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In the first weeks of 2020, a radiologist at Xinhua Hospital in Wuhan, China, saw looming signs of trouble. He was a native of Wuhan and had 29 years of radiology experience. His job was to take computed tomography (CT) scans, looking at patients’ lungs for signs of infection.

And infections were everywhere. “I have never seen a virus that spreads so quickly,” he told <a href="https://bit.ly/Caixin_InternalDoc" target=_blank>a reporter for the investigative magazine Caixin.</a> “This growth rate is too fast, and it is too scary.”

“The CT machines in the hospital were overloaded every day,” he added. “The machines are exhausted and often crash.”

But this tableau of chaos was hidden from the Chinese people — and the world — in early 2020. Chinese authorities had acknowledged on Dec. 31, 2019, that there were 27 cases of “pneumonia of unknown origin,” and <a href="https://www.who.int/emergencies/disease-outbreak-news/item/2020-DON229" target=_blank>44 confirmed cases</a> on Jan. 3, 2020. The Wuhan health commission reported 59 cases on Jan. 5, then abruptly reduced the number to 41 on Jan. 11, and claimed there was no evidence of human-to-human transmission or any signs of doctors getting sick.

That claim was a lie. The <a href="https://www.washingtonpost.com/coronavirus/" target="_blank" class="contextual_link">coronavirus</a> was running rampant. Doctors at the radiologist’s hospital, and other hospitals, were getting sick. But China’s Communist Party leaders prize social stability above all else. They fear any sign of public panic or admission that the ruling party-state is not in control. The authorities in both Wuhan and Beijing kept the situation secret, especially because annual party political meetings were being held in Wuhan, the capital of Hubei province, from <a href="https://www.washingtonpost.com/january-6-capitol-riot/" target="_blank" class="contextual_link">Jan. 6</a> to Jan. 17.

Secrecy has long been a major tool of the governing Communist Party. It suppresses independent journalism, censors digital news and communications, and withholds vital information from its people. Doctors in Wuhan who knew the truth were afraid to speak out. China did not reveal human transmission of the virus until Jan. 22, and by then, the pandemic had been ignited. In 3½ years, covid-19 has taken nearly 7 million lives <a href="https://covid19.who.int/" target=_blank>by official counts</a>. The true death toll is probably <a href="https://www.economist.com/graphic-detail/coronavirus-excess-deaths-estimates" target=_blank>twice or three times</a> that number.

This editorial is part of a series examining the <a href="https://www.washingtonpost.com/opinions/interactive/2023/political-protest-new-generation-faces/" target="_blank">inner workings of authoritarianism</a> around the world. Previously, we looked at how dictatorships <a href="https://www.washingtonpost.com/opinions/2023/07/28/myanmar-junta-telegram-resistance-snitch/" target="_blank">exploit social media</a>, at the <a href="https://www.washingtonpost.com/opinions/2023/03/29/russia-disinformation-ukraine-bio-labs/" target="_blank">creation of disinformation</a> and at <a href="https://www.washingtonpost.com/opinions/2023/06/22/dictators-trade-toolkits-cling-power/" target="_blank">how autocrats share tactics</a>. This installment examines how China’s authoritarian system handled a grave public health crisis, as seen through the eyes of doctors and other health-care professionals on the front lines who were struggling to cope with a virus no one had witnessed before. At a time when trust and transparency were needed to save lives, Chinese authorities covered up the facts and lied — and they continue to do so today.

In Wuhan, the radiologist realized the virus was jumping from person to person. On Jan. 16, he spoke privately about it with a colleague, expressing concern the disease was exploding. The colleague, in tears, replied, “Wuhan will go down in history as a result.”

Stringer

In any battle against disease, the rapid flow of information is essential. China learned this the hard way in the 2003 SARS outbreak, when <a href="https://www.ncbi.nlm.nih.gov/books/NBK92479/" target=_blank>state secrecy hobbled the response</a> as 8,098 people became ill and <a href="https://www.cdc.gov/sars/about/fs-sars.html" target=_blank>774 died in China and elsewhere</a>. After that, China set up a digital system for reporting a spreading disease. The core is the National Notifiable Disease Reporting System (NNDRS), which provides online reporting of cases. Covering the entire country, it allows for an entry to be accessible at all levels, from local hospitals to the Chinese Centers for Disease Control and Prevention (CDC) in Beijing. <a href="https://archive.li/9rgAt" target=_blank>Chinese officials boasted</a> that the <a href="https://docs.google.com/document/d/18P7kzpO7arjvwINUDMGSGuR1BqLHTvO13t-e2vwX-aQ/edit" target=_blank>new system was “horizontal to the edge, vertical to the bottom,”</a> that <a href="https://bit.ly/3SafmBo" target=_blank>it would report</a> on detected sickness within hours.

The NNDRS was largely designed to report on known diseases with an early-warning component. In particular, China was on the lookout for dangerous respiratory contagions like the first SARS, which were given a special category — PUE, for “pneumonia of unknown etiology,” or unknown origin. The CDC monitors the NNDRS reports daily. If more than five cases of PUE are found in one location, the CDC is supposed to send a special team to investigate. But by some accounts, the PUE system was plagued with false positives — cases that turned out to be something else.  And for the reporting to happen, a doctor or dedicated hospital staff must fill out an electronic “report card”; a phone call or other method doesn’t suffice.

This internal reporting is separate from what the public is told. Public disclosure is controlled by the party. This power lies with health commissions at the local, provincial and national levels, and ultimately with the State Council, China’s highest-ranking body. Every major institution in China, including its hospitals, has a party overseer. In the health-care realm, China’s CDC has standing only to offer advice about an issue, not to decide what measures to take in response.

In January 2020, the system failed as the virus spread. This can be gleaned from documents and interviews conducted by Chinese journalists. They managed to capture a revelatory picture of the struggle by doctors and hospitals despite China’s strict limits on news reporting and its system of censorship. Gilles Demaneuf of the research group DRASTIC, which has been probing the origins of the virus, has compiled and translated these materials in a <a href="https://washingtonpost.com/documents/a5102da1-9b47-4e11-b615-9f59b7d3a3c3.pdf" target=_blank>193-page report</a> he has shared with the World Health Organization’s Scientific Advisory Group for the Origins of Novel Pathogens. The report was made available to us. The findings are <a href="https://usrtk.org/covid-19-origins/foi-documents-on-origins-of-sars-cov-2-risks-of-gain-of-function-research-and-biosafety-labs/" target=_blank>augmented by disclosures from U.S. Right to Know</a>, a freedom-of-information group, and news accounts and <a href="https://www.marshall.senate.gov/wp-content/uploads/MWG-FDR-Document-04-11-23-EMBARGOED.pdf" target=_blank>congressional</a> <a href="https://oversight.house.gov/report/interim-staff-report-the-proximal-origin-of-a-cover-up-did-the-bethesda-boys-downplay-a-lab-leak/" target=_blank>investigations</a> in the United States.

In editorials last year, we called attention to how the virus was spreading in November and December 2019, earlier than China has admitted; how China had carried out <a href="https://www.washingtonpost.com/opinions/interactive/2022/china-researcher-covid-19-coverup/" target=_blank>genomic sequencing</a> of the virus in late December 2019; and we pointed to <a href="https://www.washingtonpost.com/opinions/2022/11/17/covid-early-cases-wuhan-china-mystery/" target=_blank>additional cases that were not reported</a> to a joint mission of China and the WHO. It is still not known precisely how or where the pandemic began, whether from zoonotic spillover or a laboratory leak. But by the end of December 2019, the growing caseload set off alarms in Wuhan. The <a href="https://www.washingtonpost.com/opinions/interactive/2022/china-researcher-covid-19-coverup/" target=_blank>genomic sequencing showed</a> the virus was closely related to the first SARS virus, which had set off panic in China almost 20 years earlier.

China’s small clinics are often the first stop when people get sick. For additional treatment, patients proceed up a ladder of tertiary, secondary and primary hospitals. One of those at the top was Wuhan Central Hospital, a large-scale municipal facility, providing complex health care and advanced medical training and research. It has a main campus near the river on Nanjing Road and a secondary branch, known as Houhu, near the Huanan Seafood Wholesale Market, a huge bazaar selling seafood as well as farmed wildlife — alive and frozen — that became a superspreader venue for the new virus. Wuhan Central was a sentinel hospital for China’s CDC — to be on the lookout for infectious-disease outbreaks in central China.

Both branches had started to receive patients with the new illness, and by Dec. 30, 2019, seven patients were at the Houhu branch. Several had links to the market. Other hospitals started to see patients with coughing and other virus symptoms, too.

That afternoon, at 3:10 p.m., the Wuhan health commission — the political level — issued an “<a href="https://www.washingtonpost.com/opinions/2022/11/17/covid-early-cases-wuhan-china-mystery/" target=_blank>urgent notice</a>” to health institutions to look out for PUE cases. Another notice followed at 6:50 p.m., warning “not to disclose information to the public without authorization.”

At Wuhan Central that evening, ophthalmologist Li Wenliang <a href="https://www.sixthtone.com/news/1005150" target=_blank>examined the medical report</a> of a patient whose condition seemed strikingly like SARS. He <a href="https://bit.ly/LiWenliangPosts_30Dec2019" target=_blank>shared it with his former medical school friends</a> in their class WeChat group, so they could be prepared. “Seven cases of SARS confirmed,” he wrote. On Jan. 1, Li was <a href="https://archive.ph/KbKBF" target=_blank>detained by police</a>, along with seven other doctors. He was accused of “making untrue comments” that had “severely disturbed the social order.” He was reprimanded for “this illegal activity” and signed a paper promising not to do it again.

Separately, Ai Fen, head of Wuhan Central’s emergency department, grew concerned about the infections. She alerted the hospital management that one of the patients ran a small clinic near the market and had treated many people from there, strongly suggesting human-to-human transmission was underway. She asked her staff to begin wearing N95 masks. This set off fresh alarms. The staff realized it meant transmission was underway and the virus could threaten them as well as everyone else.

Robert Cianflone

On Jan. 2, she was reprimanded by Cai Li, the party boss at the hospital, who accused her of spreading rumors. The emergency department head said she was told not to send any text or WeChat messages about the virus, but to communicate about it only face-to-face with other doctors. Similar orders went out to other doctors at Wuhan Central. The masks became an urgent issue. In response to protests, hospital leaders allowed doctors in three departments — emergency, respiratory and ICU — to wear masks but ordered those in other departments, including gynecology, urology, cardiology, ophthalmology and ultrasound, not to. Many of these doctors went unprotected — and got infected.

Also on Jan. 2, a memo went out at the Wuhan Institute of Virology, a major research center on coronaviruses. Employees were warned that “all testing and experimental data, results, and conclusions related to the epidemic should not be published on blogs and social media, and should not be shared with the media (including official media), or partner organizations.”

<a href="https://bit.ly/Caixin_InternalDoc" target=_blank>According to the radiologist at Xinhua Hospital</a>, the reprimand to Li and the other doctors “really shocked us.” He added, “This incident played a great role in the gagging of the medical community. … Most of us dare not speak out publicly for fear of being summoned by the police.”

But he saw the reality at Xinhua Hospital, which was formally named Hubei Provincial Hospital of Integrated Traditional Chinese and Western Medicine. He recalled that starting on Jan. 5, he saw two or three images indicating infections, then more each day. Then “suddenly it showed a multiple fold increase” to 30 a day and kept doubling. By Jan. 11, he said, “medical staff in the unit were infected one after another.” The government had still not acknowledged human-to-human transmission, or health-care workers getting sick, but the virus was everywhere. “The hospital was full of people, and the situation was a bit chaotic,” <a href="https://docs.google.com/document/d/1WjpPF5U7d_oq1Y9CJIg0Uhpb-igkFLtGFISiwybZYGU/edit" target=_blank>the radiologist said</a>.

“Our hospital’s outpatient clinic is crowded with a large number of suspected patients who can’t be admitted,” he said. “Some patients kneel down and beg the doctor to take them in.”

The public was given only a skimpy version of the facts. Days went by with no announcement of any new cases and no warnings. In Wuhan, crowds bustled at a mass banquet, and <a href="https://www.nytimes.com/interactive/2020/03/22/world/coronavirus-spread.html" target=_blank>millions began to travel</a> at the opening of the Lunar New Year celebrations.

But the highest levels of China’s government knew the truth. According to a key <a href="https://apnews.com/article/virus-outbreak-health-ap-top-news-international-news-china-clamps-down-68a9e1b91de4ffc166acd6012d82c2f9" target=_blank>memo obtained by the Associated Press</a>, on Jan. 14, the head of the National Health Commission admitted to provincial officials in a teleconference that the situation was “severe and complex, the most severe challenge since SARS in 2003.”

Hector Retamal

When it was needed most, China’s disease reporting system collapsed. In part, this was because of confusion and administrative bungling. Patients who showed up at small local clinics in the first weeks were sent home or to second-tier hospitals, and these cases most likely never generated the “report card” necessary for registering in the system. Also, the high costs of hospitalization in a top-ranked facility might have discouraged many sick people from going there. Moreover, <a href="https://bit.ly/3SafmBo" target=_blank>many front-line doctors had not used the disease reporting system </a>or were wary of reporting an infection of an unknown nature. Top authorities issued conflicting criteria for what defined a new case — at first, the patient had to be linked to the Huanan market, but after many people who had not been to the market became ill, that requirement was dropped.

And there was one other major factor: In the first weeks of January 2020, high-level officials made a deliberate effort to slow-walk the reporting of cases.

The admonition not to write anything down — and to pass reports only verbally — immediately thwarted the NNDRS system, which accepted only written, electronic “report cards” that could be filed only by a doctor or other select staff in the hospital, such as the public health department. As one worker in the emergency department of Wuhan Central put it, “There is no written report, it cannot be reported, and what you say doesn’t count.”

According to the radiologist at Xinhua Hospital, authorities also <a href="https://bit.ly/Caixin_InternalDoc" target=_blank>limited the number of virus samples tested</a> in Wuhan. The quantity of tests was small and the quality poor; China had neither the means nor intention at this point to test broadly. This left many people stuck in limbo as “suspected” cases, or sent home to recover, rather than be admitted to hospitals. If they died, they were kept off lists of confirmed cases. Authorities also decided on Jan. 11 that records of CT scans were not to be given directly to medical staff, who would be informed only verbally of the results. This was to conceal the infections among medical staff, which the government had claimed were not occurring.

Repeatedly in hospitals, doctors were told to be “careful” and “cautious” about filing a report card for a new case. A<a href="https://docs.google.com/document/d/1Uf_B8FAM0eOMrNxUG2M31B1ujvAUyEzDJkXq1gwwTeo/edit" target=_blank> day-to-day chronology of events at Wuhan Central</a> from Dec. 29 to Feb. 8 was prepared by a public health doctor there. The document was obtained by Caixin and another Chinese publication, the Paper. Both said they confirmed its authenticity. The document shows a pattern of slow-walking the reporting.

The initial seven patients at Wuhan Central had been reported only by telephone, and the public health doctor was eager to file the electronic report cards. But he was instructed by political officials and higher-ups to wait. Although the cases were in the hospital in late December, they were not entered into the system until Jan. 8, <a href="https://bit.ly/WCH_DescriptionHandling" target=_blank>according to the chronology</a>.

On Jan. 11, the Wuhan health commission revised the total cases downward to 41, based on the first PCR tests, and declared — yet again — that “no clear evidence of human-to-human transmission” had been found.

On Jan. 12, the public health doctor at Wuhan Central got more instructions from above: Any report card of new infection must be “cautiously” reported. On Jan. 13, a meeting was held at the hospital, and the doctors and public health officials were warned that cases of infection could be reported only with the consent of the city and provincial health commissions — the political level. These layers of approval only clogged the system more. “On Jan. 16,” <a href="https://bit.ly/WCH_DescriptionHandling" target=_blank>the public health doctor wrote</a>, “I asked the surrounding hospitals about the recent report card entries and learned that they had not reported any card recently.” But, he added, the virus was ravaging the city, and asymptomatic infection had appeared. Other <a href="https://docs.google.com/document/d/1WjpPF5U7d_oq1Y9CJIg0Uhpb-igkFLtGFISiwybZYGU/edit" target=_blank>front-line doctors estimated</a> that there were tens of thousands of cases by Jan. 21.

“In mid-January, everyone was covering their eyes,” a doctor from Wuhan Central told Caixin. “From the province to the city to the hospital: the province did not allow the city to report, the city did not allow the hospital to report, and the hospital did not allow the hospital department to report. It was just covered up layer by layer, causing the golden period of prevention and control to be missed again and again.”

The <a href="https://bit.ly/Caixin_InternalDoc" target=_blank>radiologist saw the gap</a> between the government statements and reality. On Jan. 18 at his hospital, there were 86 cases. “After that, there were more than 100 cases every day.”

If he had known a pandemic was coming, he said later, he would have taken the risk and warned the public. At the time, “I was weak and chose to remain silent.” He posted a personal message on the microblogging app Weibo, urging elderly people to wear masks, but he had few followers, and “no one heard it.”

Doctors in Wuhan bore an especially heavy burden. <a href="https://archive.is/M9yUx" target=_blank>Four of them at Wuhan Central Hospital later died of covid</a>, including Li, the ophthalmologist who was reprimanded.

Mark Ralston

Public health — the management of the well-being of a whole population — presents a special test of governance. A vital part of protecting people is communicating clearly what is happening, persuading them to modify their behavior to avert illness and death, and building trust over time. Failure in any of these tasks can lead to far greater suffering.

The United States and other open societies struggled with political polarization, fragmentation and disinformation during the pandemic. Misinformation and untruths spread fast, often outpacing sound public health counsel. Many unnecessary deaths resulted.

Lawyers plead guilty in racketeering case in Fulton County, Ga.

The Biden administration announces more than $100 million to improve maternal health.

Wisconsin Republicans back off impeachment threat against justice.

Bahrain’s hunger strike ends, for now, after concessions to prisoners.

A Saudi court sentences a retired teacher to death based on tweets.

Attorneys for Donald Trump have pleaded guilty in the racketeering case led by Fulton County, Ga., District Attorney Fani T. Willis. Even those lawyers related to the deals focused on equipment-tampering in rural Coffee County are relevant to the former president — they help to establish the “criminal enterprise” of which prosecutors hope to prove Mr. Trump was the head. The news is a sign that the courts might be the place where 2020 election lies finally crash upon the rocks of reality. The <a href="https://www.washingtonpost.com/opinions/2023/08/15/trump-georgia-indictment-rico/" target=_blank>Editorial Board wrote</a> about the wide range of the indictment in August.

The Department of Health and Human Services announced more than $103 million in funding to address the maternal health crisis. The money will boost access to mental health services, help states train more maternal health providers and bolster nurse midwifery programs. These initiatives are an encouraging step toward tackling major gaps in maternal health and well-being. In August, the <a href="https://www.washingtonpost.com/opinions/2023/08/18/maternal-mortality-united-states-policy-solutions/" target=_blank>Editorial Board wrote</a> about how the United States can address its maternal mortality crisis.

Wisconsin state Assembly Speaker Robin Vos (R) announced Tuesday that Republicans would allow the nonpartisan Legislative Reference Bureau to draw legislative maps, <a href="https://www.jsonline.com/story/news/politics/2023/09/12/vos-pushes-for-new-electoral-maps-to-bypass-liberal-court/70835377007/" target=_blank>a dramatic reversal after years of opposing such an approach to redistricting</a>. A new liberal majority on the state Supreme Court is expected to throw out the current maps, which make Wisconsin the most gerrymandered state in America. Mr. Vos has been threatening to impeach Justice Janet Protasiewicz, whose election this spring flipped control of the court, in a bid to keep those maps. This led to understandable outcry. Now it seems Mr. Vos is backing off his impeachment threat and his efforts to keep the state gerrymandered. <a href="https://www.washingtonpost.com/opinions/2023/03/29/wisconsin-supreme-court-judge-election/" target=_blank>Read our editorial on the Protasiewicz election here</a>.

Prisoners are <a href="https://apnews.com/article/bahrain-hunger-strike-prisoners-crown-prince-visit-d32bca16ff3da2b985d75e38c174c0f8" target=_blank>eating again in Bahrain</a> after the government agreed to let them spend more hours outside and expanded their access to visitors, a welcome development ahead of the crown prince’s visit to Washington this week. Activists say the monthlong hunger strike will resume on Sept. 30 if these promises aren’t kept. <a href="https://www.washingtonpost.com/opinions/2023/09/10/bahrain-hunger-strike-crown-prince/" target=_blank>Read our editorial calling for the compassionate release of Abdulhadi al-Khawaja</a>, a political prisoner since 2011 who participated in the strike.

A retired teacher in Saudi Arabia, Muhammad al-Ghamdi, has been sentenced to death by the country’s Specialized Criminal Court solely based on his tweets, retweets and YouTube activity, <a href="https://www.hrw.org/news/2023/08/29/saudi-arabia-man-sentenced-death-tweets" target=_blank>according to Human Rights Watch</a>. The court’s verdict, July 10, was based on two accounts on X, formerly Twitter, which had only a handful of followers. The posts criticized the royal family. The sentence is the latest example of dictatorships imposing harsh sentences on people who use social media for free expression, <a href="https://www.washingtonpost.com/opinions/interactive/2023/political-protest-new-generation-faces/?itid=sf_opinions_habit-bar_p003_f001" target=_blank>highlighted in our February editorial</a>.

But while democracies are swamped with information as well as disinformation, China’s dictatorship bottled up the truths and published lies. The party’s quest for absolute control — through fear, threats and intimidation — blocked action precisely when the virus spread might have been slowed or stopped. The decisions allowed a spark to become a wildfire, a disaster of immense proportions. As the pandemic unfolded, China remained a black box. It slammed the door on any further investigation of the origins of the virus inside China and did not publish accurate data on the pandemic death toll; doing so might have called into question the party’s competence and leadership. When Zhejiang province <a href="https://on.ft.com/44srNyb" target=_blank>recently published mortality data</a> indicating a surge of deaths after China abruptly lifted its “zero covid” policy in December 2022, indicating a higher death toll than China had acknowledged, the data was promptly deleted.

Edward Holmes, an evolutionary biologist and virologist who is a professor at the University of Sydney, exchanged <a href="https://drive.google.com/file/d/126z1_ot8e-GyQSkOJHQKEQXPWdA805Xq/view" target=_blank>messages on Slack</a> with other virologists in March 2020, as the pandemic gained strength. Holmes, who has extensive China experience, wrote of China: “There is so much repression and deceit, it is ridiculous.” He added that the true number of cases was probably much higher than reported and said, “I’ve also heard that some of the hospitals in Wuhan are declining to test because they want to report low/no numbers.”

Dr. Holmes noted the statements that the virus would not transmit between people, and added, “Endless coverups.”

What happened in Wuhan was not a single slip-up or misjudgment. It was a result of how the system works, demanding fealty and imposing control in all directions. It was a deliberate choice to order doctors not to wear masks that could have saved lives; to slow-walk the reporting and thus impede early warning; to shut down communications with the public; and to instruct doctors not to write anything down about the spreading danger. The consequence was death and misery for the Chinese people and the rest of the world on an unimaginable scale.

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In Wuhan, doctors were ordered to be quiet as pandemic began

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Opinion In Wuhan, doctors knew the truth. They were told to keep quiet.

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