The International Trajectory of SARS-CoV-2 & COVID-19 from Localized Epidemic in China to Pandemic End-Phase Part 1: The China Experience

 

©laurence@svirchev.com

by: Laurence Svirchev and Vivan Danping Sheng

Introduction

On March 9, 2020, Dr. Tedros Adhanom Ghebreyesus, the World Health Organization’s Secretary-General), stated that the SARS-CoV-2 virus caused “the first pandemic in history that could be controlled….The great advantage we have is that the decisions we all make – as governments, businesses, communities, families and individuals – can influence the trajectory of this epidemic…[it is] an uneven epidemic at the global level.”

But controlling the SARS-CoV-2 is not what happened. Just as China was suppressing the virus through aggressive disaster- and infection control-response techniques, tsunami-like the virus entered Europe in a second wave and then clobbered the United States in a third wave. The majority  of nations with highest levels of health resources did not heed the warning signs and squandered the time that a few nations, principally in Asia, bought for them. What China, South Korea, Singapore, Viet Nam and New Zealand were able to accomplish in a relatively short period of time did not happen in almost all of Europe, the United States, Canada, and Latin America.

According to the July 10 Daily Situation Report, there have been a total of 12,102,32 cases of COVID-19 causing 551,046 deaths globally, a crude death rate of 5%. The accompanying surveillance graph shows that the epidemiological curves is accelerating for all WHO-defined regions except for Europe and the Western Pacific, which includes China. Note that the last affected region, Africa, is in the first stage of acceleration.

In Memory of Dr. Li Wen Liang 李文亮 (12 October 1986 – 7 February 2020) Dr Li was an ophthalmologist, experienced in recognizing coronavirus signs and symptoms from SARS-1. While treating an a-febrile elderly patient in the early stages, he sent a private message to eight colleagues via WeChat, a social media platform, to watch out for a pneumonia of unknown etiology, a SARS-like disease. The message went public via a screen-shot, and he was reprimanded by local police for rumor-spreading. The next day, the patient had a fever. These were the days before it was known that a-symptomatic people could shed virus and infect others.

Dr. Li went back to work, now infected and died of COVID-19 on February 7. Because of the injustice against him, his case became a cause célèbre within China and internationally. He was vindicated by a decision of the Supreme Court of China. During the Spring Festival celebrations he was nationally celebrated in poetry and song on Chinese television. He is survived by his wife, a first child, and a second child born fatherless in June.

 

It Started In China

Every day the western media are filled with new stories about SARS-CoV-2 & COVID-19. On a regular basis there are reports that China failed to respond quickly enough (“fumbled”), that WHO did not do a good job of responding to the pandemic and needs to be investigated. Lost in the daily flood of information and accusations is an overview of the trajectory from localized epidemic in Wuhan China to pandemic, or international epidemic. We are writing this essay to examine the trajectory of the virus and disease, to discuss how China -the original epidemic epicenter at Wuhan- managed through hard struggle and citizen discipline to suppress the disease. We are also writing to illustrate that no country was prepared with surge capacity in spite of repeated warnings from health scientists that pandemic was a real possibility. Equally, no one could predict how globally cataclysmic it would be.

The virus (SARS-CoV-2) and the disease (COVID-19) have become the principal international threat to humanity since WWII. But instead of armies, navies, and air forces crusading over land, sea, and air for victory over Nazism and Japanese imperialism, humanity faces off against an invisible enemy that can only be defeated with medical science, international cooperation, societal discipline, and patience. 

International scientists, including those in occupational health and safety (OHS) have been collaborating as never before. The same is true of the medical scientists developing treatment protocols and vaccines. Hosts of engineers and architects are designing new ways of protecting the public  from being exposed to the hazard. The same engineering and architectural professionals are re-configuring workplaces to protect workers from the viral hazard.

Yet some elected national leaders (United States & Brazil, for example) have proved incapable of leading their countries in campaigns to suppress the disease. They speak of “re-opening the economy” but they conveniently leave out the word “safe” because their reptilian-like brains are only interested in their own power, profit, and deceipt. 

The manufacturing giant called the United States has not been able, in the five months since the disease manifested itself outside China, become self-sufficient in something so basic as N95 respirators to protect its medical and emergency service workers. That is not the fault of dedicated public servants, medical and safety professionals, the engineers and architects referred to above, and even civic-minded business leaders.

Instead, the medically-illiterate elected executive branch of the United States even denies that more testing is warranted to isolate those with symptoms. Instead, they claim that more testing will reveal a higher number of infections, which make them look bad in the public eye. Wannabe Emperors, they “fiddle while Rome burns.”

In this two-part essay, a special edition of Misterioso departing from its normal focus on improvised music, we trace the general history of COVID-19 starting in China as a localized epidemic to an international pandemic. We discuss the first cases, medical and occupational health and safety responses, and China’s successful national campaign. In Part Two we will discuss international trends, touching on the success stories of countries such as South Korea, Singapore, New Zealand and Viet Nam, the role of the World Health Organization and end with a coda containing some lessons to date.

Some Characteristics of the Novel SARS-CoV-2 & COVID-19

SARS-CoV-2 is a novel coronavirus. The term novel refers to the new and unusual, containing many unknowns that can only be discovered through experiences of tragedy, struggle, tears, and scientific, medical, and social research. 

SARS-CoV-2 is a zoonoses, a disease transmitted from animals to humans. In the beginning of the pandemic, the US Centers for Disease Control characterized the virus as emerging and rapidly evolving. This uneven development is what makes this powerful opportunistic virus especially tricky to deal with. Along the way there have been many surprises, with more coming at us in the future: the terminology of  emerging and rapidly evolving still holds true six months later.

The are multiple unknowns and characteristics of the SARS-CoV-2 & COVID-19, including: 

  • How did it get from animals to humans?
  • How long was it circulating before the first person was diagnosed?
  • Since there is no human immunity, no population is exempt.
  • In spite of the lack of immunity, the poor populations crowded into urban conditions, and the migrant farm workers are particularly vulnerable (as the US and Singapore experience demonstrate).
  • The core value in the time of COVID-19 is the protection of healthcare workers (HCW) including support staff in medical settings and Emergency Response Workers (ERW).
  • There are multiple challenges to research in the medical, occupational safety & health, engineering, architectural, and social disciplines.
  • Personal protective equipment (PPE) for HCW and ERW rapidly depleted: existing manufacturing capacities could not keep up with surge capacity requirements. The factors that caused these depletions are particularly gnawing and ignoble.

The struggles against the virus have for six months tested the abilities of the capacities of whole nations, every strata of society, and the carefully wrought international relations expressed through organizations like the World Health Organization (WHO). Yet much to the dismay of millions, there are medically-illiterate elected leaders in some countries who ignore the facts, sow falsehoods, and exploit ignorance to preserve their political power.

The First Days In Wuhan

The first case diagnoses of COVID-19 were made in Wuhan city, Hubei Province, China. Wuhan was the first epicenter of what became a multiple epicenter international pandemic. Wuhan is a key centrally-located rail-highway-river transportation hub, population about 11 million. The first diagnoses were made by Dr. Zhang Jixian, Director of Respiratory and Critical Care Medicine of Hubei Provincial Hospital of Integrated Chinese & Western Medicine. Zhang was well-experienced from the first SARS epidemic in 2003.

On Dec 26, 2019, two elderly patients presented themselves at Hubei Provincial Hospital accompanied by their son. They had high fever and cough with the signs and symptoms of flu. Upon examination, Dr. Zhang ruled out common virus. These two patients lived in a community near the Huanan wholesale seafood market, also known as a “wet market.” In such markets, meat processing and fruit-vegetable sales are also carried out. On the same day, a worker from Huanan Seafood Market also presented with same signs and symptoms of flu. Common virus was again ruled out.

On the next day, Dec 27, computerized tomography scans on the elderly patients revealed “ground-glass like opacities” in their lungs, something Dr Zhang had not seen before. She classified the disease as “Pneumonia of Unknown Etiology.” On Dec 28, Dr Zhang reported the four cases to the hospital authorities, who then informed the Center for Disease Control of Wuhan city. In a later video interview, Zhang stated, “China’s Law on Licensed Doctors requires us to report diseases of unknown causes.”

Over the next two days, three more patients from Dr. Zhang’s Hospital and two from other hospitals who had addresses located at the Huanan Seafood Market were also diagnosed as having “pneumonia of unknown etiology.” Zhang noticed a pattern and later stated in a press interview that doctors need to learn about the patients’ occupations and addresses. Four patients came from one seafood market and had similar symptoms, she said. “How can there be no problem in such situation? This is the thinking pattern I had got from fighting against SARS.” 

The Hubei Provincial CDC sent a team to investigate the 7 patients and on Dec 30, the Wuhan Municipal Health Commission sent notifications to medical institutions under its jurisdiction about an outbreak of pneumonia of unknown cause in the city. As a cautionary measure to prevent spread of the disease, the Huanan Seafood Market was shut down on January 1. 

Two days later there were 44 cases, clear enough evidence for China to inform the WHO and on January 4, the head of the China CDC had a telephone conversation with the equivalent official at the USA CDC. By January 5, influenza, avian influenza, adenovirus, the original SARS and the Middle East Respiratory Syndrome coronavirus had been ruled out by laboratory testing. 

On January 8, an evaluation team identified a novel coronavirus and the heads the Chinese and US CDCs held a second consultative phone call on the new virus. On January 12, the genome sequence of the novel coronavirus (2019-nCoV) was submitted to WHO and was published by the Global Initiative on Sharing All Influenza Data (GISAID) to be shared globally. Approximately 16 days had past from first diagnosis of a disease of unknown etiology to sharing the genome internationally.

The Global Initiative on Sharing All Influenza Data (GISAID) Since May 2008 GISAID has promoted the rapid sharing of data from all influenza viruses and the coronavirus causing COVID-19. This includes genetic sequencing and related clinical and epidemiological data associated with human viruses, and geographical as well as species-specific data associated with avian and other animal viruses, to help researchers understand how viruses evolve and spread during epidemics and pandemics. The Federal Republic of Germany is the official host of the GISAID platform and EpiFluTM database; there are multiple public-private partnerships, including the US CDC, the first government to support the creation of the GISAID.

Infection Control and Occupational Health & Safety Response at Hubei Provincial Hospital

After her initial diagnosis, Dr. Zhang Jixian took a number of infection control and personal protective equipment measures to treat patients and protect workers from an infectious disease. The first step Dr Zhang took was to isolate 9 of the 45 available beds for patients with the pneumonia unknown etiology. Then she ensured her staff  were supplied with N95 respirators to protect their breathing zones when entering the isolation area. For full-body protection she bought 30 sets of white canvas work clothes online, going\ outside the normal hospital network because “Applying for equipment [inside the hospital system] would have taken longer.”

What are PPE (Personal Protective Equipment)? PPE are specialized gear designed to protect workers from toxic and biohazardous materials. Medical grade PPE are typically designed for one-time use, disposable items that cannot be disinfected without losing their structural integrity and ability to protect the nurse, doctor, technicians, and care aids. Medical grade PPE include respirators, tyvek full body suits, and gloves. The N95 respirator is a specialized device designed to be disposable. It is made of a treated polymer fabric that filters out 95% of all particles greater than 0.3 μm in diameter. When used correctly, an N95 forms a seal with the skin of the face. They are designed to have fluid resistance to blood and body fluids. They cannot be shared or reused.

Surgical masks & bandanas are not respirators. They are loose fitting and have very low protective factors against airborne infectious materials. Other items, such as hard-plastic face shields and eye-goggles used against splashes of blood and body fluids can be disinfected and reused.

By December 31, there were 27 cases in Wuhan, by January 3 another 44 cases were diagnosed, and the case load increased to 59 on January 5. As the small case load at Wuhan’s hospitals rapidly increased and developed into epidemic, the hours worked per shift increased rapidly.

Stocks of N95 and tyvek suits rapidly ran low. Doctors and nurses ate and drank as little as possible during their shift. To take a toilet or meal break meant they had to change PPE and further deplete the supply. They could not take a chance and transfer infectious materials to canteens or toilets. So they wore adult diapers. Very soon extreme and chronic fatigue set in. Health Care Worker fatigue is the best friend of this corona virus, the precursor to lowered vigilance leading to self-inoculation. Some of Zhang’s colleagues became infected due to prolonged exposure to a large number of patients.

Meet Nurse XU

She is holding a mobile phone, the photo on the screen shows her with one of her patients. Many HCW, and not just Chinese, have developed dermatological problems during the prolonged medical struggle against COVI-19. While an N95 respirator sealing with the skin of the face prevents inhaling the viral aerosols, prolonged pressure against the skin creates ‘pressure wounds’ as a result of friction between the respirator and the naturally moving skin with each inhalation and exhalation. In addition, the respirator has a metal clip which must be tightened over the low nose bridge to prevent leaks. Goggles also cause pressure wounds, especially on the bridge of the nose. Prolonged wearing also means heat and sweat being trapped by the respirator. HCW around the world have developed heat rash from long hours or wearing PPE. A close examination of this photo shows deeply embedded fatigue lines in Nurse Xu’s face.

Many HCW have seen too much. Yet they remain determined. Their physiological and psychological health is critical to bringing about the end-phase of the pandemic. Their struggle will not be over on that day, for there will be after-effects. These days, it is called PTSD. In former times, soldiers developed a self-protective hyper-awareness, ever vigilant to protect themselves and those around them. It was called the “Thousand Yard Stare.”

Epidemic End-Phase in China 

The number of cases in Wuhan and Hubei accelerated throughout January but on about February 4th, the number of new cases peaked and the epidemic in China, concentrated in Wuhan, began to decelerate. By March 10, (see the WHO Epidemic Curve 19 March below) the epidemic in China had been brought down to only a few cases per day. Then began the official counts as required by a law which states, “if statistical data are incomplete or have obvious mistakes, the target under statistical investigation shall provide supplementation or correction according to law.”

Door-to-door and hospital epidemiology work was done resulting in previously-reported mortality tripling from 1,290 to 3,869. The final number of cases was 50,333.  Some of the reasons for the under-estimation were that the surge of cases overwhelmed administrative capacity, there were multiple new treatment centers that put priority on emergency patient treatment over administrative detail, and tragically, many of those who died at home (often the elderly) were not counted. (NB: this statistical issue will be a common feature of all countries).

The Chinese central government reported that by May 31, 2020, a cumulative total of 83,017 confirmed cases had been reported on the Chinese mainland, 78,307 infected had been cured and discharged from hospital, and 4,634 people had died. The cure rate was 94.3%, the fatality rate 5.6%.

Victory was not total, it never can be. For the survivors, there is mourning. For the survivors, there must be healing, there will years of mourning. Many health care workers will have psychological scars. Periodically, much smaller case numbers of COVID-19 appeared in the northern border areas, and new infections even came in late June to Beijing’s Xinfadi Market.

But if China had overcome, as had New Zealand, Viet Nam, Singapore, and a few others, the novel SARS-CoV-2 had slipped into Europe and other areas that had not adequately learned from the experiences of these few countries. The WHO epidemic curve below shows the end of the epidemic in China and the beginning of the Pandemic. It does not show anything close to end phase but only continued acceleration. We will explore this further in Part 2.

How Did China Defeat COVID-19?

The simple answer: through a coordinated national governmental, medical, and scientific response anchored by a disciplined population. China’s people are experienced with medical disasters, having lived through the traumatic period of SARS-1 in 2003. But more, because China is a country subject to regular natural disasters such as extreme flooding and earthquake. A prime example is the May 12, 2008 Ms 8.0 Wenchuan earthquake, mortality >70,000. In SARS-1 and the Wenchuan earthquake, the activation of national emergency response laws resulted in a collective response similar to the sequence of events we now describe.

In the case of this epidemic, the National Emergency Response Plan for Public Health Emergencies was activated in accordance with the Law of the People’s Republic of China on the Prevention and Control of Infectious Diseases. The Premier of the State Council set up a central leading group including the National Health Commission as the central management body for the response. A simplified sequence of events looks like the following:

  • December 31, 2019 the WHO China Country Office was informed of cases of pneumonia of unknown etiology detected in Wuhan City, Hubei Province of China.
  • January 12, 2020: The first complete genome of SARS- was identified & submitted to GISAID & WHO.
  • January 23, 2020: Wuhan travel restrictions, “locked down” at beginning of Chinese Spring Festival.
  • February 3: Production of surgical masks, N95 and GB19083 disposable medical respirators increased to 3,000,000/day.

The key element in the coordinated national response was the dispatch to Wuhan of a total of 42,232 medical volunteers from all provinces. There were 11,416 MDS and 28,679 nurses. The 344 teams included 3 military medical and 17 Chinese Traditional Medicine groups. The air force was a critical component of logistical support.

The dispatch of such huge numbers of medical volunteers to Wuhan has not been  well-documented in western media. But the building of temporary acute-care field hospitals dedicated to COVID-19 treatment grabbed headlines. There were two hospitals, Huoshenshan (Vulcan the God of Fire Mountain) and Leishenshan (Thunder God Mountain), with a total of 2,600 beds. Starting in late January, both were completed within 10 ten days by the work of 40,000 construction workers.

 

Health Care Worker (HCW) Infections and Deaths

In January,Wuhan’s hospital system was soon overwhelmed, flooded with patients, families desperate for care filling hallways. Health care workers lacked PPE, and overwhelmed with fatigue soon became patients themselves. On April 16,  WHO sponsored an international webinar Protection of Health Workers on COCID-19, Lessons Learned from China. Among the presenters was Prof Zhang Min of Occupational Health Standards Committee. She presented the first international comprehensive look at casualties among health care workers: 

  • A leading expert in pulmonary medicine, dispatched from Beijing by the National Health Commission to Wuhan to investigate the outbreak, contracted COVID-19 during his field visit. 
  • On January 25, the first fatality among healthcare workers in China was confirmed. 
  • As of February 11, 1,716 medical workers had been infected by COVID-19.
  • The final tally for HCW deaths in Wuhan was 12 plus one community leader and one policeman),
  • Among the deceased HCW, four were retired and had returned to work for the emergency. There was one nurse, and three  management-level senior MDs doing front-line patient care.

Prof. Zhang Min summarized the most important factors causing the infections and deaths of HCW:

  • HCW were not always aware of or able to implement the standard precautions, especially non-emergency & non-infectious disease wards. As an example, five medical workers in a Beijing hospital’s cardiology department were infected.
  • The need for PPE out-paced the supply of medical-grade tyvek suits, respirators, and eye protection.
  • The long hours witnessing patient suffering and death with inadequate fatigue recovery time resulted in the physiological stresses of burnout and post-trauma stress disorder.
  • Support for the mental health of healthcare workers was not given priority in the early stages of the outbreak.
  • Critically, there was no standardized procedure for daily or even routinely carrying out the health surveillance and environmental monitoring of healthcare workers.

She stated: “In the long term, the outbreak of this virus has underlined how crucial it is for China to develop a comprehensive system that provides occupational health for all healthcare workers at each health facility with essential preventive services provided.”

 

In memory of Dr. Liu Zhiming. He was president of Wuchang Hospital and died on February 18 from COVID-19. He was a front-line practitioner who became infected taking care of patients. He is remembered as having told his staff, “”One bed equals one life, if we can prepare one more bed, we would save one more life.” He is said to have worked almost 72 without a real break. Brief histories of other HCW who died can be found a this link to the English-language Chinese press.

 

Preventing New Health Care Worker (HCW) Infections and Deaths

The core value of saving lives in any epidemic is the protection of HCW. With up to 42,000 medical workers being deployed over time, with vast amounts of medicines both traditional and modern being produced, with PPE and medical devices bring manufactured, and with emergency field hospitals being constructed, rapid, effective, and systemic administrative measures were put into place to preserve the health of HCW while they saved lives.

The Central Government instructed local authorities to ensure all workers in the national effort to suppress COVID-19 had adequate working conditions, including access to food, rest, and equipment. HCWs infected with COVID-19 now qualified for work-related injury insurance. The definition of occupations qualified for workers’ compensation was expanded to emergency response workers, cleaners, laboratory workers, traditional healers, traditional midwives, funeral and burial workers, home-care workers and notably, religious leaders. The salaries for all front line medical workers were tripled.

The second administrative control was comprehensive training. By January 21, the ILO/WHO joint instrument The Occupational safety and health in public health emergencies: A manual for protecting health workers and responders was translated and shared on social media. This manual was used as the basic document to give comprehensive training in preventing exposure to the  virus for all teams before they left for Wuhan.

Given the nature and experience of China up until this point, the authors assume that the ILO/WHO training document was not just adopted but was also modified according to Chinese experiences and needs.

Training was started prior to each team’s leaving its home area, and upon arrival in Wuhan everyone went through even more training. They practiced seven scenarios in a row up for up to 450 minutes. When Teams arrived in Wuhan, HCW were in the wards up to 12 hours. As PPE became available, the administrative control of shift lengths was reduced to 4 hours, and providing rest and recuperation time to exhausted workers became mandatory.

A third method was supervision and self-supervision. By this time enough experience had accumulated for the public to know how serious and powerful SARS-CoV-2 was. Chinese culture has always stressed collectivism starting with the family structure. Like it or not, understand it or not, collective action is a characteristic of Chinese society since antiquity, supremely useful when disciplined activity is required during disasters.

In context of SARS-CoV-2, a set of full-time, dedicated-to-task PPE supervisors were appointed. The responsibilities of PPE supervisors were to ensure that no patient infected a HCW and that no HCW self-inoculated herself. Prior to entry onto an isolation ward, a full-time staff-PPE supervisor:

  • Prepared and checked the quantity and quality of protective materials for all team members, 
  • Checked the respirator fit before HCW entered isolation wards,
  • Ensured the removal and disposal of PPE was done in correct order to prevent self-inoculation;
  • The supervisory system was accompanied by a buddy-system required for entry-exit of isolation wards.

The methodology of putting on, taking off, and disposing of PPE was meticulous. Taking off PPE took a half-hour spaced through 27 steps, including 12 hand sanitization, and constant nucleic acid testing. Readers who want to know more can refer to the following videos:

How to put on a set of PPE against COVID-19before going to a ward: https://www.youtube.com/watch?v=9HsGqQCLzLU

This video outlines the Management and psychological pressures on medical directors and some solutions. Director Critical Care, Zhou Xiaoyang Wuhan University People’s Hospital: https://www.youtube.com/watch?v=BCE_F53FkH8

**“After 6 hours work, many nurses haave to inhale oxyen too”: Wuhan Hospital Story
https://www.youtube.com/watch?v=os4yemZA6Qc

The results were as spectacular as the efforts put into them: zero infections among the 42,000 medical workers responding to Wuhan city and Hubei Province.

Industrial Hygiene Support for Chinese HCW On January 31 the authors wrote An Appeal for Altruistic & Humanitarian Donations For Medical Volunteers going to Wuhan to members of the American Industrial Hygiene Association (AIHA). A Chengdu, Sichuan businessman had informed one of the authors that volunteer doctor and nurse teams were going to Wuhan, but they were short of PPE. The Appeal letter even contained air courier way-bills and the numbers of medical respirators, tyvek suits and other PPE according to Chinese and international standards. The appeal explicitly stated that the supplies would go directly to Chengdu HCW destination with destination Wuhan, and not to NGOs or individuals that had their own distribution networks that were sometimes scandal-ridden.

Analysis

The Chinese government reported that by May 31, 2020, a cumulative total of 83,017 confirmed cases had been reported on the Chinese mainland, 78,307 infected had been cured and discharged from hospital, and 4,634 people had died. The cure rate was 94.3%, the fatality rate 5.6%.

Every country has its own history and culture that cultivates its ability to deal with disasters. We first note that China, New Zealand, Singapore, South Korea, and Viet Nam all have different political systems and cultural heritages. Yet each had successes in the short term against COVID-19. Each of these countries had common actions: rapid understanding at the highest national levels about the seriousness of the epidemic, quick emergency planning, relatively unencumbered decision making to deploy resources, severe restrictions of population movement, education of the public about the nature of the disease and how to prevent spread. Critically, voluntary compliance on the part of the population led to active support for preventive measures. In other words, adherence to legally mandated quarantine measures depends on: 

  • The confidence of the population in the necessity of those measures;
  • Active participation in those measures;
  • The ability of political leadership to tell the truth about the nature of the epidemic and the reasons for the quarantine measures;
  • The above three conditions depend on a public educated about health issues;
  • Conversely, the suppression an epidemic will inevitably be weak when senior governmental structures are illiterate about public health, cast aside the best of advice of experienced medical scientists, and deliberately tell lies about ineffective drugs or the actual seriousness of the epidemic.

In the next four sections, we summarize how China was able to strategically suppress and defeat the epidemic 

  1. Response Reporting Mechanisms

In the beginning, two elderly patients and a couple of others presented themselves to hospital in Wuhan. A clinician with an incisive mind made the diagnosis of pneumonia of unknown etiology which resulted in a legally mandated sequence of reports. The first report was to the hospital leadership which then informed the city CDC. After a few more cases, the Hubei Provincial CDC was informed, which in turn led to passing the information to the China office of the WHO on January 5. 

  • Total number of diagnosed cases of pneumonia of unknown etiology: 44;
  • Total time passed: 10 days.

By any reasonable standard, the response represents a rapid local hospital, city & provincial CDC response to a pneumonia of unknown etiology, all according to established protocols.

Analytical Comment: The United States Executive Branch has been persistently and perniciously vocal in saying that China and WHO “fumbled” the response to COVID-19. On July 7th it served formal notice it was withdrawing from WHO over multiple issues, including its relationship with a member country, China. Given the sequence of events and the fact that COVID-19 is a novel disease, the statements of the US Executive Branch are nonsensical, designed to deceive, and contrived for purposes other than saving lives and suppressing the virus. The medically-illiterate US Executive Branch has actively pursued policies that have ensured that it is the country with 25% of all international cases and 23% of all international deaths (calculated from the WHO Daily Situation Report). In contrast to the medical illiterates in the Executive Branch and some States, the United States possesses some of the greatest health care workers and health research scientists in the world and the US administration has regularly ignored their knowledge and advice.

B. Occupational Health and Safety

The situation was exacerbated by low stocks of PPE, physiological stresses placed on doctors and nurses working extremely long shifts in adult diapers, unable to eat and re-hydrate on a normal schedule, and to extreme psychological stresses. There were 1,716 medical workers infected by COVID-19 and six fatalities in January. Importantly, there was no system in place to educate medical workers in standardized safe work procedures and to monitor the effectiveness of the procedures. The deaths of Drs. Li Wen Liang and Liu Zhiming became highly publicized and shocked the Chinese population. As the epidemic rate increased logarithmically, other workers suffered occupational injuries and deaths. The non-medical workers included emergency response workers, cleaners, laboratory workers.

C. China’s International Response

On January 4, nine days after the first diagnoses of ‘pneumonia of unknown etiology,’ and with 44 cases, WHO was informed. On the same day, the head of the China CDC had a telephone conversation with the head of the USA CDC. On January 8, the heads the Chinese and US CDCs held a second consultative phone call on the new virus. On January 12, the genome sequence of the novel coronavirus (2019-nCoV) was submitted to WHO and was published by the Global Initiative on Sharing All Influenza Data (GISAID) and shared globally. Approximately 16 days had passed from first diagnosis of a disease of unknown etiology to sharing the genome internationally. As late as February 11, China CDC experts had a teleconference at the request of flu experts from the US CDC, during which they shared information on novel coronavirus prevention and control. 

By any reasonable standard the WHO, the US CDC, and the Chinese CDC were doing exactly what they were supposed to do, according to well-established protocols for disease prevention, identifying new diseases.

D. China’s National Response

The key element that guides our thinking is not that the Wuhan hospital system was rapidly overwhelmed by the tsunami-like force of SARS-CoV-2. Health Care Workers fought the novel corona virus with all the strength they could muscle. As their strength became physically, physiologically, and psychologically depleted, supplies running out in January, China’s disaster management system was summoning its own formidable muscle. We cannot know the behind-the-scenes discussions that happened within the Chinese government. But we can know some results.

On January 23, the transportation hub of Wuhan was closed to out-bound traffic, civilian and on January 24, military medical teams began to deploy to Wuhan. The very nature of such closures and deployment presumes pre-planning earlier in the month. Such planning requires logistical support for a quarantined city’s supply of daily necessities and for the support of what would amount to 40,000 medical workers functioning day and night. Wuhan’s exhausted HCW could now breathe easy and pass on the lessons learned from their blood, sweat, and tears. All this happened within approximately three weeks of the first diagnosis in the last days of 2019. In addition, the National Health Commission put in place reforms such as workers’ compensation and work-rest regimes for the thousands of non-medical workers who responded to the epidemic.

Between February 2 and 6, two major field hospitals were completed and began accepting serious cases of COVID-19. On February 10, a mechanism was established to organize pairing assistance from cities of other provinces to Hubei’s cities; this sister-to-sister system is a feature typical of China’s major disaster management system. By February 11, thanks to production increases, PPE supplies surpassed domestic needs, which had the side benefit that China began exporting PPE to developing countries in need.

Coda

To date, China is not the only country to have successfully suppressed SARS-CoV-2. South Korea, Singapore, Viet Nam have been successful, each of these countries of different social, cultural, and political systems. These countries and several others have made the hardest decisions to control the virus. They did not yield to the fallacy of “open the economy.” They put lives first, money second. To be sure, the virus is especially opportunistic and managed to slip back into each of the countries, mainly by international travel that was not caught at borders. But each of these countries, by dint of their successes and accumulated experiences, bought time for the rest of the world to prepare for pandemic. 

China’s experience is singular by the unprecedented scope and sheer mass of its efforts. It not only managed to decelerate the epidemic in 5 weeks, but it then began to assist the developing world with PPE, medical equipment, and its own cadre of experienced medical personnel. In so doing it worked in parallel with the World Health Organization, multiple international charities, foundations, scientists, and progressive businesses to alleviate suffering and death.

In part one, we have concentrated on the pandemic in China. In part two, we will discuss the international pandemic. The title speaks to “End Phase.” But as shown in the above graph from WHO, we are a long way from the End Phase.

Further Analysis

Canada’s Chinese Communities: Self-Quarantine – Self-Support What is not well known in Western countries is that Chinese communities throughout the world were sending stocks of PPE to China through informal channels. The authors are aware of numerable community groups in British Columbia, Canada organized through the WeChat social media that collected PPE and shipped them to a variety of private contacts in China. To our knowledge these efforts have rarely been documented and converted into social-science research which can then be aligned with the epidemiological research to improve responses to epidemics.

Post-Script

The Tunnel Engineer’s Thinking He is not a tall man, but his thinking is sky-high. He is a tunnel engineer, an expert in geology and large-bore tunnel boring machines. He does not possess ‘tunnel vision.’ One day in April he said, “You know, this virus is much powerful than any nuclear weapons, it is going to change the world. Each country spends so much money each year on military purposes, but this can do nothing for such an invisible enemy like this SARS-CoV-2. Countries like the USA have made so many powerful weapons but they can’t even make enough ventilators to save the life of their own citizens.

“I want to say that for many years human being have been moving in wrong direction. We gotta change, and we gotta change now.”

On Wednesday July 7, 2020. the United States government made their barbarian official decision that they will withdraw from WHO, blaming it for “fumbling” the response to SARS-CoV-2. Yet this is the country that today is still not self-sufficient in N95 respirators, in which the primary place of COVID-19 mortality is in the care homes for the elderly who built the nation with blood, sweat, and tears, many of them the combat veterans of WWII. This is the country that as of July 11 has accumulated 3,097,300 cases and 132,683 deaths. That is 25% of all mortality and 23% of international cases.

The tunnel engineer is correct: we gotta change. Just as Dr Tedros of WHO said, This is “the first pandemic in history that could be controlled….The great advantage we have is that the decisions we all make – as governments, businesses, communities, families and individuals – can influence the trajectory of this epidemic…[it is] an uneven epidemic at the global level.”

Erratum (July 17) The original post stated: “…the case load increased to 59 on January 18.” The date is incorrect and should be January 5.

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