As I started writing this essay, the WHO had just officially named the novel coronavirus “severe acute respiratory syndrome coronavirus” (SARS-COV-2) and the illness caused by it “coronavirus disease 2019” (COVID19). Outside of WHO’s conference room, China has confirmed 74,683 cases and 2123 deaths. Published in early February, Xuefei Ren’s Urban Now essay on the IJURR website argued that the local government’s attempts to seek approval from the central government meant that they missed the window to control the epidemic. Explaining the outbreak through a binary model that suggests clear boundaries between central and local government, or between the authorities and the public, fails to capture a more nuanced reality, in which a multi-level network of agencies cooperated to understand the emergence of a new virus and designed strategies as their knowledge grew. The learning process of this complex network can help us understand the operation of the Chinese state and offer valuable lessons for other cities regarding how to face the virus’s challenge.
Medical staff in Urumqi, Xinjiang, China during the COVID19 outbreak. Photo: January 2020, Gangstontech/Wikimedia Commons, CC BY-SA 4.0.
To me, writing from the perspective of an urban planner with professional experience working with Chinese officials at different levels of government, and currently a graduate student at a US university, this outbreak does not necessarily indicate a typically Chinese problem, as many Western media have suggested, and Ren’s article also implies. Rather, it highlights how vulnerable all cities are when faced with an unknown virus. The increasing density of, and accelerating connectivity between, cities have created improved conditions for viruses to spread quickly. The next epidemic can happen at any time and at any place. In December 2002, SARS, a more lethal and transmissible virus compared with SARS-COV-2, began to affect China. During the eight-month outbreak, it infected 5,327 people and killed 349 people in China. Compared to 17 years ago, Chinese cities have developed significantly and SARS-COV-2, a “weaker” virus, infected more than 4,000 people in just 7 weeks solely in Wuhan, according to estimates by Imperial College London researchers.
The specific nature of the virus means it is hard to diagnose and control COVID19. The latest research conducted by Nanshan Zhong’s research team revealed that COVID19’s latency period is up to three weeks, during which patients show no symptoms but the coronavirus is transmissible to other humans (Guan et al 2020; State Council Press Conference 2020). As Liming Wang (2020a), a Zhejiang University professor, wrote, “It is like an enhanced flu with a much higher fatality rate and much greater transmissibility, and most infected people display minor or no symptoms.” Sometimes, however, symptoms can become severe within a few hours and the virus can be fatal (Huang 2020). Also, the best diagnostic method for COVID19, the nucleic acid test, has an accuracy of no more than 50% and a high cost, which may be unaffordable for many (public) health care systems (Bai 2020).
Thus, by the time the coronavirus was identified, there was already an outbreak. Hospital resources were completely overstretched, even after local authorities built two new hospitals with 2,400 beds in 10 days, and maintaining sufficient stock and production of sanitary appliances proved a mission impossible. The Chinese gauze mask industry produces 20 million masks per day, which accounts for 50% of global production, according to officials in the Ministry of Industry and Information Technology, numbers that would be insufficient for even one day of use by all of Shanghai’s residents (Central Commission for Discipline Inspection 2020).
The speed of misinformation spreading via social media also overwhelmed the city. Feeding off the social panic and anxiety, rumors began to spread rapidly. A typical rumor circulates through screenshots of conversations with a person who allegedly has direct information about how severe the situation is, for instance how many dead bodies are being left in hospital hallways. In addition, many “informal” explanations of the epidemic circulated via social media, reflecting the difficulty of interpreting professional epidemic terms. For instance, many people responded to the “onset date” noted in a journal article written by Chinese researchers, interpreting this term to mean that COVID19 was first diagnosed on December 1. However, as the article’s authors explained in the media that their article is a retrospective review, the onset date is deduced on the basis of later research. The prevalence of rumors and “informal” information reflected and increased public distrust.
Could this outbreak have been prevented? Looking at past experiences, could we have done better? How did SARS-COV-2 penetrate China’s disease prevention system, which was reformed in 2004 after the outbreak of SARS? The new system provides concrete directives to doctors, disease prevention institutes, and governments to manage known and unknown diseases. It proved successful in controlled SARS’ reemergence in 2004, H7N9 in 2013, and the plague in 2019, all at their initial stage.
The authorities failed to effectively communicate the severity of this new epidemic to the public. Professor Yi Guan from Hongkong University visited Wuhan on January 22, when the situation had become severe, and evaluated Wuhan as an “unprepared city.” Information about COVID19 was actually released in a timely fashion; however, the form of communication was not effective. On December 30, 2019, as soon as the disease prevention system started to respond, its working documents were informally disseminated through the internet, published by unknown sources. In response to calls from journalists, the Wuhan Municipal Health Commission confirmed the documents’ authenticity a few hours before its own public announcement, on December 31, that 27 cases of a new unknown-cause pneumonia had been discovered in Wuhan. Hundreds of media outlets reported this, including those media controlled by the state, such as CCTV. In the period that followed, the Wuhan Municipal Health Commission (2019-2020) updated its information on the disease on a daily basis and advised residents to wear masks in public areas. Unfortunately, few Chinese people paid attention to these announcements. It could be due to the limited information these announcements provided, mostly limited to the latest number of confirmed COVID19 cases. Its slow increase, from 27 cases on December 31 to 45 cases on January 16, suggested to the public that the epidemic had been controlled.
Treating thousands of flu and fever patients every day, doctors working in local clinics were not aware of the emergence of a new epidemic with symptoms of pneumonia of unknown causes. While scholars have deduced the onset date of the first COVID19 case in Wuhan to be December 1, no case was reported to the Chinese Center for Disease Control and Prevention (CDC) until December 27, when doctor Jixian Zhang received four patients with identical pneumonia symptoms. Since many pathogens can result in pneumonia and confirming the cause depends on the result of sputum culture, which is time-consuming and unpredictable, clinic doctors usually do not consider a case of pneumonia of unknown cause to be a signal of an epidemic, unless they have information that two or more patients with identical symptoms have epidemiological correlations. For instance, a couple with the same pneumonia signals they have been affected by a virus. As CDC is the city-level information coordination hub, many hospitals did not know they were receiving patients with epidemic until December 30, when the Wuhan Municipal Health Commission noted 27 similar pneumonia of unknown cause patients in different hospitals.
China’s disease prevention system may have been too rigid and conservative in approaching the new virus. When cases were reported to CDC, the disease prevention system followed its routine course. A multidimensional network was established, including universities, research institutes (branches of the Chinese Academy), health commissions (a government sector at all jurisdiction levels), and CDCs (health consultant institutes directed by health commissions at different levels), which asked hospitals to report similar cases (Wuhan Municipal Health Commission 2019). Their investigations produced 9 papers published in The Lancet, NEJM, and Nature, as well as 43 publications on preprint servers. It is understandable that research on a new virus requires time. The expert network had about a ten-day lag in moving from a scientific hypothesis to reaching a scientific conclusion, both in identifying the SARS-COV-2 virus and confirming its “human-to-human transmission” capacity (L.M. Wang 2020b). However, these lags ended up incorrectly reassuring clinic doctors and the public. As 26 of the first 27 COVID19 cases were connected to the local Huanan Market, the expert network first set contact with the market as an important diagnostic criterion, assuming that the virus was only transmitted through specific animals to humans (China Youth Daily 2020). Thus, from December 31 to January 16, before test kits were sent to Wuhan and as SARS-COV-2 quickly spread among Wuhan residents, only 18 additional cases were confirmed. Meanwhile, the network sent very limited information to the public, so that most people only became aware of the growing epidemic on January 20, after Nanshan Zhong declared that the virus had a “human-to-human transmission” character.
Local and national decision-makers translated scientific conclusions into policies efficiently. But perhaps these policies were not sufficient. On January 1, the expert group wrote a working plan for epidemic prevention. One of the recommendations was to close the Huanan Market to cut off the infection source. A few hours after this recommendation was developed (X.D. Wang 2020), at 7 am in the morning, officials from several local government branches worked together, closing the market and disinfecting the whole area (Beijing News 2020). CDC sent an expert group to Wuhan directly after it received a report from Professor Guoyong Yuan that pointed to the SARS-COV-2’s “human-to-human transmission” ability. On January 20, based on collected evidence, this expert group confirmed Yuan’s finding and advised that people “should not go to Wuhan or leave Wuhan.” On the same day, the national leader Jinping Xi asked the party and government to control the epidemic. The National Health Commission (2020) along with the State Council entered SARS-COV-2 into the classification system of the Chinese disease catalogue. The professional classification supported local governments’ later strategies, as Chinese Infectious Diseases Prevention Law authorizes and advises cities to adopt specific policies for controlling any disease within the catalogue. Two days later, the Wuhan authorities decided to shut down its city.
“China is actually setting a new standard for outbreak response. It’s not an exaggeration”, according to Dr. Tedros Adhanom Ghebreyesus, Director-General of the WHO. This world standard, however, remains insufficient. The response has not been able to prevent the country’s dysfunction for over one month already. Perhaps if citizens had more knowledge about science and the operation of Chinese institutions they might be more vigilant in responding to public health information on epidemics. If clinic doctors had real-time information about what symptoms patients in other hospitals had, they could react more rapidly to the abnormal number of unknown-cause pneumonia. If the expert network could be expanded to a global scale, perhaps it could comprehend a virus’s character more quickly. If policy-makers had a forward-looking strategy and took actions in advance of the scientific review in order to prevent the worst-case scenario, the current epidemic in China might have been controlled more swiftly and effectively.
Finally, as a junior urban scholar, it strikes me that the role of geographers and planners has been primarily that of audiences during this outbreak. Various Chinese urban scholars expressed disappointment about their limited ability to make contributions to this war against the coronavirus, while witnessing how other professionals are more actively involved. To me, the epidemic also raises questions about how urban scholars could position ourselves in an epidemic. Urban planners, who have long been positioned to deal with uncertainty and to mediate between authorities and publics, might be well positioned to work with other stakeholders on an epidemic-response system that builds a collaborative framework among different sectors, smooths the information flow between experts and people, and helps city governments to deal with uncertain development of the outbreak.
Ming Hang is a Master student at the Department of Urban and Regional Planning, University of Illinois Urbana-Champaign, with an academic interest in urban economic development theory and practice.
References
Bai, Y.S. (2020) Interview with Chen Wang [interview]. CCTV, February 5. In Chinese.
Beijing News (2020) The Huanan Seafood Market in the event of unknown-cause pneumonia. January 2. In Chinese.
Central Commission for Discipline Inspection (2020) Hard to buy a Mask? MIIT just responded. January 29. In Chinese.
China Youth Daily (2020) The changing COVID19 diagnostic criteria: Initial criteria were too strict and doctors were criticized for over reporting cases. February 20. In Chinese.
Guan, W. J., et al. (2020) Clinical characteristics of 2019 novel coronavirus infection in China. medRxiv.
Huang, Q.J. (2020) Condition worsened immediately, not just Dr. Wenliang Li. The Paper, February 11. In Chinese.
National Health Commission (2020) Announcement. January 20. In Chinese.
State Council Press Conference (2020) Xiaowei Ma’s Speech. January 26. In Chinese.
Wang, L.M. (2020a) To prevent COVID19, may need to consider the “new trend”. In Chinese.
Wang, L.M. (2020b) Tracing the development of the outbreak, where could be improved. Sina Technology. In Chinese.
Wang, X.D. (2020) Good news, research on SARS-COV-2 has made progress. China Daily, January 26. In Chinese.
Wuhan Municipal Health Commission (2019) The announcement about the pneumonia disease in our city. December 31. In Chinese.
Wuhan Municipal Health Commission (2019-2020) Information Disclosure and Announcement. December 31, 2019 through January 21, 2020. In Chinese.