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A War Fought Once Before: China’s Response to Covid-19
By Yanzhong Huang, Samantha Kiernan

In late January 2020, China went to a full “people’s war,” led by Commander Xi Jinping. The fight, however, broke out not in the South China Sea, on the Korean Peninsula, or even along the Sino-Indian border. Rather, it began in the city of Wuhan in Hubei Province against a new but not totally unfamiliar enemy: a coronavirus.

 

The novel coronavirus, which causes the infectious disease Covid-19, emerged in Wuhan in late 2019. More than two dozen known patients in the city fell ill during December with a viral pneumonia of unknown origin. On Dec. 31, Hubei’s provincial health commission published an announcement regarding the outbreak, linking its origins to the Huanan Seafood Market. That same day, Chinese health authorities notified the World Health Organization (WHO) of the outbreak. Western news outlets rapidly began to speculate as to the origins, nature and epidemiology of this new virus, and many wondered if it was a reemergence of severe acute respiratory syndrome (SARS), a disease that the nation had battled 18 years earlier. Even in China, doctors at the front line believed the disease was linked to the SARS coronavirus. As gene sequencing soon revealed, however, it was a new type of coronavirus. As China prepared to fight this novel virus, the world wondered if this battle would be any different from the last.

 

China was widely criticized for its initial handling of the 2002-2003 SARS outbreak, including for misdiagnosing the disease as chlamydia, responding slowly, failing to co-operate with the WHO and repeatedly attempting to cover up the extent of the outbreak. China’s failures with SARS are often cited as one of the main causes for the international spread of the epidemic, which reached more than 25 countries, infected more than 8,000 people, and claimed nearly 800 lives.

 

Compared to SARS, the international feedback on China’s handling of the Covid-19 outbreak is dramatically different. By the end of January, China had received effusive praise from the highest level of the WHO. The international health agency repeatedly lauded its response to Covid-19 as a “new standard for outbreak response,” complimenting China’s commitment to transparency, international co-operation, and swift, decisive action. After visiting China to evaluate control and treatment measures in five Chinese cities including Wuhan, WHO experts hailed China’s efforts as “ambitious, agile, and aggressive” and credited the nation with changing “the course of a rapidly escalating and deadly epidemic.”

 

Is It Really Different This Time?

 

A deeper comparison between China’s response to Covid-19 and its actions against SARS raises several questions. What changed from 2002 to 2020 to transform China into the supposed epitome of public health response? Has China truly moved past its failures and missteps to become a model of transparency, co-operation, and efficiency? To what extent are the aggressive containment measures pursued by the Chinese government against Covid-19 different from those in the SARS outbreak? By many metrics, China’s response to Covid-19 seems to be both markedly different and improved over its response to SARS.

 

In China’s fight against SARS, the first known case of “atypical pneumonia” (feidian) appeared in Foshan city in Guangdong Province on Nov. 16, 2002. State news media denied reports of any outbreak, and even as provincial officials became aware of the outbreak, they did nothing more than offer a vague warning in late January. Many officials ignored that warning until after the end of Chinese New Year, allowing for the free movement of hundreds of millions of people throughout the country. Not until Feb. 7, 2003, more than 88 days after the first case appeared, did provincial officials even formally notify Beijing of the outbreak. Another four days would pass before China’s Ministry of Health finally notified WHO of a contagious disease that had already killed five people and infected 300. When informing the WHO, Chinese authorities assured the world that the outbreak was under control, and by late February announced that chlamydia bacteria was the etiological agent of the SARS outbreak.
 

However, China’s promises of control soon proved to be false. By April, there were significant SARS outbreaks in Hanoi, Hong Kong, Singapore, Taiwan, and Toronto, and the disease continued to spread throughout the world. Facing a rising international public health crisis, WHO issued a global alert and declared SARS a “worldwide health threat.” Yet, China continued to share little information, restricted WHO’s access to Guangdong and new outbreak sites in Beijing, and halted all provincial reporting on the disease. Rather than co-operate, officials turned inward, underreporting cases in Beijing and covering up the extent of the spread.

 

Only toward the end of April, after facing significant international pressure, did China finally begin to co-operate and implement stricter measures to respond to the outbreak. The central authorities mandated reporting of SARS cases and showed a new level of candor, with Premier Wen Jiabao admitting that the “overall situation remains grave” and that the highest levels of power were ready to fight an all-out war against the disease. Health Minister Zhang Wenkang and Beijing Mayor Meng Xuenong were ousted for the mismanagement of the crisis. These actions shook the complacency of government officials, who then abandoned their initial hesitation and jumped onto the anti-SARS bandwagon.

 

Driven by political zeal, they sealed off villages, apartment complexes and university campuses, quarantined tens of thousands of people and set up checkpoints to take temperatures. Approximately 30,000 Beijing residents were quarantined in their homes or designated sites. The Maoist “Patriotic Hygiene Campaign” was revitalized. In Guangdong, where 85 percent of the SARS cases were located, 80 million people were mobilized to clean houses and streets. In the countryside, virtually every village was on SARS alert, with roadside booths installed to examine all those who entered or left.
 

The direct involvement of the political leadership also increased program resources, helped ensure they were used for program purposes and mobilized resources from other systems. With $847 million funding from both central and subnational sources, free treatment was offered to SARS sufferers anywhere in the country. Within one week, a hospital that could accommodate 1,200 SARS patients was constructed and began to operate from May 1, 2003. The epidemic started to lose its momentum in late May. On June 24, the WHO lifted its advisory against travel to Beijing. On Aug. 16, with the last two SARS patients discharged from the Beijing Ditan Hospital, China was free from SARS.

 

Politics or Pathogens?
 

After SARS, China watchers and public health experts believed that China had become more transparent and co-operative in dealing with outbreaks, and it seemed unlikely that China would repeat the same mistakes it had made during the initial stage of its SARS response. The post-SARS era has seen the government invest tremendously in its public health surveillance and response capacities. In 2004, China launched the internet-based disease surveillance system, which allows grassroots healthcare workers to report potential disease outbreaks directly to China CDC. Ten years later, China announced that it had fulfilled more than 90 percent of the core competency requirements of International Health Regulations, compared with the global average of 70 percent. Indeed, as China grappled with the outbreak of Covid-19, the country’s growth in both technology and attitude seemed promising. Chinese scientists rapidly sequenced Covid-19’s genetic code and shared the information almost immediately with the international scientific community, facilitating the development of effective means (diagnostic kits, prototype vaccines) to combat the virus globally.

 

But until Jan. 20, 2020, the playbook China used to handle the Covid-19 outbreak was not fundamentally different than the one it used in 2003. In the early stages of the outbreak, local officials tried to cover it up, insisting the disease was “preventable and controllable” and punishing whistleblower doctors, including Dr. Li Wenliang, who raised the alarm over a series of SARS-like cases, accusing them of “rumor-mongering.” Despite the high transmissibility of the disease and evidence of community transmission, Wuhan’s health commission repeatedly insisted it saw no evidence of human-to-human transmission in the city.

 

Instead of responding effectively to the outbreak, local officials placed politics above pathogens. During the January “two sessions” (the People’s Congress and People’s Political Consultative Conference), the biggest annual political events in the province, there was a news blackout on the outbreak. Local authorities even held a banquet for over 40,000 families on January 20th, just days before the city submitted to total lockdown. When central authorities finally intervened three days later, the disease had already spread beyond Hubei and China.

 

Just as Chinese leaders did after mid-April 2003, President Xi responded to the severity of the outbreak after Jan. 20 by launching relentless and arguably draconian measures to contain the spread of the virus. But this time aggressive containment measures were implemented on a much larger scale and in a more aggressive manner than during SARS. On Jan. 23, Chinese authorities announced they would lock down Wuhan, the epicenter of the outbreak and a city of 11 million people. The government canceled planes and trains leaving the city and suspended municipal transportation services. Residents could not leave the city. Within two weeks, these city-wide quarantine measures extended to more than 50 million residents of Hubei Province as China faced what Vice Premier Sun Chunlan called “wartime conditions.” In less than one month, 760 million people, more than half of China’s population, faced municipal and residential lockdowns of varying strictness in an effort to contain the outbreak — a stark contrast to the quarantine efforts implemented during the SARS crisis. Moreover, in Wuhan, officials placed thousands of individuals — in one day alone more than 22,000 — deemed to be “high risk” into one of more than 500 quarantine centers across the city. Officials even extended Chinese New Year to help slow down the spread of the virus, despite the potential economic fallout.
 

These measures seem to have been effective in containing the further spread of Covid-19 within China. In hindsight, the inflection point was reached in late February in most parts of the country. Provinces other than Hubei began to see only single-digit or zero increase of confirmed cases from local transmission since the end of February. Even in Wuhan, the situation has become increasingly stabilized. On March 11, the city reported only eight new cases, a record low. As of March 10, 70 percent of the 80,000 people sickened by the virus had recovered and been discharged from hospitals. As a result, all of the 16 makeshift hospitals in Wuhan had closed before the middle of the month.
 

Economic Costs
 

The draconian measures are credited with bringing the crisis under control and buying the world time to prepare for the global spread of Covid-19, but they have also caused tremendous disruption to China’s economy and society. Their disregard for civil liberties and human rights notwithstanding, they dealt a severe blow to Chinese manufacturing and service sectors, disrupted the global supply chain and made it more likely for China to fall into the Middle Income Trap. Furthermore, they have generated many second-order problems, such as hindering access to healthcare and medicines for people suffering from other illnesses, such as AIDS and cancer. As Hubei’s healthcare system reoriented itself to fight Covid-19, other patients couldn’t receive both critical and elective care at hospitals, especially in Wuhan. Some were rejected outright due to fears of cross-infection; others simply could not find a hospital with the capacity to treat them. Among the most tragic of these spillover effects was the fate of a 17-year-old boy with cerebral palsy, Yan Cheng. After officials quarantined his family members and caregivers on suspicion of having coronavirus, he was left at home without regular care, food or company. Six days later, he passed away. His story, though deeply tragic, was not unique; it was a part of the human suffering and societal disruption caused by China’s response to the coronavirus.
 

While the making of this crisis clearly shows that the root cause of the problem is political, as in the SARS outbreak, Covid-19 has not created the same window for meaningful political change that SARS did. To the extent that SARS allowed President Hu Jintao, who had just assumed leadership in 2003, to strike a different note than his predecessors, Covid-19 has provided strong incentives for the leadership not to adapt and reform, but to defend and justify what they have pursued over the past eight years. So when Li Wenliang’s death triggered nationwide mourning and anger on Feb. 4, it did not force the party to examine and address public anger over its failures or suppression of information. Rather, his death only alerted leaders to the danger of encouraging more transparency or openness. Not surprisingly, Li’s death was immediately followed by a new round of crackdowns on Chinese social media and civil society. Central authorities detained critics and rights activists such as Xu Zhiyong, who criticized Xi’s handling of the outbreak. In the war against coronavirus, the party and its leaders have hardened their stances and methods, not softened or refined them. While certainly some of China’s response to Covid-19 deserves praise, its early mistakes should not be overlooked. The more than 4,000 deaths recorded, the well over 100 countries already affected, and the dying hope of containment are attributable not just to the disease but also to a governance failure. The parallels between China’s response to SARS and Covid-19 are clear. But to the extent that SARS prompted Chinese leaders to push for meaningful political change, Covid-19, in a strange twist of events, only reinforced the desire to sustain the existing political system. This grim truth does not bode well for addressing future outbreaks. 

Back to Issue
    As China got to contain the coronavirus outbreak that apparently began in a Wuhan wet market, the world was duly impressed. China was praised by the WHO for setting a ‘new standard’ in response. In contrast to the foot-dragging that Beijing was accused of in the SARS epidemic of 2002-2003, it seems China had learned its lesson. But has it? The early days were marked by some of the same reflexive cover-ups and media clampdowns that occurred during SARS. China should be praised for its aggressive response, write Yanzhong Huang and Samantha Kiernan, but its authoritarian governance continues to be at risk for placing ‘politics above pathogens.’
    Published: Mar 30, 2020
    About the author

    Yanzhong Huang is Senior Fellow for global health at the Council on Foreign Relations and a professor at Seton Hall University’s School of Diplomacy and International Relations.

    Samantha Kiernan is Research Associate on Global Health, Economics, and Development at the Council on Foreign Relations.

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