CORONAVIRUS How Disease X, the epidemic-in-waiting, erupted in China

The following article was given to me by the editor of the South China Morning Post.

By Simone McCarthy, Linda Lew, William Zheng, Echo Xie and Phoebe Zhang

They called it “Disease X”. The epidemic-in-waiting.The World Health Organisation added it to a list of eight of humanity’s worst-known infectious diseases back in 2018. Didn’t have a name because it hadn’t happened. One aim of the list is to show the 194 countries that fund the United Nations body the threat from global public health emergencies, namely epidemics.

Ebola is there, bullet point No 2 – a virus thought to have jumped from African fruit bats to animals that humans butcher to eat. It kills about 50 per cent of the people it infects, mostly through massive loss of body fluids. The Ebola virus uses those same fluids – spit, blood, vomit – to infect humans that come into contact with them. A deadly swimmer.

Severe acute respiratory syndrome is bullet point four. Sars can cause pneumonia and took the lives of more than 800 people, most of them in mainland China and Hong Kong, before largely vanishing by 2003, less than a year after it appeared.

Again, bats are thought to be the host for the virus, which subsequently got into animals that humans eat, in this case probably civet cats sold in China’s markets as meat. Sars doesn’t need to swim to infect, it can float between human hosts in droplets from coughs or sneezes, or get picked up by touching an infected surface.

Disease X is at the bottom of the list, bullet point eight. The description: “[it] represents the knowledge that a serious international epidemic could be caused by a pathogen currently unknown to cause human disease.”

After the Ebola crisis in West Africa, the WHO had a rethink on what needs to be done to better prepare for epidemics and drew up the list, says Marion Koopmans, head of the Viroscience department at the Erasmus University Medical Centre in Rotterdam.

Disease X is on the list because it’s a global wake-up call, says Koopmans, a member of the WHO advisory group for research and development. It’s a warning to start thinking about how to better deal with these threats, she says.

This is a new disease, it’s threatening to the world, it’s socially disrupting, and we need to come up with ways of detecting it, controlling it, treating it, preventing it on the fly – to me, that is a Disease XMarion Koopmans, Erasmus University Medical Centre

That’s also a fair description of the killer that stole into China’s Wuhan city in the dying days of the last decade. Although now it has a name and a mugshot, of sorts.

The face of Disease X appears in a smudgy grey image of an orb studded with minuscule spikes, snapped by a scientist with an electron microscope. Researchers could put a face to the virus because they had captured it.

The next step in the identity process was getting the mystery pathogen to give up its secrets. For that, they turned to a DNA sequencer about the size of an office fax machine, which spits out a jumble of code that can be reassembled like a jigsaw puzzle to give a genetic identity.

From this data it emerged that the killer in Wuhan came from a nasty family, a new member of the coronavirus clan and a cousin of Sars. Scientists first named it 2019-nCoV based on the date it appeared and its family ties. It was later renamed SARS-CoV-2.

Beside this initial laboratory rap sheet, the only other certainties about this virus are that no one knows exactly where it came from, how it slipped into the city of 11 million people, when it arrived, and what triggered it to run riot.

ZOMBIES OF POISON

Around 122 years ago, scientists looking into causes of disease began to identify substances smaller than bacteria, or what Dutch microbiologist Martinus Beijerinck in 1898 referred to as parasitic infectious agents.

In the same year in Germany, bacteriologist Friedrich Loeffler and his colleague Paul Frosch found evidence of material smaller than bacteria that caused foot-and-mouth disease in animals.

Their findings opened the door to a new microscopic world of “ultravisible, ultrafilterable substances” previously unseen. The parasites were later named “viruses” from a Latin term meaning “poison”.

A raft of discoveries followed, including the human influenza virus in 1933.

The University of California, Berkeley describes the Loeffler and Frosch work in zombie-like terms: “This was the first clue to the nature of viruses, genetic entities that lie somewhere in the grey area between living and non-living states.”

If SARS-CoV-2 was in zombie mode when it entered Wuhan, it soon got to work doing what viruses do: find living host, hijack cells, propagate, multiply, spread.

The havoc different viruses leave behind in the process of conquering, occupying and killing human cells has many names: measles, herpes, polio, rabies, Ebola and Aids.

The type of havoc depends on where the virus finds a home, what type of cells it locks onto, burrows into, and hijacks. Where it hits a person depends on which body tissue cells bind best with that particular virus.

Pneumonia is the havoc speciality of SARS-CoV-2. It kills people by choking off the body’s oxygen supply. The infection causes the lungs to ooze with fluid that then thickens into phlegm or pus, which slowly blocks the lungs’ ability to transfer oxygen into the blood. Breathing becomes ever more laboured, forcing the heart into overdrive to pump more blood to oxygen-starved organs. Death can come when the overworked heart itself fails, along with other weakened organs. Or – gasping for air – the infected person falls into a coma and basically suffocates to death.

Pneumonia killed an estimated 2.56 million people worldwide in 2017, according to the Institute for Health Metrics and Evaluation at the University of Washington.

WUHAN IN
DECEMBER

Temperatures were warmer than usual in early December in Wuhan, an inland port city with a population larger than New York. By mid-month, it had cooled to the 9 to 10 degrees Celsius typical of the mild early winters in the city that sits on a bend in the Yangtze, Asia’s longest river. Its metropolitan district spreads out on both banks of the waterway to cover an area five times the size of London.

The Yangtze flows from the mountains of Tibet through the limestone gorges of central China, and elbows southeast at Wuhan, through an area around the city dotted with lakes. It then carves its way some 600 nautical miles to Shanghai and the East China Sea, the route for ships carrying the 1.7 million containers that passed through Wuhan ports in 2019.

Wuhan’s prominent location in central China on the Yangtze made it a linchpin of the country’s commerce for centuries, made all the more so with the arrival of railways. As a transport hub it was a prime target during war in the 1940s, when the city was largely destroyed in firebombings.

Recent decades of economic growth have seen companies from around 80 countries invest in Wuhan, drawn not just by its transport links and location, but top ranked universities in science and technology. Japan’s Honda Motor Co and multinational beer brewing giant AB InBev are among them.

British-backed companies alone had pumped US$5 billion into the city by 2018, former mayor Wan Yong said at the time.

It was later in December that doctors in Wuhan started to pull together the first pieces of a pneumonia puzzle that would generate the largest national response to a health crisis in human history. It involved the lockdown of cities and regions across the province of Hubei, which is home to nearly 60 million people – almost the population of Britain.

In a matter of weeks, alarms about the killer in Wuhan would be flashing across television screens, mobile phones and social media sites in Washington, Moscow, Nairobi, Tokyo, Milan and all points in between, upending world economic growth targets, fracturing global supply chains, grounding thousands of flights, and shutting down borders.

It has so far claimed thousands of lives, and infected tens of thousands more.

The South China Morning Post sent five reporters into Wuhan on intermittent days from January 3, with the last one leaving just hours before the city was locked down on January 23. The events reconstructed here are from eyewitness accounts, visits to hospitals, interviews with doctors and residents, published research, official reports, and commentary by medical specialists from around the world.

As of publication, global health experts are still trying to come to grips with and understand this outbreak. But it is clear the first signs of the tragedy that was about to befall Wuhan emerged slowly, as doctors in the city tried to make sense of what they were seeing in patients.

IS SARS BACK?

The first cases started to trickle into Wuhan’s major hospitals in mid-December. The patients typically had dry, raking coughs, high fevers and laboured breathing – symptoms that could mean a bad bout of winter flu.

But something else showed up in X-ray images constructed into computed tomography scans of their lungs. Medically, they were described as “ground-glass opacities”, or areas filled with fluid or partially collapsed, a telling sign of pneumonia.

Lung infection was evident in one of the early patients moved to Tongji Hospital, one of Wuhan’s leading medical centres, for treatment. He was transferred on Christmas Day with “widespread patches of shadows” on his lungs, a Tongji doctor says. “Even after antibiotics, he showed no sign of improvement.”

That patient was among many with combinations of fever, coughs and lung shadows who started to “flood in” to Tongji in the last week of December, says the doctor, who asked to remain anonymous because of his hospital’s restrictions on speaking to the media.

Discussing the cases with colleagues, he says they wondered whether Sars was back. Patients with Sars-like symptoms were also being admitted to Wuhan Union Hospital.

On the front line we all know how lethal Sars is, and no one will be complacent – even 17 years laterDoctor, Wuhan Union Hospital

During the Sars outbreak, China faced heavy criticism for delays in reporting about the disease, which allowed it to spread.

In response it built an online system that connected hospitals around the country with the Chinese Centre for Disease Control and Prevention (China CDC) in Beijing, to allow faster reporting of outbreaks, including what is known as “pneumonia of unknown etiology” – or PUE.

Building the network was one thing, but using it was another. Logging pneumonia cases in the computer system was complicated, time-consuming and many doctors were not properly trained to use it, according to China CDC surveys of hospitals in 2015 and 2016 cited in a report by its deputy director, Feng Zijian.

Those problems apparently still existed when PUE patient numbers started to rise in Wuhan hospitals towards the end of December, with doctors mostly escalating concern about the infections in direct reports to hospital supervisors.

That was the case as they began to notice many of those falling sick had been working at the same wet market, the Huanan Seafood Wholesale Market. This raised another warning flag since the 2002-03 Sars outbreak had been tracked to infected meat at a wet market in Guangdong.

“Sars is a matter of life and death, for us and our patients,” the Wuhan Union Hospital doctor says.

As doctors began to grasp the pattern emerging, two department heads in different hospitals led the early alarms.

Ai Fen, head of the emergency department at Wuhan Central Hospital, saw her first case on December 18, an elderly man with a stubborn high fever and lung infection. About a week later, a man in his 40s was referred from a local clinic with the same symptoms. She sent fluid samples for tests, according to Ai’s account in China News Weekly.

When the results came back on December 30 she took them straight to hospital officials: the samples showed indication of a Sars-like coronavirus.

Zhang Jixian, director of respiratory medicine at the Hubei Provincial Hospital of Integrated Chinese and Western Medicine, a six-minute drive from the Huanan market, was seeing a similar pattern.

She treated an elderly couple with coughs and fever on December 26. CAT scans revealed the lung blurs associated with pneumonia. More puzzling, their son had no symptoms, but a scan taken at Zhang’s request showed the same shadows in his lungs.

Later that day, Zhang saw a patient with the same symptoms who worked at the Huanan market, according to the provincial health commission website. None of the four patients tested positive for the usual bevy of viral and bacterial culprits, from influenza to chlamydia.

Zhang, a Communist Party veteran of the Sars epidemic and Sichuan earthquake disaster in 2008, was concerned enough to notify hospital supervisors who then contacted district health authorities.

When three more pneumonia patients, all with links to the wet market, showed up in her ward in the next two days, she gave her hospital head an urgent update. Now there were seven.

At 1pm on December 29, the hospital’s vice-president, Xia Wenguang, called doctors from 10 departments to a conference room and laid out the case files of the seven patients. Together they pored over the lung scans, clinical symptoms and laboratory test results. They agreed the evidence was worrying.

Xia decided the cases had to be escalated. The same afternoon he reported them to the health commissions and centres for disease control for the city and province.

That evening, patients showing the symptoms started being transferred to the city’s Jinyintan Hospital, which specialises in treating infectious diseases.

When local CDC officials received the alert, they contacted hospitals in the city urging “a field investigation with a retrospective search for pneumonia patients potentially linked to the market”, according to a report by the national body.

And they found them: 27 patients.

That was enough for Hubei’s health authorities. On December 30, they called officials in the glass-fronted building housing the China CDC in Beijing. The next day, a team of experts led by its deputy director, Feng, flew into Wuhan.

He brought heavyweights with him: Xu Jianguo, director of the State Key Laboratory for Infectious Disease Prevention and Control; Li Xingwang, chief infectious disease specialist at Beijing Ditan Hospital; and Cao Bin, a respiratory specialist at Beijing’s China-Japan Friendship Hospital.

They went “to support the investigation and control effort”, a China CDC report said.

This timeline indicates that from escalation of the alert on December 29 to the China CDC team landing in Wuhan took about 72 hours. The wet market was shut down a day later, on January 1.

It’s not so easy to pick up a disease and link it to one place … Doing that as fast as it was done, looking at it from a distance, I think it’s impressiveMarion Koopmans, Erasmus University Medical Centre

Between the Sars outbreak and the arrival of the killer in Wuhan 17 years later, a fundamental shift had taken place in how the world communicates: social media.

On December 30, a copy of a directive urging Wuhan hospitals to report cases of “pneumonia of unknown origin” leaked onto Chinese social media networks such as WeChat and Weibo, with hundreds of millions of users.

So as the virus established a beachhead in Wuhan and doctors raised the red flag to infectious disease specialists in Beijing, news of its arrival jumped to social media and speculation began to churn online: Sars may have returned.

One of those sounding the alarm was ophthalmologist Li Wenliang at the Wuhan Central Hospital, the same place Ai worked.

On December 30 he posted a photo of the test report that Ai had ordered in a WeChat group of alumni from his medical school. Circled in red: indication of Sars.

On December 31, Wuhan’s health commission went public. Hospitals had identified 27 cases of pneumonia, many linked to the Huanan Seafood Wholesale Market, it said in a statement on its website, adding there was “no obvious human-to-human transmission”.

Party mouthpiece People’s Daily followed up, saying the infection was more likely to be another form of pneumonia than Sars.

As public authorities sought to take control of the message, they cracked down on social media. Li was called in by his own hospital managers and admonished for his post on WeChat, according to later media reports. Even Ai said she was questioned by hospital officials about “creating rumours”.

Wuhan’s police department waded in, announcing on social media it had “taken legal measures” against a group of eight people who had “spread rumours” about a potential outbreak of Sars. The group included at least three doctors.

Ophthalmologist Li was caught in that dragnet. He was summoned to the local police station and forced to sign a humiliating confession letter promising to make no further disclosures about the outbreak. Li signed the letter on January 3, the same day the city said 44 pneumonia patients had been identified in clinics around the city and were in isolation.

WUHAN IN
JANUARY

Flying into Wuhan on a Cathay Dragon plane from Hong Kong on that same January 3 evening, all the flight attendants wore surgical face masks. The A320 passenger jet seating 150 people was mostly full for the two-hour flight, though only about a quarter of the passengers had masks on.

If that was an indication of public concern about emerging news of the virus, all seemed normal at Wuhan Tianhe International Airport – no temperature checks or screening.

A taxi driver on the way to the hotel had heard about the outbreak, but thought it seemed under control. He rummaged in his pocket and pulled out a surgical mask. “If I wore a mask, I would create panic and scare customers,” he says.

The following Saturday morning it was overcast, chilly and a misty rain was falling. Another taxi driver reacted with mild shock when asked to drive to the Huanan Seafood Wholesale Market. Wang Pengju was in the army during the Sars outbreak, and says he remembers it well.

Those who experienced Sars are extra nervous about this. I feel nervous when I have to take customers to this market neighbourhoodWang says as he brings the cab to a stop.

The Huanan Seafood Wholesale Market sits just outside Wuhan’s No 2 ring road in the west of the city. It’s a built-up area, with a kindergarten, apartment buildings, an Industrial and Commercial Bank of China and shopping centres nearby.

The market stretches over an area of about four soccer fields on either side of Xinhua Road. The road was open but all the pedestrian entrances to the ground-floor market and its warren of stalls were blocked off with red barricades. Guards in heavy overcoats were posted outside every 50 metres or so on both sides of the road.

Cleaning workers in high-visibility vests stood outside closed shops, which had blue and white pull-down metal shutters and names like Yangzhihui Hairy Crab and Zeming Fishery Wholesale, advertising shrimp and striped bass.

A look up one entranceway showed large, live spider crabs staring back from a huge glass water tank. A closed store had a Chinese flag fluttering outside.

About a dozen or so seafood stall owners were outside the market, most in surgical face masks and bundled up in down jackets and dark overcoats, wearing gumboots and caps.

They were negotiating with the guards to try and get into the market to retrieve stocks of fish, crab, shellfish and other produce left inside. One woman was allowed in to get two boxes of seafood around lunchtime.

The waiting stallholders were all aware of the illness, but some had another theory for the chest problems that were hospitalising workers.

They said a fire had broken out in the market at the end of November. It raged for several hours and destroyed large amounts of refrigeration equipment and produce, according to one stallholder in a bright orange coat with pink sleeve protectors.

“We think the fire may have released a harmful substance into the air and when people breathed it in, it hurt their lungs,” she says, adding that was an explanation going around the market for why people were coughing and having breathing problems.

Asked about what beside seafood was sold in the market, the vendors said meat from farm-raised animals, goat, sheep and rabbit was available, as well as snakes, but they denied knowledge of wildlife trade in live animals or meat.

Those denials run counter to what was said to be available at one of the stores in the market, Dazhong Livestock and Wild Game, which had a list of animals and prices on its website. On January 4, there were three white SUVs parked outside the shop, which was also locked down, though recognisable from the advertising banner draped across the building.

Their list of animals available ran to about 100 varieties both live and butchered. They ranged from red deer and peacocks to fox and wolf cubs, squirrel, spotted dove, bamboo partridge and Tibetan snowcock. Masked palm civet, the raccoon-like nocturnal animal linked to the Sars outbreak, was also listed at the equivalent of US$19 for a live animal.

Most of the animals for sale on that list could be legally bred on so-called farms within China’s regulated wildlife trade. From those farms, they could be loaded into cages and trucked to markets like Huanan all across China.

Until Beijing banned the practice some weeks later, China allowed licensed captive breeding for commercial purposes and there was no restriction on consumption of wildlife.

“It’s a big loophole in the current legislation,” Liu Jinmei, an environmental lawyer with the NGO Friends of Nature, said before the law was changed.

If there’s no regulation on what can be used for food, you’ll have this kind of market … some people will eat it, some people will trade it, some people will domesticate it and hunt itLiu Jinmei, environmental lawyer

China’s wildlife trade and breeding industry employed more than 14 million people in 2016 and was valued at 520 billion yuan (US$74 billion), according to a government report published by the Chinese Academy of Engineering in 2017.

It includes animals raised for their fur, use in traditional Chinese medicine, as well as for food. The licensed breeding law was seen as a way to take the pressure off wild populations.

“There are many big companies breeding wildlife and selling to markets and restaurants,” says Zhou Zhaomin of Southwest China Wildlife Resources Conservation at Sichuan’s China West Normal University.

Wildlife vendors at markets like Huanan need a “sustained and reliable source” of supply, so livestock farms to breed the animals fit the bill, he says.

But another consequence of China’s trade in wildlife for the dining table is animals that don’t normally live together in the wild are thrown together in cages, often in confined, unsanitary conditions.

That makes for a dangerous potential pool of virus combinations, says Timothy Sheahan, an assistant professor of epidemiology at the University of North Carolina, Chapel Hill.

Ecologically all these animals don’t necessarily have a chance to interact in nature, so in a way you are creating this environment that is ripe for cross-species transmissionTimothy Sheahan, University of North Carolina, Chapel Hill

When that phenomenon hits the human food chain, the result can be fatal, says Erasmus Medical Centre’s Koopmans.

“If you put wild animals into the food chain they may carry diseases that do not affect them, but if people get them it can be deadly,” she says.

The WHO says 70 per cent of disease-causing pathogens discovered in the past 50 years come from animals.

But scientists trying to track the origins of the new coronavirus still can’t definitively say it made the move from an animal to a human at the Huanan market because the animal and patient zero – the first person to be infected – haven’t yet been identified. It’s possible the link may never be conclusively found.

Aids, or acquired immune deficiency syndrome, was named as such in the United States in 1982 and in the following year the virus that causes it, HIV, was discovered, according to the non-profit Aids Institute in the US.

It wasn’t until 1999, or 17 years later, that a chimpanzee subspecies in Central Africa was named as the likely source of the virus, probably infecting humans who hunted it for meat and mutating into HIV within human hosts.

The earliest known case of infection was found in a blood sample taken from a man in 1959 in Kinshasa, in then-Belgian Congo, the institute says. It notes that it’s still not known how that man became infected, but Aids then spread across Africa for decades before finding its way to the US and other countries.

Likewise with Sars. The WHO has said the disease is “thought to be” an animal virus that spread from an “as-yet-uncertain” animal like bats, which then transferred to humans in China from civet cats.

Other commentary on the source of the new coronavirus has turned to the possibility that it may not have come from an animal in the Huanan market. This cited published medical records showing in the earliest case admitted to hospital, the infected person had no known relationship with the market.

That has led to speculation it came into the city from another route, possibly passing between hosts unnoticed as it mutated.

Other theories suggest the virus “escaped” from the Wuhan Institute of Virology, which built one of the world’s largest databases of viral strains found in bats. The lab and one of its leading bat virus researchers have rejected that speculation.

The evidence in tracking Aids and Sars shows that definitively marrying a virus to its original host, showing how it got there, and then how it jumped to an identified human patient zero is inexact science at best.

However, once it “broke out” in Wuhan, the path of SARS-CoV-2 could then be seen in the trail of the sickened and the dead, moving among its new human hosts and travelling with them as they took buses, trains and flights within China and onwards to overseas holiday destinations in Thailand, business meetings in Germany and trips on cruise ships to Japan.

But chasing it in the opposite direction, back down the food chain, back through the spit or blood that could have caused cross-species viral transfer between two animals, and back into the farm or forest that was home to the infected animal leaves no such visible trail, only a genetic one.

The trail of that “ultravisible, ultrafilterable substance” referred to by German bacteriologists more than 100 years ago.

What made the tracking of the virus possible is the work done by China’s researchers at institutions that crunched the pathogen in genetic sequencers.

By January 12, the virus’ genetic code had been uploaded by those researchers into a global open-access database and shared with the WHO, which called it a “remarkable achievement” critical for public health authorities to understand the illness.

It’s probably the earliest, fastest roll-out of a genome in association with an outbreak we’ve ever seen. And it’s so essential to our understanding of what’s happeningIan Mackay, University of Queensland

“And it’s so essential to our understanding of what’s happening,” he says, explaining that it helps to identify the source animal and for work on a vaccine to begin. Ian Mackay, University of Queensland

Analysis of the genetic make-up also revealed a never-before-seen feature in this family of coronavirus: sticky sugar molecules that may allow it to hide itself from attacks by the human immune system.

It also yielded a shortlist of potential animal reservoirs – key suspects are among China’s 147 known species of bat.

The horseshoe bat (Rhinolophus affinis) carries a strain with 96 per cent similarity to the new coronavirus, identified in January by renowned bat coronavirus researcher Shi Zhengli of the Wuhan Institute of Virology.

That 4 per cent difference indicates another animal likely came between the bat and a human, with the virus reshuffling its genetic make-up to better bind to cells in the new host, and then again when it hopped into humans.

The scaly pangolin has appeared on the potential line-up of intermediary animals after researchers found a viral strain with up to 99 per cent genetic similarity to the novel coronavirus inside one of the mammals.

“Pangolins are certainly interesting because they have a related virus, but this does not necessarily make them intermediate hosts. There are a wide range of animals that could similarly carry related viruses,” says infectious disease specialist Eddie Holmes of the University of Sydney.

The 10 million yuan question is what is that animal? We need to know, it’s a critical bit in the emergence jigsawEddie Holmes, University of Sydney

“The identity of any intermediate host for SARS-CoV-2 is currently unknown. This issue likely won’t be resolved until we have done a lot more animal sampling,” he says.

As part of the hunt to track down the possible springboard animal host, a team of scientists descended on the Huanan market on orders from the China CDC on January 1 and again on January 12. They collected 585 “environmental samples” from countertops or animal traces or products left behind.

In that market there would have been “faeces on the floor, gut piles, there’s blood”, says Peter Daszak, president of the New York-based research organisation EcoHealth Alliance, who has been involved in research on bat coronaviruses in China and Southeast Asia for 15 years.

“They would have swabbed those floors, they would have swabbed around the stalls, with little swabs like earbuds, each one they would have put in a separate vial, and … taken them under very tight security back to the lab, and they’d tried to find the sequence of viruses from that,” he says.

Among those samples, 33 were found to contain the genetic material of the novel coronavirus. They were mainly collected from the western zone of the market where wildlife was sold, Chinese state media said on January 26.

“The 10 million yuan question is what is that animal? We need to know, it’s a critical bit in the emergence jigsaw,” says Holmes of the University of Sydney, who visited the Huanan market in 2014 and saw mammals in cages for sale.

There is another challenge to the search for the animal host: before Wuhan shut down the Huanan market, teams of workers with gallons of disinfectant came in to clean it down. This has raised comparisons to the market as a contaminated “coronavirus crime scene”, with the genetic fingerprints and tracks of the virus wiped away.

“The ‘crime scene’ was completely gone. How can we solve a case without evidence?” University of Hong Kong Sars researcher Guan Yi told Caixin magazine in January.

The ‘crime scene’ was completely gone. How can we solve a case without evidence?Guan Yi, University of Hong Kong

While scientists were trying to answer the 10 million yuan question that Holmes in Sydney raised, the Huanan market may have been the source of another transmission route for the virus out of Wuhan.

Although its ground floor was closed down on January 1, the market building on the eastern side has two floors, with the second level mostly occupied by retail outlets including a large concentration of stores selling spectacles.

From January 3 until at least January 6, the second floor was still open and shoppers and staff were going in and out of the building each day, right above the shuttered food stalls below, according to eyewitness accounts by Post reporters.

If this became an escape route for the virus, evidence would show in an infection trail – and there may be one. The coastal province of Zhejiang was to later report more than 820 infections, the highest outside Hubei at the time. But by far the highest concentration of 340 patients was in the Zhejiang city of Wenzhou. One of the manufacturing specialities of Wenzhou is spectacles.

WUHAN
HOSPITALS

On January 4 in Wuhan, pneumonia patients were being moved across the city by ambulance to Jinyintan Hospital, a seven-floor white, curve-shaped building north of downtown.

Some were stretchered into the hospital by staff in coverall protective wear, others walked.

Floors four, five and six of Jinyintan’s south building were reserved for the virus cases, but the hospital itself was open to the public. Family members were bringing meals and other items to inpatients.

One man in his seventies, who declined to give a name, arrived on the fourth floor carrying a metal lunchbox with a meal for his wife. He knocked on the locked door to the ward. A hospital staff member in a white protective suit, blue surgical face mask and blue silicon gloves opened it and took the meal inside.

The man said he and his wife both worked at a stall at the Huanan seafood market and his wife had come down with symptoms of pneumonia. She then came to the door to speak with him. She was standing in a long winter coat and had on a surgical mask, but no other protection.

Another man, surnamed Yi, was visiting the hospital because his 25-year-old son was due to be discharged that afternoon. He showed the discharge paper, explaining that his son was brought in for observation on December 31 with a fever. They live one block from the Huanan market.

That evening, a Watsons pharmacy in the Wanda Plaza shopping centre was starting to run short of surgical masks. An assistant said a steady stream of people were starting to come in and buy them.

Back at Jinyintan Hospital in the afternoon of January 5, security had increased.

A staff member in full protective gear with hood pulled up, bright blue sneakers and turquoise face mask was guarding the door on the fourth floor. He wasn’t there the day before.

A woman arrived to drop off items for her husband, who was on the sixth floor. They shopped at the Huanan market and lived not too far from there. Her husband’s symptoms started two weeks earlier with a fever, then he developed viral pneumonia. He was transferred to the hospital on December 31.

Since then, he had started to recover, she said. His fever was gone, but he was still coughing a lot. The doctors said if his temperature stayed normal for seven days he could be transferred into a ward for observation. The woman was optimistic as he has not had a fever for three days.

“I just hope he can recover and come home before Chinese New Year,” she says, adjusting her mask as she speaks. “The most important thing is to have the family together for the celebration.”

Authorities were tracking the spread of the disease by following up with family members of the patients, according to the woman. The police had called her home and asked questions, such as how many people were in the household and how was their health.

Another woman at the hospital was distressed. Her husband had been admitted with pneumonia symptoms. She had her hair tied back, and wore a bright red scarf and a dark winter coat. She came in and out of the hospital over several hours, questioning other visitors to try and find out the conditions of other patients.

Her husband was 39 and being treated on the sixth floor, she said, starting to cry when she spoke about him. Medical staff were preparing for the arrival of another patient and asked her to leave. She refused.

“I don’t want to go,” she says. “I want to stay close by, that way I feel closer to him.”

A nurse suggested she call him by phone and not worry too much because it could also upset her husband. She snapped back that she was in contact with him by phone and had not let him know how worried she was.

A hospital staff member then noticed a Post reporter typing notes into her mobile phone. She identified herself as from the hospital’s propaganda department and asked if the reporter was a journalist. She took the reporter’s arm and escorted her to a police office within the hospital grounds.

“China’s national propaganda department is already involved, we’re taking this very seriously,” she said. Reporters should not be at the hospital talking to patients’ families as they do not have complete information and the media must wait for official government releases, she said.

At the station, a police officer asked the reporter who she worked for and wanted to see her identification information, saying if it wasn’t provided, she would be detained overnight.

She then took a photo of the reporter’s Hong Kong ID and made her delete the notes and photographs on her phone, though they were already saved in cloud storage.

She was ordered to leave the hospital and the city. Later media reports showed other journalists were also questioned by police in Wuhan, searched and ordered to delete photographs and text.

On the evening of January 6 at Wuhan airport, there were no temperature checks or other procedures.

The flight again was fairly full. And when it landed in Hong Kong, five airport staff were waiting at the gate with temperature guns checking each passenger. Health department fliers were handed out giving tips on preventing pneumonia, respiratory tract infection and general health advice.

WUHAN
GOES DARK

Overseas virus specialists the Post spoke to for this story have commented on the speed of the response by doctors and researchers in Wuhan and elsewhere in China in identifying the outbreak and sharing genetic information on the virus.

Those specialists – whether in the US, Europe or Australia – cited the difficulty of making that identification in the middle of winter when thousands of people in Wuhan would be shuffling through doctors’ waiting rooms and hospital outpatient clinics every day with coughs, colds and flu.

But they also noted that from January 5, something happened. Wuhan seemed to go dark.

Official daily updates on the medical situation stopped for five days. However, from the outside looking in, the situation did seem under control when on January 9, the WHO issued a statement citing Chinese authorities, noting “the virus in question can cause severe illness in some patients and does not transmit readily between people”.

Then on January 11, Wuhan’s health commission said no new cases had been detected since January 3. They did announce one death – a 61-year-old with chronic liver disease who shopped at the market.

They also added: “No clear evidence of human-to-human transmission has been found. We are conducting further epidemiological investigations and related laboratory tests. In addition, no related cases have been detected among people who have been in close contact with the patients, including medical workers.”

But Wuhan hospitals were in chaos.

“We had so many patients flooding the hospital, creating a run on almost everything – beds, doctors, masks, medicines, disinfectants, you name it, we were short of it,” the doctor at Tongji Hospital says of those first weeks of January.

“Patients queued for hours for a CAT scan, and the queue for a proper test was even longer. I felt so bad – old folks were on the verge of collapsing but we didn’t even have enough chairs, they had to take turns sitting down,” he says. “The ward was overrun.”

I felt so bad – old folks were on the verge of collapsing but we didn’t even have enough chairs, they had to take turns sitting down. The ward was overrunDoctor, Tongji Hospital

But most of these patients were not showing up as new coronavirus cases, because they didn’t fit the specific diagnosis criteria set by health authorities. Three boxes had to be ticked: exposure to the seafood market, fever symptoms, and a positive diagnostic test result, according to the doctor at Wuhan Union Hospital.

This set of criteria had been the cause of an intense argument between local doctors and the China CDC team that flew in on December 31.

Wuhan doctors said the criteria were too strict and narrow and would miss infected patients. They also argued that what they were seeing in hospitals showed human-to-human transmission was taking place. The CDC team pulled rank and set the criteria.

“Doctors on the ground in Wuhan effectively had their hands tied by this strict criteria and because we lacked the test kits, we couldn’t meet the criteria for those showing symptoms, leaving infected people to run around the city spreading the disease to others,” the Wuhan Union doctor says.

“We had to follow the directive even though our experience showed we had over 80 per cent accuracy based on lung CAT results. I don’t know why they set the criteria as they did.”

The situation also prevented medical workers from appealing for equipment assistance, according to the Tongji Hospital doctor, describing how he poured boiling water over his plastic goggles in an attempt to keep them sterile.

“If we cannot tell the outside world what’s happening, how can we call for help? Our medical supplies already ran low after two weeks, but we had no choice but to wait for supplies from official channels,” he says.

As hospitals became overwhelmed and lacked the equipment to deal with the spreading disease, doctors and nurses started to get hit by the new coronavirus. Leaked records from the China CDC showed that medical workers were falling sick from the end of December.

Do you know what it is like to read the CAT scan of a colleague and have to tell them they are infected?Doctor, Tongji Hospital

“I wanted to cry, but I couldn’t because it would blur my vision and we didn’t have enough sanitising towels to clean our faces.”

Among medical staff showing symptoms was Li Wenliang, 34, the whistle-blower ophthalmologist who warned his medical college classmates of the Sars-like illness in the WeChat group in late December. He fell sick on January 10.

THAILAND
RED FLAG

As Li was suffering the dry cough and fever attack of the coronavirus, halfway around the world in New York, Yanzhong Huang was closely tracking developments in China. The senior fellow for global health at the Council on Foreign Relations says the information coming out of China at this stage indicated the virus was not being spread by human-to-human transmission. He says he gave credence to this information, noting that China had the experience of dealing with epidemics.

“I believed Sars was a watershed, that it had led the government to become more transparent and more responsive,” Huang says.

But then he saw a red flag – not in China, but in Thailand.

On January 13, a 61-year-old Chinese tourist in Bangkok was diagnosed with the coronavirus, but she had had no reported contact with the seafood market.

“That raised the flag that something unusual is happening,” says Huang, who then started to question the official narrative that the disease was not spreading.

On January 15, Wuhan’s health commission shifted its tone in an online statement: “The possibility of limited human-to-human transmission cannot be ruled out.”

While health authorities were starting to acknowledge the possibility that the virus was jumping between humans, and hospitals were under siege, elsewhere in Wuhan, city bureaucrats had their attention on other matters, including celebrations and feasts.

Party officials were in the midst of a two-week chain of meetings to laud achievements of the past year and plan for 2020.

From January 6, thousands of delegates from the city- and provincial-level People’s Congress and People’s Political Consultative Conference had gathered in Wuhan for their annual conclaves. Delegates presented proposals like easing subway security checks for airport passengers and mobile apps that reward environmentally friendly behaviour.

Filling the Hongshan Auditorium, decorated with party slogans and red drapery, they lauded the eight “joyous occasions” that marked 2019 – hosting military games, a revolutionary from Hubei winning a national honour, and regional per capita GDP exceeding US$11,000.

On Friday, January 17, nearly 700 People’s Congress members stressed their dedication to implementing “Xi Jinping Thought”, and committed to “focus on solving key and difficult issues of people’s livelihood, and continuously enhance the people’s sense of happiness and safety”, according to the Hubei government website.

And thousands of residents gathered on January 18 for an annual community potluck dinner, according to local media. This year the Baibuting community tables were laden with a record number of dishes – 13,986, according to one media report. Artistic culinary creations included a model of Wuhan’s riverside park constructed of carrots, broccoli and quail eggs.

But by Monday, January 20, the narrative started to shift rapidly as medical authorities reported 136 new confirmed cases of the coronavirus over the weekend.

At the same time, 83-year-old Zhong Nanshan, one of China’s leading specialists on respiratory diseases and a hero of the Sars crisis, was pulled into press conferences to explain what was happening.

Human-to-human transmission had been proven and medical staff were infected, he said. Authorities confirmed 15 health workers in Wuhan had contracted the virus. But that number, like the number of those infected, was already much higher.

Still, the following day on January 21, Hubei governor Wang Xiaodong and the province’s then-party secretary Jiang Chaoliang went to the theatre for a Lunar New Year show. Performers in flowing gowns and traditional dress of regional ethnic minority groups danced across the auditorium stage, twirling into formation after formation, trailed by huge red ribbons and heart-shaped props.

The next day, Hubei initiated a Grade 2 response to a public health emergency, but it was no longer just a problem in the city. China had 440 confirmed cases across 13 provinces, and the virus had surfaced in travellers in Thailand, South Korea, Japan, Taiwan and the United States.

About a week later, Wuhan mayor Zhou Xianwang acknowledged the delay in the response during a CCTV interview, saying he needed to wait for approval from senior officials to update the public about the virus.

LOST TIME

For Huang at the Council on Foreign Relations in New York, important time was wasted and opportunities missed to confront the outbreak earlier. After Sars, China revised the disease prevention law to encourage transparency and sharing of information and built the world’s largest online surveillance network that allows health personnel to report infectious diseases directly to the China CDC, he says.

“You would expect all these things should work in an outbreak like this,” Huang says. “But obviously the system failed.”

Meantime, many residents of Wuhan had other matters on their mind.

Lunar New Year on January 25 was approaching, the biggest holiday of the year when hundreds of millions of people travel across China on journeys back to their hometowns and to see families.

Many had already started to leave Wuhan and not all were aware of the virus among them.

The city’s Hankou railway station on the morning of January 21 was one place crowded with passengers getting an early start on the holiday.

A 55-year-old man surnamed Yin was waiting for the train with two large black travel bags and a backpack. He wasn’t wearing a mask.

“I don’t know why people are wearing masks,” he says. “I thought it was because of pollution.” But he was confused because it had been raining and the air quality wasn’t that bad.

When told it’s because of the virus, he says he isn’t worried. “I won’t have that problem. I’m very healthy,” he says. He was heading to his hometown in Jingmen, in the west of Hubei about three hours from Wuhan.

In contrast, Lan Chuqiao, 28, was making a trip to Yueyang city in Hunan province and was surprised so few travellers were wearing masks.

You would expect all these things should work in an outbreak like this. But obviously the system failedYanzhong Huang, Council on Foreign Relations

“If you read the news online it seems like zombies are invading the city but in the real world it seems calm,” she says.

Dozens of volunteers in red jackets and masks were assisting people in the station, but no announcements were made to remind people of the virus and there were no temperature checks.

Two days later at 10am on January 23, Wuhan was locked down.

At 7am that day, the waiting hall of the Wuhan railway station was packed and people were rushing in from all directions with backpacks and suitcases to beat the deadline.

A Post reporter who caught one of the last trains out of the city that morning said although there were so many people crowding in, it was quite different to the raucous departure scenes of a typical Lunar New Year holiday.

There was an intensity to the mood and a quietness. People were intent on listening to departure broadcasts every several minutes. Everyone was anxious about making it out before the gates shut.

As the deadline passed, trains, buses and flights were cancelled and other restrictions placed on entering and exiting the city to try to block the spread of infections beyond the epicentre. In subsequent weeks other cities and regions across China would do the same in an unprecedented attempt to prevent a pandemic.

“Locally, domestically for China, they delayed action, but we have very little idea about what deterred quicker action – was it because, like the mayor said, the delay of the central government? Or really because of his delay?” says Xi Chen, an assistant professor at the Yale School of Public Health.

“There was strong evidence of human-to-human transmission but they were not able to release this information in a timely way. I don’t know what happened then,” he says. “But people have died.”

There was strong evidence of human-to-human transmission but they were not able to release this information in a timely way. I don’t know what happened … but people have diedXi Chen, Yale School of Public Health

One of them was the whistle-blower ophthalmologist Li. After falling sick with symptoms on January 10, he waited weeks to be confirmed as having the virus.

He died in the early hours of February 7, which triggered a massive outpouring of grief and anger on China’s social media sites – grief for Li in paying with his life after risking his career to warn others about the disease, and anger against the government.

The scale and depth of the public anger clearly unsettled Beijing, which later fired a raft of local officials. It also released a speech in which President Xi Jinping said he had instructed authorities to deal with the budding outbreak as early as January 7, indicating Xi was involved in directing the crisis response early on.

However, one possible indicator of how Beijing viewed the seriousness of the outbreak in January is to look at Xi’s travel itinerary.

China’s leader left the country on January 17 on a trip to Myanmar, his first state visit of the year.

There he was snapped by official photographers visiting local temples and in talks with Myanmar’s de facto leader Aung San Suu Kyi about a “community of shared destiny”, and signing multibillion-dollar infrastructure deals.

His visit to Myanmar was also an anniversary of sorts.

On January 21, 2019, or almost exactly one year earlier, Xi had given a much-quoted speech to senior party members and had issued a warning.

Beware and be on alert for “black swans” in the year ahead, was Xi’s message to the party faithful.

The wording he used was taken from the book written by Nassim Nicholas Taleb titled The Black Swan: The Impact of the Highly Improbable – a reference to unexpected, unprecedented events.

A year later as he was shaking hands and smiling for the cameras in Myanmar, a black swan was stretching its neck in Wuhan, flapping its wings and taking flight right behind him.

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