Helen Ramscar

It’s almost 20 years since I stepped into a Chinese ‘wet market’. As a ‘lǎowài’ (‘foreigner’), it was certainly an eye-opener. So, when in January 2020 news started to trickle out of China of a new SARS-like coronavirus spreading from the Huanan Seafood Market in Wuhan, the assumption that the heaving wet market was the vector for a serious viral infection seemed straightforward. But along with almost all other details of COVID-19 coming out of China since then, it was not.

This is a matter of some political importance; not to ramp up anti-Chinese resentment – of which there is already a growing wave across the western world – but to help create stronger international protocols to deal with this sort of problem in the future, given its devastating effects both on global public health and the world economy. The world should bring political pressure to bear on China, as the originator of this particular pandemic, to end any further obfuscation and publicly accept the need for absolute transparency and fearless investigation in significant cases of global public health.

There remain troubling issues around what actually happened at ‘ground zero’ in Wuhan, which Beijing in its own interests should deal with straightforwardly. Only then does it have a chance to arrest the slide in its international image that looks set to increase as the human and economic effects of COVID-19 play out.

The Origins of the Outbreak

Were Huanan Seafood Market traders to blame? Reportedly the Huanan Seafood Market was closed on 1 January 2020, and certainly President Xi subsequently spoke out against the wild animal industry in China.[1] Scientists have been advocating for years a straight ban on wet markets and the exotic animal trade, comparing it to a global health ticking time bomb. Wet markets were banned back in 2003 after the SARS outbreak, but subsequently sprang up again. Banning wet markets is a complex and problematical issue, not least because they play a big role in poorer economies. And in China, 5000 years of culture does not stop overnight. Nevertheless, wet markets exist in many countries and the issues surrounding should be tackled internationally. The obvious place to launch a new campaign on the wet markets problem is in China.   

Another theory of how Wuhan became the COVID-19 epicentre was shared by Chinese scientists Botao Xiao and Lei Xiao in February 2020. They cast doubt on the Chinese-state narrative that the virus was transmitted by infected bats being sold at the Huanan Seafood Market. Their interviews with locals indicated that bats were not traded in that market. The authors highlight the close proximity of the market, however, to the Wuhan Center for Disease Control and Prevention and to the Wuhan Institute of Virology; laboratories specialising in SARS coronavirus, in particular bat-borne ones, and from where there had been accounts of lab workers having to self-quarantine after contact with blood and urine of infected species. The nearest known natural hotspots for bats infected with 96% identical genome sequencing as Covid-19 are in the likes of the Shitou Caves in Kunming, some 1500km away (discovered by Professor Shi of the Wuhan labs[2]). The authors suggested that the ‘coronavirus probably originated from a laboratory in Wuhan. Safety levels may need to be reinforced in high risk biohazardous laboratories’; not conclusive proof but entirely reasonable suppositions from two professional scientists that a member of staff may have been contaminated and unintentionally carried the virus outside the lab into Wuhan.[3]

It matters to the rest of the world, and to China’s credibility as a political partner, that Beijing is seen to be prepared to get right to the root of the COVID-19 outbreak. It is not only a question of epidemiology, but one of political signalling to a sceptical world. It is unlikely we will ever know the identity of ‘Patient Zero’ or know how that person came to be infected. It is possible he or she did not know they were infected either. It’s possible, too, that Patient Zero subsequently died.

The Inconvenient Truths 

One of the lessons of this crisis is the danger of politicising professional medical opinion – not the considered opinions of eminent medical committees established to investigate something – but the day to day experience of medical professionals who have no other agenda than their own medical duty to patients.

While the first defence against coronavirus remains to ‘wash hands’ frequently, the world owes Ignaz Semmelweis from the 1840s a great debt of gratitude. Through his observations while director of the maternity unit of the Vienna General Hospital in Austria, he spotted a trend in the high rates of maternal deaths from puerperal fever. It seemed to occur in mothers who had been treated by student doctors (as opposed to midwives) and, in those days, doctors did not wash their hands between patients. Semmelweis observed this crucial difference and spoke out widely. He could not scientifically prove his observations and, ultimately, was castigated by the established medical community.[4] He died without ever knowing that his observations would go on to change medical practice worldwide and be vital to global public health thereafter.

Li Wenliang, a 34-year old ophthalmologist at Wuhan Central Hospital, was the first doctor to observe multiple patients displaying SARS-like symptoms in December 2019.[5] On 30 December 2019, he shared his observations with medical colleagues via social media to warn them to wear protective clothing, and was reprimanded by Chinese officials for doing so. In early January he treated a patient with glaucoma, not knowing they had the new coronavirus. In his Weibo post he describes how on 10 January he started coughing, the next day he had a fever and two days later he was in hospital. Not until 20 January did China confirm to the outside world human-to-human transmission. On 6 February 2020, Li Wenliang died of Covid-19. He died in the hospital where he observed something different and alarming, shared his clinical hunch out of concern, and kept trying to share with the outside world from his hospital bed. Fellow doctors at the same hospital died in quick succession. By early April, Wuhan government officials had given fourteen frontline medics the honour of ‘martyr’.[6] It is impossible to know how many doctors and nurses died from their exposure to the coronavirus before China formally confirmed the emergency. But the fact that a system needs professional clinicians to become ‘martyrs’ does not speak well of its receptiveness to professional judgements – or even good hunches.

China and the International Response

Commentators, and an increasing number of western politicians are laying at China’s door a number of charges about its responses to COVID-19; that it was too slow to respond to early warnings, that it tried to suppress the inconvenient truths – and the doctor who highlighted them; that it allowed the 7-day Chinese New Year celebrations to begin on 24 January despite President Xi confirming on 20 January the need to ‘resolutely curb the spread of the epidemic’, [7] so clearly it was known there was a potentially catastrophic problem building up; that it insulated Wuhan from the rest of the world before it locked it down from the rest of China. Not least, for a country two and half times the size of the European continent, with much poorer public hygiene in general than in Europe, a declared infection toll of 88,000 and 5,000 deaths, compared to Europe’s current running total of over 800,000 infections and 90,000 deaths simply lacks credibility. Beijing claims to be ‘adjusting’ its figures but the suspicion is that they are misleading by an order of magnitude.

None of this helps create a better way of dealing with international pandemics. It is on public record that as recently as 2019 virologists in Wuhan itself were publishing important material on the threat posed by coronaviruses.[8] Covid-19 appears to be the sixth bat-borne viral outbreak in recent years, either by direct bat-to-human transmission or via another animal (horse, camel, possibly pangolin) in between: Hendra in 1994,[9] Nipah in 1998,[10] SARS in 2002,[11] MERS in 2012,[12] and Ebola in 2014.[13] The solution is not the extinction of bats, even if such a cull were feasible. They play an important role in their unique ecosystems and are harmless to humans when left alone.[14] Scientists have been warning that most emerging pathogens originate in wildlife and spill-over into human hosts due to a range of ecological, demographic and socio-economic changes.[15] And China is not the only hotspot – areas of major emerging economies, such as Bangladesh, India, Nigeria and the Atlantic Forest Biome in Brazil, pose great risks too.[16] Some have been calling for developing countries in the tropics, where wildlife diversity is greatest, should be regarded as the front line of the battle against viruses.[17]

Identifying these new threats and devising strategies to counter them will require a very multi-disciplinary approach, bringing together the best of veterinary, ecological, conservation and human medical perspectives on disease emergence.[18] Medical scientists and pharmaceutical companies are required on treatments and vaccines; mathematicians and modelers, economists and social scientists on mitigating the damage created by business and societal restrictions or lockdowns; think-tanks to support policy-makers; civil servants, politicians and statesmen on local, national and international governance levels.

If not WHO, then Who?

Wildlife pathogens respect no borders or persons, and COVID-19 is repeatedly characterised as a new type of war, global in scale. It will, at least, as Kipling said of the Boer War, be ‘no end of a lesson’. And fighting it will require the alignment of new multilateral public, private and philanthropic cooperation, and an international organisation with the infrastructure, credibility and legitimacy to act effectively, widely and quickly. The WHO has come under international criticism for apparently ignoring warnings from Taiwan in December 2019, being too slow to declare a pandemic and too quick to praise China’s handling of it. But the essence of the problem is not the existence of the WHO itself. What would replace it that did anything fundamentally different? Like all UN bodies, it can only work with the membership it has. And in this case, its failings go back – again – to the approaches taken in Beijing over the last five months.

New international protocols for dealing with coronavirus outbreaks are necessary; dealing not only with epidemiological matters, but also with the economic and political implications and the need to communicate them more clearly and swiftly to the international community.

Going back honestly and fearlessly to the COVID-19 ground zero, and perhaps to Patient Zero, will be an important test for the Chinese leadership in the eyes of the rest of the world. It would be a very retrograde step for Beijing to react to the growing wave of international criticism with paranoia and further dishonesty. But a genuine silver lining to the present crisis would open up if Beijing re-dedicated itself to learning and sharing the epidemiological, and political, lessons of the COVID-19 disaster – beginning in and around the wet market in Wuhan.    

 

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[1] ‘We have long recognized that the consumption of wild animals is very risky, but the “wild game industry” is still huge and poses a major hidden danger to public health security. Never be indifferent again! I have given instructions on this issue. Relevant departments should strengthen the implementation of laws, strengthen market supervision, resolutely ban and severely crack down on illegal wildlife markets and trade, resolutely eliminate the bad habits of overeating wild animals, and control major public health risks from the source. It is necessary to strengthen the construction of the rule of law, carefully evaluate the revision and improvement of laws and regulations such as the Law on the Prevention and Control of Infectious Diseases, and the Law on the Protection of Wild Animals, as well as the introduction of laws such as the Biosecurity Law.’ President Xi, Speech at meeting of the Standing Committee of the Political Bureau of the CPC Central Committee, 3 February 2020, Qiushi Journal, available http://www.qstheory.cn/dukan/qs/2020-02/15/c_1125572832.htm

[2] Jane Qui, ‘How China’s “Bat Woman” Hunted Down Viruses from SARS to the New Coronavirus’, 11 March 2020, Scientific American, available at https://www.scientificamerican.com/article/how-chinas-bat-woman-hunted-down-viruses-from-sars-to-the-new-coronavirus1/

[3] Botao Xiao and Lei Xiao, ‘The Possible Origins of 2019-nCov Coronavirus’, February 2020, available at https://img-prod.tgcom24.mediaset.it/images/2020/02/16/114720192-5eb8307f-017c-4075-a697-348628da0204.pdf

[4] Ignaz Semmelweis (1818-65), Science Museum,  http://broughttolife.sciencemuseum.org.uk/broughttolife/people/ignazsemmelweis

[5] BBC, ‘Li Wenliang: Coronavirus death of Wuhan doctor sparks anger’, BBC, 7 February 2020, https://www.bbc.com/news/world-asia-china-51409801

[6] Xinhua, ‘14 people who died in fight against COVID-19 identified as martyrs’, Xinhua, 4 April 2020, http://www.xinhuanet.com/english/2020-04/02/c_138941747.htm

[7] ‘On January 20, I specifically issued instructions on the prevention and control of the epidemic, pointing out that the epidemic must be highly valued, and the prevention and control work must be done well. Take effective measures to resolutely curb the spread of the epidemic. On January 22, in view of the rapid spread of the epidemic and the serious challenges facing prevention and control, I specifically requested Hubei Province to implement strict and comprehensive control over the outflow of personnel.’ President Xi, Speech on 3 February 2020, available at http://www.qstheory.cn/dukan/qs/2020-02/15/c_1125572832.htm

[8] Yi Fan,^, Kai Zhao, Zheng-Li Shi and Peng Zhou, ‘Bat Coronaviruses in China’, Viruses, 2019, 11(3), 210, available at https://www.mdpi.com/1999-4915/11/3/210; Jie Cui, Fang Li & Zheng-Li Shi, ‘Origin and evolution of pathogenic coronaviruses’, Nature Reviews Microbiology, 2019, Vol 17, pp.181–192, available at https://www.nature.com/articles/s41579-018-0118-9

[9] Hendra Virus Infection, WHO, https://www.who.int/health-topics/hendra-virus-disease#tab=tab_1

[10] Nipha Virus, WHO, 30 May 2018, https://www.who.int/news-room/fact-sheets/detail/nipah-virus

[11] SARS (Severe Acute Respiratory Syndrome), WHO, https://www.who.int/ith/diseases/sars/en/

[12] Middle East respiratory syndrome coronavirus (MERS-CoV), WHO, https://www.who.int/news-room/fact-sheets/detail/middle-east-respiratory-syndrome-coronavirus-(mers-cov)

[13] Ebola Virus Disease, WHO, https://www.who.int/news-room/fact-sheets/detail/ebola-virus-disease

[14] ‘Benefit of Bats’, National Park Service, https://www.nps.gov/subjects/bats/benefits-of-bats.htm

[15] Jane Qui, ‘One world, one health: combating infectious diseases in the age of globalization’, National Science Review, Vol 4, Issue 3, May 2017, pp.493–499, available at  https://academic.oup.com/nsr/article/4/3/493/3789515

[16] Toph Allen et al, ‘Global hotspots and correlates of emerging zoonotic diseases’, Eco Health Alliance, 2017, available at https://www.ecohealthalliance.org/wp-content/uploads/2017/10/s41467-017-00923-8.pdf

[17] Kate E. Jones et al, ‘Global trends in emerging infectious diseases’, 2008, Nature, Vol 451, pp. 990–993, https://www.nature.com/articles/nature06536

[18] For more on ‘One Health’, see Andrew A. Cunningham, Peter Daszak and James L.N. Wood,  ‘One Health, emerging infectious diseases and wildlife: two decades of progress?’ 5 June 2017, available at https://royalsocietypublishing.org/doi/10.1098/rstb.2016.0167