Opinion Wuhan’s early covid cases are a mystery. What is China hiding?

Medical workers inside Wuhan Central Hospital in Wuhan, China, on April 1, 2020. (Noel Celis/AFP via Getty Images)
Medical workers inside Wuhan Central Hospital in Wuhan, China, on April 1, 2020. (Noel Celis/AFP via Getty Images)

The story of how the pandemic got started — and turned into a global catastrophe — remains a black box. It should not be.

The first cases could provide the most important clues about the origins of the virus, yet we know the least about them. They could show whether the outbreak began by a zoonotic spillover, perhaps from animals sold at the Huanan Seafood Market in Wuhan, China, or was an inadvertent research-related accident, such as a leak from a research facility in Wuhan. The early cases could illuminate missteps in public health that allowed the virus to spread. They could point to failures in the early warning and surveillance systems, offering important lessons for the future. And knowing more about the early cases could reveal the extent to which China concealed vital information from the public when the outbreak might still have been brought under control.

The Beijing government has insisted the virus came from somewhere abroad, perhaps imported on frozen food. But the key to unlocking the origins lies within China. It is particularly important to discover how far and wide the virus spread in December 2019. The outbreak probably eluded detection at first, then was detected but not recognized as a new disease by doctors and nurses. After that, it was both detected and recognized, but the vital reporting was suppressed by Chinese authorities, both local and national.

To prevent the next pandemic, and to better understand this one, a serious, sustained and credible investigation is needed.

What is China hiding?

The Wuhan early cases —

more questions than answers

An accurate account of 2019 covid cases could help establish the origin of the pandemic. But the tallies for that time differ substantially. A serious investigation is needed.

What China told the WHO team

in early 2021:

174 total covid cases in Dec. 2019

What three peer-reviewed Chinese

scientific papers tell us about cases

recorded as of February 2020:

Between 73 and 86 more cases

than the count given to WHO

Between 247

and 260 cases

in Dec. 2019

What South China Morning Post

reported March 13, 2020, based on

leaked Chinese government documents:

9 cases in November not mentioned

in the official count.

266 total

cases in

Nov. and Dec.

2019

83 more cases in December

than the count given to WHO

Sources: World Health Organization; Cao Wuchun, et al., International Journal of Environmental Research and Public Health, 2020; Yu Chuanhua, et al., Global Health Research and Policy, 2021; Josephine Ma, South China Morning Post, March 13, 2020; An Pan, Li Liu, Chaolong Wang, et al., JAMA, April 10, 2020; Gilles Demaneuf, DRASTIC.

THE WASHINGTON POST

The Wuhan early cases —

more questions than answers

An accurate account of 2019 covid cases could help establish the origin of the pandemic. But the tallies for that time differ substantially. A serious investigation is needed.

What China told the WHO team in early 2021:

174 total covid cases in Dec. 2019

What three peer-reviewed Chinese scientific

papers tell us about cases recorded

as of February 2020:

Between 73 and 86 more cases

than the count given to WHO

Between 247

and 260 cases

in Dec. 2019

What South China Morning Post reported

March 13, 2020, based on leaked

Chinese government documents:

9 cases in November not mentioned

in the official count.

266 total

cases in

Nov. and Dec.

2019

83 more cases in December

than the count given to WHO

Sources: World Health Organization; Cao Wuchun, et al., International Journal of Environmental Research and Public Health, 2020; Yu Chuanhua, et al., Global Health Research and Policy, 2021; Josephine Ma, South China Morning Post, March 13, 2020; An Pan, Li Liu, Chaolong Wang, et al., JAMA, April 10, 2020; Gilles Demaneuf, DRASTIC.

THE WASHINGTON POST

The Wuhan early cases — more questions than answers

An accurate account of 2019 covid cases could help establish the origin of the pandemic. But the tallies for that time differ substantially. A serious investigation is needed.

0

50

100

150

200

250

What China told the WHO team in early 2021:

Each square represents one covid case

174 total covid cases in Dec. 2019

What three peer-reviewed Chinese scientific papers

tell us about cases recorded as of February 2020:

Between 73 and 86 more cases

than the count given to WHO

Between 247

and 260 cases

in Dec. 2019

What South China Morning Post reported March 13, 2020,

based on leaked Chinese government documents:

9 cases in

November.

83 more cases in December

than the count given to WHO

266 total

cases in

Nov. and Dec.

2019

Sources: World Health Organization; Cao Wuchun, et al., International Journal of Environmental Research and Public Health, 2020; Yu Chuanhua, et al., Global Health Research and Policy, 2021; Josephine Ma, South China Morning Post, March 13, 2020; An Pan, Li Liu, Chaolong Wang, et al., JAMA, April 10, 2020; Gilles Demaneuf, DRASTIC.

THE WASHINGTON POST

The December mystery

In the autumn of 2019, there were many signals that something unusual was happening in Wuhan, a city of more than 11 million people. Russell J. Westergard, the deputy consular chief at the U.S. Consulate there, later wrote that, by mid-October, the consulate team was aware of “an unusually vicious flu season.” Medical records show influenza-like illness, a measure of patients with respiratory ailment, soared late in November and in December in Wuhan at a rate higher than previous winter surges. The National Center for Medical Intelligence, a U.S. intelligence-gathering outfit that keeps watch for unusual health events that could affect the military, also registered signs of unusual illnesses at the time.

Officially, the first case was someone who fell ill on either Dec. 10 or 11, though it has been difficult to establish. When sick patients first appeared, health-care workers might not have been able to distinguish their ailment from a bad seasonal flu. Later, doctors wrote “pneumonia of unknown etiology,” or origin, on patient records. At the same time, the doctors and nurses were aware that a new SARS (severe acute respiratory syndrome) outbreak would mean trouble. A previous one in 2002-2003 sickened 8,098 people, killed 774 and made SARS a synonym for fear, something to watch out for.

Josephine Ma, the China news editor of the South China Morning Post, in Hong Kong, reported later that the first patient was a 55-year-old who fell ill on Nov. 17, 2019. Eight more people, from 39 to 79 years old, got sick later in November. Quoting leaked government documents, Ms. Ma found 27 infections by Dec. 15, and 60 by Dec. 20. The total number of cases — mostly retrospectively confirmed either by laboratory tests or clinical diagnosis — had risen to 266 by Dec. 31, including the nine November patients. Her report was published March 13, 2020.

Read the DRASTIC report on Wuhan's early cases here.

The research group DRASTIC, which has been probing the origins of the virus, has now found evidence that Ms. Ma’s report was right on target. The researchers have determined that by the end of February 2020, China had identified as many as 260 cases from the previous December. Yet China reported to the World Health Organization a year later — in early 2021 — that there were only 174 cases that December. This raises important and still unanswered questions: Who were these early cases? How did they get sick? Why were they not reported to the WHO?

The January silence

The Wuhan Municipal Health Commission issued an “urgent notice” to health institutions to look out for cases of “pneumonia of unknown origin” at 3:10 p.m. on Dec. 30. Then, at 6:50 p.m., came a second notice, warning “not to disclose information to the public without authorization.” That evening, ophthalmologist Li Wenliang, a physician at Wuhan Central Hospital, wrote in a private Weibo chat group that seven people had contracted a virus like the one that causes SARS and were quarantined at his hospital. He and other doctors were summoned by police on Jan. 1 and reprimanded for spreading rumors about SARS-like cases appearing in Wuhan hospitals. Li later died of covid-19.

On Dec. 31, the Wuhan health commission issued its first public bulletin. It reported 27 cases of “pneumonia of unknown origin.” On Jan. 3, 2020, the commission issued a second bulletin, with 44 confirmed cases. On Jan. 4, the National Health Commission demanded laboratories and others not release any information about the illness to any media, or post it on social media. On Jan. 5, the Wuhan commission reported 59 cases, but claimed that there was no sign of human-to-human transmission and that no health-care workers had been infected.

In late December and early January, Chinese scientists identified and verified the virus as a SARS-type through genomic sequencing. This raised a red flag: It had strong potential for human-to-human transmission. But they did not warn the public. On Jan. 11, the Wuhan health commission issued a fourth bulletin, revising the total cases downward to 41, and declaring — once again — that “no clear evidence of human-to-human transmission” had been found.

The Huanan Seafood Market, considered a possible source of the virus, had been closed and cleaned on Jan. 1, but that did not stop the spread. Instead, it was exploding.

After the SARS disaster of 2003, China had invested in building the National Notifiable Disease Reporting System for tracking infectious diseases. Supposedly, it would provide a very quick detection of outbreaks. But in Wuhan, it failed. Many front-line doctors were not aware of it, confused about how to report an infection of unknown nature, deterred by procedures, and fearful of making a mistake and being blamed for falsely reporting a new type of infection. As a result, according to journalists from the magazine Caixin, most medical reports were passed verbally, by mail and by phone for the first 28 days and thus were not entered into the system that was supposed to track them.

The annual political meetings in Hubei province and in Wuhan were held from Jan. 6 to Jan. 17. The government did not disclose any new cases to the public. Chinese authorities covered up the truth rather than reveal it — the trademark of an authoritarian, secretive system that prizes political stability at any cost. But privately, on Jan. 14, the head of the National Health Commission admitted to provincial officials in a teleconference that the situation is “severe and complex, the most severe challenge since SARS in 2003,” according to a memo obtained by the Associated Press.

Not until Jan. 20, three weeks after the Huanan market had been closed, and amid a rapidly expanding caseload, did Chinese experts appear on television and acknowledge the seriousness of the human-to-human transmission. On Jan. 23, China locked down Wuhan.

But it was too late.

Gag orders

China’s Center for Disease Control and Prevention (CDC), which reports to the National Health Commission, lacks clout, unable by law to publish epidemic data, or declare an epidemic on its own. It acts as a consultant to the health commissions, which are political and have decision-making authority.

But experts at the CDC did want to understand the outbreak, and that required accurate data. Starting on Feb. 6, the agency intensified its work to identify cases, including tracking retrospective ones by using hospital medical records. A leader in this effort was Yu Chuanhua, a professor of epidemiology and health statistics at Wuhan University, and a prominent scientist in his field. As he and his team examined cases, working with the CDC, the totals for December grew quickly. On Feb. 17, the CDC published a revelatory official bulletin for December, which showed 104 cases confirmed by laboratory test, 37 of them clinically diagnosed. This was a drastically different picture from the 27 cases the government had first reported to the public for that month.

But in making its report, the CDC likely overstepped its authority. On Feb. 25, the National Health Commission imposed a gag order on the CDC, demanding that it not publish papers “until the epidemic is under control,” that it must get approval from above for any new research, and no one in the CDC could share information about the epidemic, or samples. On March 3, a much wider, confidential notice was issued by the State Council — a gag order on all research and data in China on the pandemic.

The WHO probe

About a year later, in early 2021, another attempt to answer questions about the origins of the pandemic got underway. From Jan. 14 to Feb. 10, a joint mission of 17 Chinese scientists and 17 from other countries and the World Health Organization met in Wuhan. Within the overall mission, a smaller working group on epidemiology studied the vital question of early cases. As part of this exercise, Chinese scientists reported to the WHO team that 174 December cases were found in the National Notifiable Disease Reporting System. These were cases of patients who had been hospitalized. Of them, 100 were confirmed by laboratory testing and 74 by clinical diagnosis.

Some of those infected had contact with the seafood market in Wuhan, some did not, and some had contact with other markets. The WHO report said “no firm conclusion” could be drawn yet about the seafood market, which sold live animals and frozen meat, among other products.

The WHO team, led by food safety expert Peter Ben Embarek, wanted to know: Were there any earlier cases, say in October or November, that might offer clues to how the pandemic began? In response, the Chinese scientists conducted a search of 233 health institutions in Wuhan, examining 76,253 records of respiratory conditions in the fall of 2019. Only 92 cases were considered possible, but all were excluded after review by the Chinese experts or retrospective testing. The Chinese apparently did not provide original raw data, methods or any independent means for corroboration by the WHO team of these results. The final report concluded that “it is considered unlikely that any substantial transmission” was occurring in October and November.

The joint mission was contentious. Dr. Embarek later said that China had brought heavy pressure on the researchers to not make any mention of a possible laboratory leak as the origin. Eventually, Chinese scientists relented to a statement that such a leak was “extremely unlikely.” But they had provided the visiting WHO team no way to verify such a conclusion. Dr. Embarek also said, after leaving China, that the virus “was circulating widely in Wuhan in December,” suggesting the official 174 cases were only the tip of the iceberg and the virus could have infected 1,000 or more people that month.

Who were the additional cases?

Despite the gag orders, Dr. Yu and another leading Chinese scientist, Cao Wuchun, had access to the official CDC database. Dr. Cao is a colonel in the People’s Liberation Army who studied abroad and has many connections in the international community. He was responsible for preparing what is now the official record of the 2003 SARS outbreak. Surprisingly, both scientists published papers on pandemic epidemiology that are revelatory. Dr. Yu’s paper appeared in Global Health Research and Policy in May 2021. Dr. Cao’s report in the International Journal of Environmental Research and Public Health came out in September 2020. A third paper, by scientists from Harvard University, Huazhong University in Wuhan and Fudan University in Shanghai, provided additional details from the CDC database. It was published in the Journal of the American Medical Association in April 2020. All three papers were peer-reviewed.

The papers show that there were between 247 and 260 cases in the official CDC database for that troubled December, far more than China admitted at the outset of the pandemic, and more than the WHO was told a year later. According to the research group DRASTIC, the exact total was probably near the top of that range. The cases had reached that total in the CDC database as of the end of February 2020. This also dovetails with what Ms. Ma reported in the South China Morning Post on March 13. In the end, 33 people who fell ill in December eventually died.

The research group says the Chinese papers and other materials show the larger total includes at least 165 cases that were laboratory-confirmed, ruling out any question of validity. That compares with 100 such cases reported to the WHO. Who were these additional cases? Where? And what about November cases? The papers from the Chinese scientists do not provide answers to these questions, which might help determine how the pandemic began.

Finding an ‘epicenter’

Scientists continue to focus on the early cases, even without cooperation from China. Michael Worobey of the University of Arizona, Kristian Andersen of the Scripps Research Institute and others took the 174 cases from the WHO-China joint mission and plotted the residential location for 155 of them using maps in the WHO report.

In a paper published in Science magazine in July, they and their co-writers argued that the December cases were “geographically centered” on the Huanan Seafood Market, which they call the “epicenter” of the outbreak. They argue that a zoonotic spillover from wildlife happened there. Dr. Worobey has stated that a zoonotic spillover is the only plausible scenario for the origin of the pandemic, based on his research. We asked Dr. Worobey whether additional cases could change his conclusion. “With any kind of situation like a SARS-CoV-2 virus that can cause mild or even asymptomatic infection, you’re always taking a sample,” he said. “There’s probably at least 10 times more cases that we haven’t sampled because only something like 6 percent end up in the hospital. We fully expect the cases that we don’t sample to come from exactly the same geographic distribution as the ones that we do sample.”

What if, as the Chinese scientists revealed, there were far more confirmed December cases than in the WHO report? What about the nine in November, as the leak published by Ms. Ma disclosed? The additional cases could affect the scenario of how the outbreak began, and the timing. The seafood market might have been the point of a zoonotic spillover, but it might also have been the scene of a superspreader event. The incomplete data from China is a serious obstacle for anyone trying to reach a firm conclusion about how the outbreak began.

It is critical to gain a better understanding of how such a monumental disaster for mankind came about. A serious investigation must return to China, looking at both the zoonotic and research-related hypotheses. It must be thorough and credible, carried out with broad expertise that includes both scientists and public health experts from within China and beyond. Nothing should be off limits or excluded.

A major lesson of the pandemic is that disease surveillance — early warning systems — is crucial. Surveillance can give a leg up on mitigating disease spread, track the path and makeup of transmission in the population, and help vaccine and therapeutic researchers start to develop countermeasures. But as China discovered, the window for early warning might be short, and spotting an illness can be especially difficult if the pathogen has never been seen before. If the origins of the pandemic are found, it would give the world a head start in looking for the next one. China’s vaunted electronic notification system didn’t start working for nearly a month while the virus was rapidly spreading. That was a failure, in part, of the Chinese political system, which created a series of roadblocks, starting at the local level and later imposed at the national level. But it also is a failure that could be avoided anywhere with well-designed disease surveillance, especially taking advantage of the great advances in genomics.

Secrecy led to fatal consequences in the pandemic. The world owes those who have died — 6 million people by official count, but probably twice that or more — to be better prepared in the future. The coverup is immense and still in place. China should now agree to a full and thorough scientific investigation that returns to Wuhan. This black box needs to be opened.

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