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Retired soldiers disinfect a community in Huaibei, China, on February 7, 2020.
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China hid the severity of its coronavirus outbreak and muzzled whistleblowers — because it can

The tricky business of disease diplomacy.

Nearly six weeks after China announced the coronavirus outbreak, there’s still a surprising amount we don’t know about this newly discovered disease. But one thing is becoming clear: China’s silence in the earliest days of the crisis may have made it worse.

Chinese authorities delayed informing the world about the severity of a deadly disease spreading within the country’s borders — even trying to muzzle whistleblowers, like the late Dr. Li Wenliang. Now hailed as a national hero, Li was forced on January 3 by police to sign a letter saying he spread “untrue speech” for warning colleagues about the virus that eventually took his life.

With more than 40,500 people infected and 910 deaths, China’s missteps early on seem increasingly fateful. The fact that the international community has not acknowledged those missteps is also consequential.

On Friday, President Trump applauded China. “They’re working really hard and I think they’re doing a very professional job,” Trump told ABC News. Meanwhile, the leading global health body, the World Health Organization, has stayed mum about China’s blunders — and is drawing criticism for failing to publicly criticize the country and creating “a false sense of security” about an emerging health crisis.

But the reality is this: China’s mishandling and the ensuing silence from the international community is emblematic of how the global system governing the international response to pandemics fails to work, half a dozen global health experts told Vox.

A woman cradles her dog, both wearing protective masks, on the streets of Beijing, China, on February 7, 2020.
Kevin Frayer/Getty Images

Though we have global health laws — in particular, the International Health Regulations, or IHR — meant to guide countries dealing with outbreaks, they’re not actually enforceable. “You can’t penalize [countries that] don’t follow it,” said Devi Sridhar, the chair in global public health at the University of Edinburgh. Instead, the international community has to rely on “soft law and norms” — or “disease diplomacy.”

This means that when a pandemic threat looms, the world has little recourse to punish those that fail to live up to the IHR for not detecting a public health problem, or hiding a crisis, even when that mishandling imperils the health of billions. And with just about every outbreak, history repeats.

“Our global outbreak response system depends on the full participation of all actors at all levels of government,” Steven Hoffman, director of the Global Strategy Lab and a professor of global health at York University, summed up. “But our system is only as strong as its weakest link.” Understanding the IHR, and how disease diplomacy is done today, helps explain why.

How China bungled its response to the new coronavirus outbreak

Before we get into the international response, here’s a quick recap of how China delayed reporting the crisis and employed cover-up measures to play down the threat of 2019-nCoV, as the virus is known.

On December 31, when China first announced the outbreak of a mysterious pneumonia, officials there emphasized a few things. Most of the patients had been to a food market in Wuhan, the city that’s still the epicenter of the outbreak. They said there was “no clear evidence” of human-to-human transmission, meaning the virus wasn’t yet spreading from one person to another but instead, they suggested, from an animal to humans. And they said the earliest case had shown symptoms only recently — on December 12.

Yet, for weeks now, reports in both the scientific literature and local and international news have contradicted what Chinese authorities were telling the world. These reports show the outbreak started weeks or months sooner than China let on, and the virus was already spreading among people — and beyond the food market in Wuhan — in early January. Authorities also censored information and silenced the whistleblowers who tried to sound the alarm.

A study published on January 24 in The Lancet showed that in the first days China acknowledge the outbreak, by January 2, more than a third of patients had no connection with the Wuhan food market, including the outbreak’s index (or first) case. What’s more, that person became ill on December 1, nearly two weeks earlier than Wuhan health authorities had said of the first case.

Source: Johns Hopkins University Center for Systems Science and Engineering

This means the virus could have been moving through Wuhan as early as October, Daniel Lucey, an infectious diseases physician and adjunct professor of infectious diseases at Georgetown University Medical Center, told Vox.

The Lancet paper also reported that the first person who died from the virus, on January 9, passed it along to his wife a week prior. Similarly, another recent report in the New England Journal of Medicine also shows there were already seven health care workers infected by January 11.

“This is the smoking-gun evidence of human-to-human transmission,” Yanzhong Huang, a China expert and senior fellow for global health at the Council on Foreign Relations, told Vox. “But the public was not kept informed about this situation until January 18,” Huang said. Instead, “People were still told there was no strong evidence of human-to-human transmission.”

Meanwhile, Li Wenliang, the physician who had tried to warn his colleagues about the severity of the outbreak back in December, was silenced by police and “forced to sign a statement denouncing his warning as an unfounded and illegal rumor,” according to the New York Times.

On February 7, he died of the coronavirus, the China’s People’s Daily reported. And his was just one tragic example of China’s attempts to control the narrative, quiet dissenters, and censor information. (The latest comes in news that Chinese lawyer and citizen journalist Chen Qiushi, who has been reporting critically on the conditions in Wuhan, has disappeared.)

This image from video, shows a selfie of Dr. Li Wenliang. The doctor who got in trouble with authorities for sounding an early warning about the coronavirus outbreak.
A vigil in Hong Kong held for Dr. Li Wenliang, 34, who died in Wuhan after contracting the virus while treating a patient, on February 7, 2020.
Anthony Wallace/AFP via Getty Images

That’s not all. Lawrence Gostin, a global health law professor at Georgetown University, pointed out that while China deserves credit for sharing 2019-nCoV’s genetic sequence shortly after announcing the outbreak, it “has not been forthcoming with additional information about the virus from different samples at different times in different regions.”

Nor have Chinese scientists shared the virus itself with other national labs. And yet this information is crucial for understanding “whether the virus mutated, how, and also about its transmissibility,” Gostin explained.

What’s more, China refused weeks of offers from the US Centers for Disease Control and Prevention and WHO to send experts to China, according to a February 7 report in the New York Times. (Only on February 9 did the WHO announce that a mission for China was finally departing — but it’s not going to Wuhan yet.)

“Then, of course, China has implemented the most extensive cordon sanitaire [or quarantine] in the history of humankind,” Gostin added. “They’ve restricted movements, caused fear and panic. They’ve violated human rights.”

Whatever the motivation for this secrecy and delay — China’s rigid bureaucratic structures, its culture of obedience and compliance, an unwillingness by government officials to share bad news, a desire to protect economic interests — the outcome is the same: The world had less time to prepare and react to the new coronavirus, which has likely worsened the outbreak and increased the risk of a global pandemic, global health experts said.

“[This] delay in announcing the first cases of coronavirus for several weeks meant that during that time, millions of people traveled outside of Wuhan, so it was precious time lost,” Gostin said. According to the Financial Times, some 5 million people left Wuhan in the weeks before the city was quarantined on January 22, “thus helping to transport the virus all over the country and overseas.”

“If the officials had disclosed information about the epidemic earlier,” Li told the Times before he died, “I think it would have been a lot better. There should be more openness and transparency.”

Disease diplomacy, explained

If you listened to the World Health Organization director general’s January 30 speech on why his agency was declaring the outbreak a public health emergency, you would not have had a clue about the concerns over China’s lack of transparency and early response. That’s disease diplomacy in action.

The WHO’s head, Dr. Tedros Adhanom Ghebreyesus, praised China, and has repeatedly done so on Twitter and in public statements since. Here’s what he said in the speech:

... the Chinese government is to be congratulated for the extraordinary measures it has taken to contain the outbreak, despite the severe social and economic impact those measures are having on the Chinese people.

We would have seen many more cases outside China by now — and probably deaths — if it were not for the government’s efforts, and the progress they have made to protect their own people and the people of the world.

The speed with which China detected the outbreak, isolated the virus, sequenced the genome and shared it with WHO and the world are very impressive, and beyond words. So is China’s commitment to transparency and to supporting other countries.

In many ways, China is actually setting a new standard for outbreak response. It’s not an exaggeration.

For context, countries under the International Health Regulations are supposed to report outbreaks immediately, take evidence-based measures to stop them from spreading, and uphold human rights in the process. Yet even on January 30, when Tedros made the speech, there was already ample evidence that China hadn’t reported the outbreak in a timely manner, not to mention the human rights questions raised by China’s unprecedented quarantine of more than 50 million people.

WHO Director General Tedros Adhanom (left) shakes hands with Chinese State Councilor and Foreign Minister Wang Yi before a meeting in Beijing on January 28, 2020.
Naohiko Hatta/AFP via Getty Images

Some of the global health observers Vox spoke to were surprised by the heavy-handed nature of Tedros’s praise.

“It was quite disappointing when there was a clear opportunity for some leadership to be shown on health and human rights and raising questions about [China’s] response,” Mark Eccleston-Turner, a global health law researcher at Keele University in England, said of WHO’s response. “The evidence for quarantining infected people is fairly decent,” he added, “but we are not just talking about quarantining infected people; the overwhelming majority of people in China are not infected with the coronavirus.”

Others said Tedros had little choice. “WHO has a difficult balancing act,” said Sridhar. “They have to somehow retain being the lead coordinator and director of international health work and the trade-offs they are having to make are about the greater good.

“Right now, the greater good is to create positive incentives for countries to collaborate with WHO — to share data, to let missions into China. If that means publicly [Tedros] has to praise China, I understand it.”

“If WHO criticizes China publicly,” Gostin added, “it’s possible they can be less transparent, less cooperative. If I were in Tedros’s shoes, I am not entirely sure I’d do anything differently.”

Adam Kamradt-Scott, a professor in global health at the University of Sydney who studied China’s SARS response, agreed. “As the world’s most populous nation, it is in the world’s interest to ensure China remains engaged, that it is transparent about disease events, and that those events are reported as soon as humanly possible.” Chastising China at a pivotal moment in the outbreak may have had the opposite of the desired effect.

When asked why the agency wasn’t saying more about the concerns over China’s response, a spokesperson said that while WHO condemns any human rights violations, “WHO’s top priority is supporting the people of China and the world to limit transmission of 2019-nCoV. ... We have a window of opportunity at the present time to slow the outbreak. This is what WHO and countries are focusing on.”

The world is vulnerable to countries’ whims in responding to outbreaks

The underlying reason for WHO’s silence about China’s missteps: The International Health Regulations don’t actually have any teeth.

“We have rules around how countries should behave when diseases cross borders, but because those rules have no enforcement mechanism, when countries do the wrong thing then they tend to get away with it,” Kamradt-Scott said.

The IHR — which WHO’s 196 members countries are supposed to adhere to — were revised in 2005 precisely because of China’s mishandling of another outbreak, SARS. Like today, China was heavily criticized for withholding information about SARS, in part because of concerns over the economic repercussions of reporting. The virus eventually killed 774 people and infected more than 8,000 around the world.

The revised IHR asks countries to build out their disease surveillance capacities and report public health crises immediately. It also asks nations not yet affected by a new pathogen to avoid punishing those that are through travel and trade restrictions. “These revisions were all about trying to get countries to sacrifice their short-term interests for the long-term well-being of all countries,” Sridhar said.

Empty intersections during Friday rush hour in the normally busy Central Business District of Beijing on February 7, 2020.
Kevin Frayer/Getty Images

Yet the revisions haven’t changed much. When an expert panel reviewed the response to the H1N1 swine flu scare of 2009, for example, it found the world “ill-prepared to respond to a severe influenza pandemic or to any similarly global, sustained and threatening public-health emergency.” The WHO also struggled to lead the global response (even though it’s supposed to play the coordinating role in the IHR).

Ditto the 2014-16 Ebola epidemic, when the three West African countries at the center of the outbreak didn’t have the disease surveillance networks in place to quickly identify the spread of the virus, delaying the global response for months. Then other countries implemented travel and trade bans on West Africa, despite that not being recommended under the IHR. Again, WHO was criticized for doing too little, too late.

“We’ve seen travel restrictions with every major outbreak from SARS through to Ebola in West Africa,” Gostin said. With the new coronavirus outbreak, countries around the world — from the US to Russia to Australia — are putting travel bans in place and closing their borders to China.

“The IHR operates on mutual trust largely, and it is a mutual trust,” Eccleston-Turner said. “That mutual trust has been eroded over a number of outbreaks where member states have ignored the recommendations from WHO.”

There’s even a debate about whether the IHR should be called a set of laws, Sridhar said. “You can contest whether you call it binding legislation if there’s no consequence.” While there’s been some discussion about tying a country’s performance during a pandemic to financial levers, such as World Bank or International Monetary Fund loans, little has happened in the way of reform, Sridhar added. How many more outbreaks, how many more deaths, will it take to change that?

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