHO’s comment was due to the limited information coming from the Chinese government, a reluctance to challenge Beijing in light of its political and economic influence, or scientific mediocrity.
It was only on Jan. 20 that Zhong Nanshan—a widely respected Chinese public health leader—was rolled out to officially confirm human spread and medical worker infection. His admission triggered the WHO to call an emergency committee to consider whether the outbreak constituted a Public Health Emergency of International Concern.
Yet when the committee met on two days later, although more than 400 health care workers had confirmed cases of COVID-19, China admitted to only 16 such cases, and the emergency was not declared.
On Jan. 28, as Tedros Ghebreyesus, the WHO director-general, met with Chinese President Xi Jinping and requested permission for a WHO-led mission to visit China, Xi’s agreement appeared responsible. On Jan. 29, when Li’s diagnosis surfaced, the static number of 16 infected health care workers was reassuring. When Li died, Beijing responded to the public outcry by launching an investigation into the circumstances of his punishment. But that posture of contrition only reinforced belief in Beijing’s lies.
Beijing’s announcement on Feb. 14 that 1,716 health care workers had been infected sent shock waves around the medical world. Of those, 230 people were staff at the Central Hospital of Wuhan, one of the hospitals at the epicenter of the outbreak. By Feb. 20, at the time of the WHO-China Joint Mission, the total had risen to 2,055 cases.
Chinese authorities paraded the mission participants around various cities far from Wuhan and took care to keep the 12 Beijing-approved international members from speaking with their Chinese counterparts. On the second-to-last day, select members—with no U.S. representatives included—spent less than 24 hours in Wuhan. A carefully staged itinerary included Tongji Hospital and a clinic at Wuhan Sports Center. The key hospitals in Wuhan—Central, Jinyintan, and Union—as well as the market and the level 4 biosafety lab were all off-limits. This cover-up had echoes of SARS, when Chinese authorities actively hid patients from the WHO, driving them around in ambulances while the WHO team visited hospitals.
The joint mission report stated that “transmission within health care settings and amongst health care workers does not appear to be a major transmission feature” and among health care worker infections, “most were identified early in the outbreak in Wuhan when supplies and experience with the new disease was lower.” A China CDC report published Feb. 17 contradicted both statements, as did the prior experience of epidemiologists. Pretending inexperience was implausible, given China’s familiarity with SARS. Other places that had suffered through SARS—Hong Kong, Thailand, Vietnam, and Singapore—had no COVID-19 infections or deaths among health care workers by that point. All of those places mandated masks.
Based on distorted data from the Chinese government, the joint mission falsely reassured the world there was no major danger to health care workers. In Italy, 16,991 health care workers were infected within six weeks. While authorities focused on testing new arrivals from China, the virus was spreading rapidly and often silently among unsuspecting Italians. Hospitals became hotspots, and the epidemic exploded. By mid-April 2020, 206 health care workers had died, including 119 doctors. The most vulnerable were retired doctors who had been recruited back to help address the crisis.
Silencing doctors—the weak link in official censorship efforts—isn’t new. In 2010, India ridiculed the doctor who first published on NDM-1, the drug-resistant superbug. In 2012, Saudi authorities forced the doctor who alerted the world to MERS into exile. In 2013, the Syrian government put doctors who proved polio’s return on the “to be disappeared” list. The Chinese government is still punishing the surgeon who spoke out on SARS in 2003.
This medical censorship is particularly dangerous because physicians are indispensable for surveillance of emerging threats. The WHO’s role includes global surveillance of public health threats, but as a United Nations organization, it has no power to send investigators to an outbreak without the government’s permission. Governments worldwide downplay epidemics, fearing that trade will be hurt, legitimacy compromised, or holes in their health care system revealed. This makes doctors the eyes of the international community, essential for protecting all of us.
The Chinese government’s attempt to cover up SARS led to the revision of the International Health Regulations and an international mindset that Beijing had learned its lesson. But the only lesson that the CCP authorities seem to have learned involved how to better cover up outbreaks and manipulate international rules. Beijing, for example, was careful to cooperate with the WHO sufficiently to avoid being called out for its overall lack of honesty while concealing key facts.
Strengthening International Health Regulations without addressing the propensity of governments to cover up pandemics is unlikely to make a difference. After China’s SARS cover-up, WHO’s then director-general, Gro Harlem Brundtland, used her clout as a former prime minister to revise those regulations. Since then, states have not elected another former head of state as director-general.
Because the WHO, as a U.N. agency, has a limited ability to criticize governments, it would be helpful to establish an independent group of experts with the mandate to spotlight governments that flout their obligations. Similar bodies are routinely deployed by the U.N. Human Rights Council, and they speak out without the inhibition that so often hampers U.N. agencies.
Beijing’s cover-up continues to this day. It let a second WHO-led mission into China but denied it access to essential data on the earliest patients recorded with COVID-19 while sending it on a wild goose chase investigating whether the outbreak could have been sparked by the virus resting on frozen food—a diversionary theory for which there is no evidence. Meanwhile, the mission itinerary included a Wuhan exhibit of health care workers portrayed in the very masks and protective gear they were denied for weeks.
Propagandists promoting the Chinese government’s ultimately successful control of COVID-19 to justify authoritarian rule miss the fatal flaw: It is precisely that authoritarian system of party-line censorship and cover up at all costs that facilitated COVID-19’s spread in the first place and enabled it to go global.
When the next coronavirus emerges—COVID-22, say—which Chinese doctors will be brave enough to report it? Which scientists will be willing to post the genetic sequence? This time, China has cost itself, and the world, the only reliable warning system in the country where it may be most needed.
Editor’s Note: This article is part of a series on what experts missed during the early days of the pandemic. Read Ethan Guillen on American hubris here, and Michael Varnum, Cendri Hutcherson, and Ivan Grossmann on how badly wrong predictions of social change were here.
