Uncontrolled spread, p.5
Uncontrolled Spread, page 5
Evidence later emerged that Hubei Province was dealing with what it believed was a major outbreak of flu that began on December 2.56 Hubei was reporting twenty times the normal number of flu cases, a surge that may have started in November, putting an enormous burden on the local healthcare system. It now seems possible that some of those cases could have been SARS-CoV-2 making its first entry into the local population. Robert Kadlec would later say that the US uncovered evidence that China was starting to hoard medical supplies like masks and gowns by early December.57 The anecdote was offered to suggest that China had a run on these products well before the US was aware of the impending risk, or at the very least, China was worried that demand for medical goods could start to rise and was stockpiling the material.
Without access to stored blood and respiratory samples from some of the earlier patients who were presenting with flu-like symptoms in November, it’s impossible to know for certain if what was believed to be an epidemic of influenza was also some of the initial cases of the novel coronavirus making its first entry into the city. A year later, as part of its investigation of the virus’s origin, a WHO team sent to China sought samples collected as far back as the fall of 2019, but the investigators were told by Chinese officials that the Chinese government lacked the necessary permission from patients to test samples, many of which were held in blood banks. It seemed disingenuous for Chinese officials to invoke far-reaching patient privacy protections in this instance, with such critical public health questions on the line.58 Leaked internal documents would later show that in November, routine tests being carried out on the patients suspected of having flu were returning a higher-than-normal rate of indeterminate results.59 Many of the Chinese patients who were thought to have complicated cases of influenza were instead sick with some other, unidentified respiratory illness.
A modeling study done later by researchers at the University of California, San Diego, and at the University of Arizona, found that the first cases of the novel coronavirus probably began spreading in Hubei Province in early November but could have been transmitted at low levels as early as October 2019.60 The South China Morning Post would report on Chinese government data, that traced the first known cases in Hubei to November 17. “Chinese authorities have so far identified at least 266 people who were infected [in 2019], all of whom came under medical surveillance at some point. Some of the cases were likely backdated after health authorities had tested specimens taken from suspected patients,” the newspaper wrote. “Of the first nine cases to be reported in November—four men and five women—none has been confirmed as being ‘patient zero.’ They were all aged between 39 and 79, but it is unknown how many were residents of Wuhan.”61 If China had shared some of the early patient samples from November, it could help reveal—or put to rest—conjecture that the virus may have been spreading widely much earlier than December 2019. The WHO team also sought wastewater samples from central China to see if the virus could be detected in sewage from late 2019 and were told the samples had been discarded.62 In the absence of a more complete investigation, speculation would persist that the virus might have begun spreading in the fall.
The slow flow of information about COVID had echoes in the earlier experience with SARS-1 in 2002. When that outbreak first emerged, Beijing learned at some point that a novel virus was the culprit but continued to blame the cluster of infections on a bacterium.63 Two months later, when an outbreak of the infection appeared in Canada, a Canadian lab promptly sequenced the pathogen for itself, firmly establishing that it was a novel coronavirus. It shared this information with the world. Only then did the Chinese government release data on the full scope of its epidemic, announcing that Beijing had 346 cases—a ninefold jump from the 37 cases government officials had previously disclosed.64
When the novel coronavirus first emerged, similar challenges hampered the early response. Without access to the viral samples, it made it more difficult for other nations to fashion diagnostic tests and to begin work on drugs and vaccines. Countries could synthesize the whole virus in the lab, but that took months and had to be done in special, high-security facilities equipped to handle dangerous pathogens. It was not until much later, on March 3, that Swiss scientists became the first group to accomplish the feat, synthesizing the virus at a high-security lab in Mittelhäusern.65 By then, many countries already had access to samples of the live virus because it was spreading uncontrollably around the world. I was told by a member of the White House staff that at least one early sample that the US secured possession of came from one of China’s neighbors. China’s hesitancy had given rise to a global barter system for early samples of SARS-CoV-2.
The lack of information also put medical providers at increased risk. If you look at the medical workers in China who initially fell ill, few from emergency and respiratory departments were sick, Ai Fen later observed. It’s likely that doctors in these settings had the mind-set to protect themselves. “The most seriously ill have been those from the departments on the periphery,” she said.66 These doctors were more likely to be unaware of the virus and naive about its spread and didn’t have the presence of mind to wear protective gear and take respiratory precautions.
The work of many Chinese doctors and researchers early in the outbreak, to distribute information on the novel pathogen and post sequence reports and other bottom-line data, ultimately helped inform physicians around the globe about the virus. In the moment, these were heroic acts. Many Chinese scientists and physicians took risks, and their efforts saved lives. Yet, ad hoc reporting by individual doctors was not a substitute for more coordinated disclosure by the government, which didn’t happen until much later in the crisis. Even on the one-year anniversary of the lockdown of Wuhan, Chinese officials tried to soften news about the government’s response to the pandemic, stripping terms like “first anniversary” and “whistleblower” from Chinese websites like Weibo.67 Li Wenliang, the ophthalmologist at Wuhan Central Hospital, who had been threatened by the local police for disclosing information about the outbreak, eventually returned to his clinical work and was himself infected with SARS-CoV-2, probably in early January while caring for a glaucoma patient who was asymptomatic but infected with SARS-CoV-2.68 Li died of COVID on February 7. In all, more than two hundred medical staff at his hospital contracted COVID, and three of his colleagues died from the disease in March. Some of them were not made aware early enough of the virus’s risks, and they were not warned to take precautions.69
Li Wenliang’s death shocked the public around the world and galvanized criticism inside China to the government’s handling of the crisis, but it didn’t have any discernable impact on China’s sharing of information. I was told by members of the White House staff that during the same week that Li died, the Chinese government started to clash privately with officials at the WHO, trying to head off the declaration of a PHEIC, which could give other nations political cover to apply travel restrictions in an effort to keep an outbreak contained, even though such travel measures continued to be heavily discouraged by the WHO.70 China wanted to avoid those burdens.71 Its officials also wanted to avoid any public suggestion that China was losing control of the outbreak. However, the situation in China had been worsening for weeks. On January 20, the Chinese Xinhua News Agency had reported that the total number of coronavirus infections in the country had climbed to 217, including 14 cases in Guangdong and 5 in Beijing. Shortly afterward, China’s National Health Commission confirmed the first case in Shanghai.72 Chinese health officials reported the next day that six people in Wuhan had already died from the illness.73 China’s grim epidemic was under way.
Chinese officials would say that they were in regular contact with the WHO and sharing medical information with the global body. As a technical matter, this was true. But the private emails between WHO officials and their Chinese counterparts would tell a different story. The WHO would submit long lists of questions to Chinese officials, related to the scope and severity of the epidemic. In return, the Chinese government would provide achingly incomplete replies. This wrangling would continue, with the WHO resending the same questions and receiving modified replies that didn’t fully address the key questions. All the while, the WHO—afraid to jostle Chinese officials, afraid to confront them, afraid to lose its limited access—would maintain that it was in constant dialogue with the Chinese government. As a technical matter, they were in dialogue. But the interchange was not productive.74
Twice the Chinese delegation in Geneva tried to block the declaration of a PHEIC. The first time was on January 22, 2020, and they succeeded. The second time, on January 30, the effort failed. This was right after WHO director Tedros returned from China where he was meeting with senior Chinese officials, including President Xi Jinping, as part of an effort to show engagement and support for China’s efforts. Before leaving China, Tedros called his team in Geneva and told them to establish a new emergency committee to reconsider the declaration of the PHEIC. On January 29, the morning before the declaration was reconsidered, Ambassador Bremberg met with his Chinese counterpart in an effort to convince China to support the measure. Bremberg argued that a declaration of a PHEIC would not be perceived as a condemnation of China’s effort to contain COVID. However, quite the opposite would be true, Bremberg said, if China continued to oppose the WHO effort. Blocking the measure, he said, would be seen as an attempt to restrain global action that could help other nations prepare for onward spread. Bremberg felt confident that he had convinced the Chinese ambassador, but he wasn’t sure Beijing would sign off. That’s where it was left. China continued to fight the declaration, although this time it failed. Privately, Tedros used the episode, and his eventual support for the declaration, to try to counter accusations of being soft on China.
Yet in practice the declaration would have limited impact. The idea of such a declaration was to trigger international action to contain the spread and avert, or at least temper, a wider pandemic. But many nations had not updated their domestic laws governing public health emergencies since 2005, when the world was confronting the aftermath of SARS-1 and was increasingly focused on the risk of pandemic flu. Most countries still had laws in place that tied their local action not to the declaration of a PHEIC, but to the declaration of a pandemic by the WHO—a higher standard that had not yet been met in the WHO’s estimation. Indeed, the WHO wouldn’t declare the novel coronavirus to be a pandemic until five weeks later, on March 11, well after it was clear to anyone watching the news that a global pandemic was already under way. “We are deeply concerned both by the alarming levels of spread and severity, and by the alarming levels of inaction,” the director general said at a briefing held to announce the belated declaration of a pandemic.75
By that point, the ground was shifting. A day earlier, on March 10, President Xi visited Wuhan to mark the culmination of a harsh seventy-six-day lockdown of that city that had largely succeeded in arresting the epidemic there. Researchers from the University of Southampton in England, using mobile-phone location data from Chinese internet firm Baidu, estimated that if China had implemented its strict measures in early January, it would have reduced the epidemic’s victims to just 5 percent of the eventual total.76 That’s a small enough outbreak that Chinese officials might have been able to fully contain the spread inside China. But from January 5 to January 17, hundreds of patients were appearing in China’s hospitals, not just in Wuhan but across the country.77 The containment window, to avert wider transmission, had slammed shut. The contagion was ending in China, but its global spread was just beginning in Europe and America.
I spent March 10 on Capitol Hill, briefing members of Congress. In the morning I addressed the entire Republican House Conference. The Republican leadership, especially Representative Liz Cheney, was trying to build support for a COVID relief package that was coming before Congress. Cheney was deeply concerned about the threat that COVID posed and had invited me to brief the caucus that morning. She would continue to seek my perspective throughout the crisis and asked me to brief the Republican caucus on two more occasions later that spring, by telephone, after the US epidemic was under way. At the March 10 meeting, I delivered a downbeat assessment of where we stood, predicting that the virus would soon begin to spread widely in the US, and we would be forced to turn to mitigation to slow its spread. I told the members that the relief package, which would become the Coronavirus Aid, Relief, and Economic Security (CARES) Act, would be crucial to help bridge Americans through the crisis and enable the actions we would need to take to slow the spread of the virus. In the afternoon, I briefed Democratic members of the House Progressive Caucus. Shuttling between the two meetings, from a room filled with some of the most conservative members of Congress, to a meeting with some of Congress’s most liberal representatives, the one constant was a palpable sense of anxiety. There was, however, little recognition that the danger that many feared was on the way had already arrived. That morning, most of the Republican caucus, nearly two hundred members, crowded into a single conference room in the basement of the Capitol Hill Visitors Center. During the meeting, one of the few tangible signs of the looming danger was the food line: the meals were ready to eat, grab and go. Two staff members, stationed behind a table, dispensed coffee into disposable cups, all to avoid people touching the same utensils.
The pandemic was under way. And it would be made worse by the distortion and suppression of information, in many different settings, at different times and levels: at first balefully, through the efforts of some government officials in China—especially local authorities in Hubei Province; and then later, in the US, amidst wrangling over how forcefully to confront the virus.
Had the Chinese government been more forthright at the outset, there was a chance that the virus could have been contained there. Later, in the US, the effort to find effective tactics and therapies to stop the virus would also suffer from a lack of reliable information as we struggled to establish a truth standard about what would be most effective, and to agree on a reliable set of actions for containing spread. In a public health crisis, reliable information is a vital currency for decision making. The spark of transmission was lit amid the suppression and distortion of key facts.
We could and should have known and done more in the US. But it’s important to remember that in December 2019 and for the first few weeks of January 2020, the Chinese government didn’t share vital information that could have mobilized an earlier response in China and alerted the world to the full scope of the threat much sooner. In the US, we made plenty of mistakes of our own, so it’s arguable how much the earlier warnings would have helped us galvanize a more effective response. But global conventions, many implemented after SARS-1, were supposed to keep us fully informed of these risks, and they were disregarded. This should change the future course for how we deal with these threats. We’ll need to rely much more on our own tools for gathering information about novel pathogens and menacing outbreaks. We can no longer depend largely on global cooperation and the competency and transparency of other nations. COVID wasn’t caused deliberately, but it was enabled and nurtured by the intentional quashing of information.
Chapter 3
Pandemics as National Security Threats
We needed to get boots on the ground.
By late January, US officials were mounting a full-court press for China to let staff from the CDC enter Wuhan. Chinese officials initially balked, then promised access, stalled, refused, and finally relented after it was almost too late to do the CDC much good. China’s willingness to sidestep some of the key commitments made as part of global agreements that were implemented after SARS-1 was felt viscerally at the CDC—which couldn’t get permission from the Chinese government to let any of the dozen CDC staff, permanently stationed in Beijing, to visit Wuhan.1
The CDC had been trying to get access to Wuhan for more than a month, with no success. On December 31, Dr. Anne Schuchat, the CDC’s top career official, was one of the first officials at the agency to spot the threat. She read a brief report in a scientific bulletin that tracks outbreaks, a description of four cases of “unexplained pneumonia” in Wuhan, and emailed a group of CDC colleagues asking if “any of your folks know more about the ‘unknown pneumonia’ in Wuhan.” Within hours, an email reply came from Dr. Nancy Messonnier, the director of the CDC’s National Center for Immunization and Respiratory Diseases, who wrote that she learned there were actually now twenty-seven patients with pneumonia. The characterization of the cases, she said, “raises concern about SARS.”2
The next day, January 1, CDC Director Robert Redfield emailed his Chinese counterpart, Dr. George Fu Gao, a virologist and immunologist who had served as director of the Chinese Center for Disease Control and Prevention since 2017. After receiving no response, later that day Redfield called Gao to press for more information. By January 3 the two had talked multiple times about the outbreak. The following day, on January 4, Redfield sent Gao another email, again entreating for more information on the situation in Wuhan and requesting that the US CDC staff be given access to the hot zone. “I would like to offer CDC technical experts in laboratory and epidemiology of respiratory infectious diseases to assist you and China CDC in identification of this unknown and possibly novel pathogen,” Redfield wrote. Gao was emphatic that there was no person-to-person transmission and no evidence of spread within hospitals. Gao’s working theory was that the virus had been spread by contact with an animal, still unidentified, at the Huanan market. All the early cases seemed to be tied to that market. But Gao had sent Redfield a list of the first twenty-seven cases that the Chinese CDC had identified, and Redfield noticed that among them were three clusters where multiple family members were affected—a husband and a wife, or a child and a parent.3 It seemed implausible to Redfield that multiple members of three different families had all contracted the virus from the same zoonotic exposure. Redfield told Gao he was extremely worried that this was evidence of human-to-human transmission, urging Gao to look aggressively through local medical admissions for people with matching respiratory symptoms who didn’t identify the food market as a common point of contact.
