Dali Yang Explains the Dynamics of the Chinese Response to Covid-19 in Wuhan

FISC: How did you approach researching this topic, and what are the bottom-line findings that you want people to take away from the book? 

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Yang: I happened to be in Beijing in 2003 during SARS, and I also have studied public health issues, so in the beginning of the Covid-19 outbreak, I felt compelled to follow it. I commentated publicly in the early days of the outbreak to try to help my readers understand what was happening in Wuhan. In the process it very quickly became a mission for me to try to make a contribution to understanding what happened in this global event. 

 

My bottom-line question was, given that China had extraordinarily strong capabilities to deal with this outbreak, how could this misjudgment have happened? Following the SARS outbreak in 2003, China had introduced a number of changes, including instituting a nationwide disease reporting system that was designed to overcome some of the deficiencies that became apparent in 2003. It had successfully contained an avian influenza outbreak called H7N9 in the 2010s, and science like genomic sequencing and so on had progressed. China had a lot of scientists and laboratories and was working on cutting-edge research related to coronaviruses and other respiratory pathogens. You would think that if there was anywhere you didn’t have to worry about this sort of crisis, it would be Wuhan, because it’s the location of a top biosafety lab and experts on coronaviruses. And yet with all these capabilities and all the preparations, three weeks elapsed before it was announced that there was human-to-human transmission of the novel coronavirus (SARS-Cov-2). 

 

How much better could China have done? This book is an invitation not just to discuss and think about what could have happened in Wuhan, but also to think about this globally. There are many coronaviruses and other pathogens still lurking around the world. If we want to avoid or prevent these kinds of events from happening again and again, there needs to be a global effort, not just in China, to improve monitoring and surveillance and to make sure that decisive action will be taken to contain newer outbreaks.

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02   Consequences of Fragmented Authoritarianism 

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FISC: For the benefit of people who haven’t read the book, could you talk about fragmented authoritarianism and the role that you argued it played in this crisis? It’s not the only factor that you said impacted the Chinese government’s botched response, but it is something you placed a good deal of emphasis on.

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Yang: That’s an important point. Typically, the press and casual observers of China tend to give a sense that the Chinese system of governance is a monolithic edifice under the command of Xi Jinping. In fact, scholars of China have emphasized over time how the system is subject to all sorts of fissures. 

 

To give one example, I mentioned in the book that there is a distinction between the China CDC and the Chinese CDC system. The Chinese system for the CDC comprises not only the national China CDC based in Beijing but also provincial, municipal, district, and county CDCs. Every one of those subnational CDCs belongs to a health commission, in the province, city, district or county. They do not directly report to the China CDC administratively. Following SARS, the China CDC promoted a nationwide disease reporting system in the hope that it could enable clinicians and local hospitals to report cases directly to Beijing rather than going through the health commissions. in reality, that did not happen, and power therefore is not concentrated with the national CDC. 

 

As a result of this fragmentation of authority, the Director-General of the China CDC did not hear reports of an outbreak in December 2019 directly from Hubei province or Wuhan municipality at first; he found out from social media. That’s an illustration of the kind of fragmentation whereby information did not directly flow to Beijing. This whole edifice that seems to be so impressive was compromised by such fragmentation. Those kinds of tensions and fissures in the system  undermined a lot of the outbreak response as well. Of course, it’s only one aspect of the Chinese system, but it’s a very important dimension.

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03   Obstacles to Sourcing?

 

FISC: Not doubting that there was a lot of this obfuscation and that many of these problems flowed from fragmented authoritarianism, is there an issue with finding reliable sources on what the central government was doing at this time and what it knew or did not know? I felt like the book had more information on what went on in Wuhan than what went on with decision makers in Beijing, perhaps in part because the political and media apparatus in China has of course given prominence to the missteps and culpability of local officials rather than the central government.

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Yang: That’s a great question. It’s a very significant methodological issue that you’re touching on, and I’m really glad you are putting it up front.

 

In the book, and especially in the concluding chapter, I actually discussed the issue, because you may recall there was a serious and public confrontation between the National Health Commission, which is part of the State Council (the national government), and the Hubei and Wuhan municipal officials. In the very beginning, the NHC publicly stated that management of disease outbreaks is primarily a local responsibility under the principle of territorial responsibility, but of course once the NHC people were in Wuhan, city and provincial officials started to say, this is a national issue. I also document in the book that the early public press announcements from Wuhan were vetted by the NHC. So I do provide evidence of central involvement, and I reveal a variety of things that people don’t generally recognize.

 

The second aspect, as you mentioned, is the sources. What’s remarkable about a major event like this is that there were many courageous reporters who did a lot of the reporting. Because of the vast number of sources of information, not only from published sources but interviews I did and so on, I don’t feel like there’s a significant bias in terms of sources in this case. Would I like to know more about what the health commission people were doing in Wuhan, in Hubei? Absolutely. It’s regrettable that I don’t have more information about what they thought, and what they said in public is fairly limited, so it may take time for some of that information to come out. But I do document a lot of the actions that emanated from their decisions. 

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04   Non-Transparency on Central Decision-Making

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FISC: To be clear, there was a lot of great information in the book about the leaders of central public health organs like the China CDC and NHC, so I was thinking more about the availability of sources on political decision makers, not just the public health apparatus. Xi Jinping barely makes an appearance for large stretches of the book, for example; it wasn’t until January 7 that he made subsequently reported comments on epidemic control work at a Politburo Standing Committee meeting, and then there was another long gap before he issued nationally reported epidemic instructions on January 20. A lot of the information in the book about the words and actions of political leaders came from official sources, and I got the sense that there is no real way to get the inside story on central deliberations at this point, given the lack of transparency.

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Yang: It just happened that for the major part of the period, this was considered to be a local issue for Wuhan/Hubei by the national health authority. I know quite well to what extent the national leaders were involved. They were not involved heavily. In fact, a big part of the problem was that the leaders of Wuhan and the leaders of Hubei were involved in their own municipal and provincial people’s congress meetings, so part of the problem was that they didn’t want to be bothered. For much of that period, national leaders got the sense that things were under control, and you can imagine their frustration later.

 

Dealing with infectious diseases is a very professional task. There are many layers of information. That information got to the very top very early, on December 31, 2019 but at the same time, we would not expect Xi or the premier to rush to Wuhan, right? That’s what the experts are trained for. 

 

But at the same time, all those experts had to operate in a political environment. I discuss in great detail the deliberate actions, such as censorship, and the incentives issues in organizations such as hospitals and local governments that caused multiple channels of information to be blocked. 

 

And it’s not just a local issue; it includes not only the Wuhan and Hubei provincial authorities, but also the NHC, which made certain decisions about lab regulation and so on. It’s not always that they simply wanted control for control’s sake; in the case of the NHC and China CDC, they had certain priors that led them to make certain decisions about the pathogen verification process that they thought were needed, and sadly these decisions caused delays. 

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05   Origins of SARS-CoV-2

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FISC: The book didn’t draw conclusions about whether the virus started at Huanan seafood market or whether it has a zoonotic origin. Did you omit mention of the laboratory leak hypothesis because you don’t consider it to be the likeliest explanation, or did you simply think that the question of the origin of the virus itself was beyond the scope of the study?

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Yang: It’s more the latter. I do mention that as I wrapped up the book for publication, I was aware of the intense debate about the origins of the virus. I bracketed the issue, because I’m keenly aware that virologists and many others have been intensely debating this issue over the last few years.

 

As far as my research is concerned, it is what the decision-makers thought at that point that matters, and this is where I put a lot of effort in trying to understand the lenses through which the leading epidemiologists and health policymakers in China viewed this issue. Their decisions were based on the zoonosis hypothesis partly because of their prior experience with SARS. In the early days, a zoonotic origin was the only thought, and it accounted for decisions like the channeling of resources to sampling the Huanan seafood market when some of that testing capability should have been deployed for other purposes, including testing people who had symptoms but not exposure to the Huanan seafood market. It also relates to the decision to define the case to include exposure to the Huanan seafood market, which was a big error. And the errors were compounded in this process. 

 

A big part of my argument is that on December 31, 2019, the decision-makers had a lot of information about symptoms, the number of patients, the novel coronavirus sequences, and so on, so there was the possibility of a different set of procedures and actions being adopted regardless of where the virus came from. My argument is that the decision-making could have been different, and it could have made a big difference to the course of the epidemic in Wuhan and the pandemic globally.

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06   Willful Blindness?

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FISC: There were many passages in the book that impressed upon me that China’s central public health leadership was drawing conclusions that were extremely scientifically dubious on the basis of the information that they had. You described how when outside experts from Hong Kong and Taiwan went to Wuhan and spoke to local health officials with national health officials also present in the room, even though these experts were given very limited information, it was clear to them that there was human-to-human transmission and that the situation was much more serious than they were being told. At another point in the book, you said, “Unless there is reason to accuse the China CDC leadership of willful blindness, it seems that the most plausible explanation for their failure to review the pre-January 3 data and recognize community spread is that they were influenced by a powerful cognitive framework that prevented them from seeing what was essentially right in front of them.” Would it be unfair to posit that the China CDC leadership did in fact exhibit willful blindness, considering the obviousness of the situation and their political incentives at that time to downplay issues?

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Yang: That’s a fair question, and I think you’re absolutely welcome to ask that. But the point is, they were waiting in Beijing for new cases to be submitted. China CDC Director General Gao Fu consistently emphasized over the years the importance of evidence. If there was new evidence, he would be open to new possibilities. And of course the prior that he had was also that there would be some sort of human-to-human transmission, but of course that also meant that having limited human-to-human transmission was no surprise to him. 

 

A lot of this actually relates to the issue of the language. For the public, having human-to-human transmission was the litmus test. For the experts, it’s not. They assumed there was some human-to-human transmission. What was really at stake was the severity or efficiency of the transmission. So based on what I can see at this point, I think it doesn’t appear to be willful blindness. It’s simply that they thought things were under control, and they went coasting in a way.

 

Given China’s SARS experience, they did take the outbreak very seriously, so the first thing the book does is disabuse people of the impression that the Chinese government didn’t pay attention initially. They did. At the end of December 2019, they adopted an action program for a health emergency response. But then they thought things got under control. Part of that is because they had assumptions, they had a set of lenses through which they viewed the situation, and in the meantime new information got bottled up in the sprawling system. This is how the fragmentation of the Chinese administrative and political system hampered and undermined the response in the end and turned what might have been a containable outbreak into something much bigger.

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07   Could the Pandemic Have Been Prevented?

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FISC: One of the most striking parts of the book for me, which you just touched on, is that you considered it a reasonable hypothesis that if the Chinese officials and media and the whole system had been more transparent, this outbreak may have been contained. 

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Yang: We know that Chinese journalists were waiting to report and were in Wuhan on December 31, as soon as the outbreak became known. We also know that Chinese doctors were willing to speak, but they were cracked down on. We know that the labs had the information and some of them even submitted internal reports in the process. China is also one of the countries that had searing memories of SARS. It had a public that was willing to respond. If you tell the Chinese people to put on facemasks, they are going to do it if they were told of the SARS-like coronavirus. But instead, between December 31 and January 20, a lot of time was wasted not communicating the risks to the public. 

 

If China had a much more transparent system, it would not have been December 30 that Dr. Gao Fu learned of the pneumonia outbreak. It would have been earlier. How much earlier, we don’t exactly know, but I would argue that a week would be possible. That would bring us to December 23 or so, when there were quite a number of cases already available at that point. It could be even earlier, potentially, given the testing capabilities and so on, because there were rumors of cases already in mid-December 2019. Dr. Zhong Nanshan jointly published an article that indicated that even if the lockdown had happened just 5 days earlier, the number of cases would have been cut down dramatically, by 2/3 or so. The virus spreads exponentially when it’s unimpeded, so every day counts. If you can go back 3 or 4 weeks, then suddenly we are talking about a much more limited outbreak. 

 

I’m not saying that it’s an absolute conclusion that the pandemic could have been contained at the source, but I think given the magnitude of this global event, even a relatively modest chance is very significant and very important to know. 

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08   Final Takeaways

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FISC: Are there any final points you want people to take away from your book or this interview?

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Yang:  First, I have a set of interpretations based on a lot of evidence about how the Chinese system works, but of course I’m open to readers getting different takeaways from the book. 

 

Second, one of the big challenges going forward is the importance of intra-state issues. In discussing the pandemic accord at the WHA, it shouldn’t just be about countries. Whatever reforms are being done with regard to international cooperation need to be cognizant of the extremely complicated domestic context. Some countries have much better scientific capabilities, some do not, and there are administrative and other variations as well. I think I will leave it at that.