Oct. 28, 2024
Background: The novel coronavirus (-nCoV) causing an outbreak of pneumonia in Wuhan, Hubei province of China was isolated in January . This study aims to investigate its epidemiologic history, and analyze the clinical characteristics, treatment regimens, and prognosis of patients infected with -nCoV during this outbreak.
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Methods: Clinical data from 137 -nCoV-infected patients admitted to the respiratory departments of nine tertiary hospitals in Hubei province from December 30, to January 24, were retrospectively collected, including general status, clinical manifestations, laboratory test results, imaging characteristics, and treatment regimens.
Results: None of the 137 patients (61 males, 76 females, aged 20-83 years, median age 57 years) had a definite history of exposure to Huanan Seafood Wholesale Market. Major initial symptoms included fever (112/137, 81.8%), coughing (66/137, 48.2%), and muscle pain or fatigue (44/137, 32.1%), with other, less typical initial symptoms observed at low frequency, including heart palpitations, diarrhea, and headache. Nearly 80% of the patients had normal or decreased white blood cell counts, and 72.3% (99/137) had lymphocytopenia. Lung involvement was present in all cases, with most chest computed tomography scans showing lesions in multiple lung lobes, some of which were dense; ground-glass opacity co-existed with consolidation shadows or cord-like shadows. Given the lack of effective drugs, treatment focused on symptomatic and respiratory support. Immunoglobulin G was delivered to some critically ill patients according to their conditions. Systemic corticosteroid treatment did not show significant benefits. Notably, early respiratory support facilitated disease recovery and improved prognosis. The risk of death was primarily associated with age, underlying chronic diseases, and median interval from the appearance of initial symptoms to dyspnea.
Conclusions: The majority of patients with -nCoV pneumonia present with fever as the first symptom, and most of them still showed typical manifestations of viral pneumonia on chest imaging. Middle-aged and elderly patients with underlying comorbidities are susceptible to respiratory failure and may have a poorer prognosis.
Victor C. Shih
As of September , China has had one of the most successful responses to COVID-19 in the world, despite being the origin of the epidemic and having the largest population and multiple dense urban centers. Yet China&#;s response did not begin serendipitously. Despite receiving a wealth of information about COVID-19 by the end of the first week of January, the top authorities in China decided to keep vital information on the epidemic from the public for two weeks, thus allowing the disease to spread through much of Hubei province and in other major cities. This led to the unfolding of a large-scale tragedy in Wuhan, a city of ten million people, and in other cities in Hubei. The precise scale of the death toll caused by COVID-19 and by draconian government lockdown policies remains unknown.
On January 20, , the ruling Chinese Communist Party (CCP) shifted gears and initiated mobilization for containment. The resulting draconian quarantine and self-quarantine, as well as the rapid construction and production of quarantine sites, personal protective equipment (PPE), and medical supplies, allowed China to quickly control the spread of COVID-19 so that by early March, untraceable community transmission had come to an end in the vast majority of regions in China. This mobilization not only stopped the epidemic in Wuhan but also prevented the large-scale spread of COVID-19 in another major urban center in China. Because the mobilization mainly focused on containing COVID-19, medical care for other diseases and many social welfare issues were largely ignored by the government.
In both the information repression phase and in the mobilization phase, the CCP&#;s hierarchical and authoritarian structure, the party&#;s ability to transcend state institutions, and the state&#;s ownership over vital economic resources greatly facilitated the party achieving key objectives in these two different phases. In the first phase, through its control of the media and arbitrary detention, the party largely succeeded in preventing the spread of not only information but also panic about COVID-19, thus largely preventing urban unrests. In the second phase, the mobilization of state and societal resources toward containment allowed the government to control the trajectories of the epidemic relatively quickly, compared to other countries. Beyond the party&#;s Leninist structure, the containment effort was greatly helped by community parastatal organizations, the neighborhood Page 68 &#;committees, which the party relied on to implement core tasks related to the quarantine. Without their frantic effort, the outcomes in China would have been much worse. The digital surveillance program, which facilitated contact tracing, likely did not play a decisive role in controlling COVID-19 in China.
Yet the mobilization of the party-state could not make up for the shortfalls in China&#;s medical insurance and social security system. Although otherwise healthy urban residents working for state-owned entities or major private corporations continued to receive the benefits owed to them throughout the lockdown, the state chose not to devote significant resources to address challenges faced by both the urban and rural vulnerable population and migrant workers. Many of China&#;s 290 million migrant workers, especially, found themselves unemployed and largely outside of China&#;s patchy social welfare system, desperately fending for themselves on paltry government &#;minimal assistance insurance.&#; Although the Chinese government easily could have devoted greater resources to the sick and unemployed, in the absence of a free media or democratic pressure, it chose not to do so.
The public health responses in China can roughly be broken down into two phases: the information repression phase and the mobilization for containment phase. Clear evidence from China suggests that the information repression phase from December to January 20, , allowed COVID-19 to spread widely around China, especially in Wuhan and in the rest of Hubei province. The campaign to repress information on COVID-19 likely had to do with the regime&#;s imperative to ensure social stability in the political and economic centers along the eastern coast of China. The mobilization phase began on January 20, , which was soon followed by the closing of Wuhan to the outside world and by the self-quarantine of all rural and urban households in China in the weeks following. This was associated with the rapid decline in the new caseload across China, beginning in the second half of February .
According to epidemiologists interviewing the first wave of patients, human COVID-19 cases likely began to proliferate in Wuhan starting in early December (Huang et al., ). Among patients with contacts to the Huanan Seafood Market, the site of the first major cluster of infection, the first patients manifested symptoms starting on December 1, (Huang et al., ). By December 31, , the Wuhan Health Commission (WHC) admitted publicly that there was an outbreak of &#;pneumonia of unknown origin&#; based around the Huanan Seafood Market, which was promptly shut down for disinfection on January 1, (Huang et al., ).
On January 1, , the Wuhan police also announced that eight &#;rumor purveyors&#; were &#;dealt with according to the law,&#; but they were all doctors who had communicated their worries about a spike of patients with pneumonia symptoms in private social media discussions with families and friends (&#;Xianchangpian: Wuhan Page 69 &#;Weicheng&#; [&#;Live: The Closing of Wuhan&#;], ). Still, because of total surveillance in China, they were detained and had to sign confessions of wrongdoing. Although their posts were widely circulated online, they were ultimately scrubbed on order from the Chinese government. For workers in the medical community, this detention by the police directly prevented many of them from spreading the news of the &#;pneumonia of unknown origin&#; to friends and families and to the wider community, which helped COVID-19 spread further in Wuhan and beyond (&#;Xianchangpian: Wuhan Weicheng&#; [&#;Live: The Closing of Wuhan&#;], ).
On January 5, , the WHC announced to the public additional cases of the &#;pneumonia of unknown origin,&#; but still insisted that there was no evidence of human-to-human transmission and that no medical worker had contracted the disease (Huang, ). This was clearly untrue because the detained doctors and many others working in frontline hospitals had already noticed many cases of suspicious pneumonia among their colleagues (&#;Xianchangpian: Wuhan Weicheng&#; [&#;Live: The Closing of Wuhan&#;], ). Yet the pressure for information control persisted as the local committees of the CCP at frontline hospitals ordered all workers to &#;not create or convey rumors so as to avoid social panic&#; (&#;Xianchangpian: Wuhan Weicheng&#; [&#;Live: The Closing of Wuhan&#;], ). On January 10, , the WHC announced, again contrary to evidence, that &#;no new case has been recorded after January 3rd&#; and that wearing masks was &#;required only when necessary&#; (&#;Xianchangpian: Wuhan Weicheng&#; [&#;Live: The Closing of Wuhan&#;], ). On January 15, , during a question-and-answer session at a press conference, the WHC finally admitted that the possibility of human-to-human transmission &#;cannot be ruled out&#; (Zhang et al., ).
Despite growing worries, Wuhan still held its annual &#;ten thousand families banquet&#; on January 18, , in which groups of several hundred gathered in multiple neighborhoods to share local delicacies that they had cooked for each other (Zhang et al., ). In fact, lower-level party officials also were not privy to the growing alarm at the highest level because the Hubei Provincial People&#;s Congress meeting, attended by hundreds of mid-level party functionaries, was still held in Wuhan from January 11 to 17, (&#;Xianchangpian: Wuhan Weicheng&#; [&#;Live: The Closing of Wuhan&#;], ). Undoubtedly, many low- and mid-level government officials, as well as a much larger number of ordinary citizens, unnecessarily contracted COVID-19 because higher-level party authorities did not cancel these two major events. After the Hubei Provincial People&#;s Congress sessions ended on January 18, , the WHC finally announced an additional twenty-one cases to the public, but frontline doctors were already reporting hundreds of suspected cases to the health authorities (&#;Xianchangpian: Wuhan Weicheng&#; [&#;Live: The Closing of Wuhan&#;], ).
The tone of the information repression campaign finally changed on January 18 and 19, , when the WHC suddenly announced an additional 136 confirmed cases of COVID-19 (&#;Xianchangpian: Wuhan Weicheng&#; [&#;Live: The Closing of Wuhan&#;], ). On the night of January 20, , China Central Television, watched by the majority of Chinese households, broadcasted an interview Page 70 &#;with leading infectious disease specialist, Dr. Zhong Nanshan, who stated unambiguously that &#;there is definitely human-to-human transmission&#; and that &#;the diseases is still at its starting stage and is in a growth period&#; (China Central Television, b). This TV interview was followed by a series of drastic government actions to combat COVID-19 and thus spelled the end of the information repression phase of the response.
Although public information about potential human-to-human transmission of COVID-19 was systematically suppressed by the authorities, government experts and frontline doctors channeled the latest information in a relatively unimpeded way to the central government in Beijing. According to the authors of the first major clinical study of COVID-19, published online in Lancet on January 24, , a central government team, composed of the leading infectious disease specialists from around China as well as national level health officials, first arrived in Wuhan in early January and immediately reviewed clinical data on forty-one patients who had been admitted to Wuhan hospitals with pneumonia-like symptoms before January 2, (Huang et al., ). The fact that the government team did not review clinical data after January 2 indicates that they had begun drafting a version of the eventual Lancet paper during the first week of January, which strongly suggests that a version of the findings was available to the leadership soon after the first week of January. Based on a review of this clinical data in early January, the central government health team concluded, &#;Taken together, evidence so far indicates human transmission for -nCoV&#; (Huang et al., ).
By January 3, , the team had agreed on a set of protocols and criteria to identify a much larger sample of potential cases so that much more clinical data could be reviewed (Li et al., b). By January 5, Shanghai health authorities had isolated and sequenced the genes of COVID-19 based on a late-December sample from Wuhan and had submitted reports to both the Shanghai Health Commission and the National Health Commission in Beijing (&#;Xianchangpian: Wuhan Weicheng&#; [&#;Live: The Closing of Wuhan&#;], ). RNA testing of samples also began in the first week of January in both a Wuhan-based level-2 laboratory and in a lab run by the National Institute for Viral Disease Control (Li et al., b). In essence, by the end of the first week in January, the central government team had determined a high likelihood for human transmission of COVID-19 and had confirmed the presence of a large number of infections, but the Chinese government did not disclose these facts to the public until Dr. Zhong Nashan&#;s television interview on January 20.
Meanwhile, it seems that the shocking findings of the central government team had elicited a response from the top leadership. According to remarks by Xi Jinping in early February , by the January 7 Politburo Standing Committee meeting, he &#;raised demands on the prevention and control of the novel coronavirus&#; (Xi, ). It was also revealed in a government press release that by the January 25, , Politburo Standing Committee meeting, Xi Jinping had &#;convened meetings and listened to reports by experts on multiple occasions&#; on the Page 71 &#;novel coronavirus (Xinhua, ). It is very likely that an earlier version of the Lancet findings, published just two and one-half weeks later, had made it on to the desk of Xi Jinping himself after the first week of January; yet, publicly, the Chinese government still maintained a calm demeanor. It remains unclear what the thinking of the Chinese government was between January 7 and 19, when a more concerted reaction to COVID-19 began to manifest publicly. Perhaps the leadership had hoped that COVID-19 would be a relatively controllable disease and would not require a drastic lockdown. This seems unlikely because the authors of the Lancet paper, all leading Chinese government experts, were clear about the &#;pandemic potential of -nCoV&#; (Huang et al., ). After the lesson of SARS, it was unlikely that the Chinese leadership would have ignored such a consensus among its top experts. Perhaps the leadership had realized the magnitude of the problem early on but had decided to keep it a secret from the public for one and a half weeks while it prepared for total mobilization.
One possible explanation is that the period between January 7, , and January 23, , or so fell on the busiest traveling time for China: 290 million migrant workers working in eastern and southern China traveled to their mostly rural hometowns in central and western China for the Lunar New Year celebration, which fell on January 25, (National Bureau of Statistics, ). If the regime had instituted a lockdown in early January, most of the migrant workers would have been trapped in major cities along the coast, where they lived in cramped quarters. This obviously was far from ideal from an epidemiology perspective. Also, their presence in major cities would have taxed the medical resources in these urban centers and would have represented a much greater social stability risk for the regime. Given the regime&#;s perennial worries about instability in the major cities (Wallace, ), it was logistically and politically much more facile to first disperse them to the countryside before instituting a lockdown. The tradition of returning home for the Lunar New Year holiday provided the regime with a perfect opportunity to do so. Whatever the reason for the delay in the regime&#;s reaction, it very likely caused tens of thousands of additional infections in Wuhan and in the rest of Hubei. By January 20, when seven hospitals in Wuhan were designated for COVID-19 treatment, hundreds of patients with high temperature were lining up outside each of them, and scores would die in their hallways (&#;Xianchangpian: Wuhan Weicheng&#; [&#;Live: The Closing of Wuhan&#;], ).
In any event, on January 19, the regime began to manifest a systematic response to COVID-19. On that day, the National Health Commission announced the formation of a leading group within the agency to coordinate responses to COVID-19. Among the many tasks of this leading group, it began to coordinate the announcement of more realistic infection figures, starting with the announcement of 136 new cases on the January 20 after over a week of no new cases (&#;Xianchangpian: Wuhan Weicheng&#; [&#;Live: The Closing of Wuhan&#;], ). This was followed in the evening of January 20 by Dr. Zhong Nanshan&#;s confirmation of human-to-human transmission. Also on January 20, Xi Jinping instructed the entire party to &#;focus a high level of attention on the infection; use all resources to prevent and control Page 72 &#;the disease&#; (Xi, ). On January 25, a Politburo Standing Committee meeting chaired by Xi announced the formation of the Central Leading Group on Confronting the Novel Coronavirus Pneumonia (CLGCNCP), a plenipotentiary body headed by Premier Li Keqiang and the regime&#;s top propaganda official, Wang Huning (Xinhua, ). At the same Politburo Standing Committee meeting, Xi Jinping also issued a flurry of instructions, including the summary command of &#;Preserving life is the highest priority; let responses be guided by the trajectory of the epidemic; all will be held responsible for preventing and controlling the epidemic&#; (Xinhua, ). It was also at this meeting that the principles of &#;all infected will be concentrated in designated containment facilities; all those who had contacts (with the infected) will be placed in home quarantine&#; were issued (Xinhua, ).
With these orders from the highest authority in the party, the entire regime mobilized to contain COVID-19 while maintaining the CCP&#;s iron grip on society. As discussed in greater details later, because key state and even commercial institutions were supervised by communist party cells, the party cells issued orders to their institutions that superseded existing laws and regulations, thus allowing resources to be mobilized quickly. As of August , the Chinese government more or less had achieved its two major objectives: containment of COVID-19 and maintaining social stability.
The major challenges faced by the government by late January were threefold. First, as the number of symptomatic patients exploded, it quickly overwhelmed both testing and treatment capacity in Wuhan. The government needed to quickly mobilize resources to overcome these gaps. Second, although the vast majority of cases were in Wuhan, there was a possibility that the end of the Lunar New Year holiday would lead to a large-scale transmission of the disease to other major urban centers. Finally, if the regime is seen as dealing with the disease ineptly or if the containment caused too much collateral damage, social instability in the form of protests or riots may emerge in major urban centers, jeopardizing overall regime stability. As a vast amount of literature points out, the Chinese government devoted enormous online and physical resources to &#;stability maintenance&#; (King et al., ; Mattingly, ; Wallace, ).
As treatment and testing capacity were surpassed by the explosion of COVID-19 symptomatic patients in late January, the Wuhan municipal government (WMG) first designated seven hospitals for COVID-19 treatment, which made available over two thousand beds. Wuhan also began construction of two temporary treatment facilities, each with one-thousand-bed capacity, on January 23 (&#;Yisi Bingren Nanti&#; [&#;The Dilemma of Symptomatic Patients&#;], ). Because the construction was undertaken by state-owned enterprises each controlled by their own CCP party committees, they immediately heeded Xi Jinping&#;s order to &#;use all available resources&#; and began construction of these hospitals. The third bureau of China Construction Corporation, tasked with building the Huoshenshan Hospital, began construction on January 23, even before any contract was signed with WMG or with the central government (He et al., ). Within days, over ten Page 73 &#;thousand workers working twenty-four hours a day and a thousand trucks and construction machineries were deployed, allowing the completion of the hospital in ten days (He et al., ). Again, in the process of this break-neck pace of construction, numerous safety and labor regulations were likely ignored. Yet, because both the regulators and the firms took orders from the CCP, construction proceeded apace. State Grid, the state-owned monopoly for electricity distribution, deployed thousands of workers to makeshift hospitals across China to lay down the electricity grids for them (He et al., ). Monetary concerns were set aside for the moment with the expectation that further central government policies would address these needs in the near future. Meanwhile, thousands of doctors and nurses from around the country, including a large number of medical personnel from the military, were mobilized to help with the containment effort in Wuhan (Qin, b).
Eventually, the Wuhan model was replicated in multiple cities across China as authorities in several major cities around China scrambled to ensure sufficient treatment facilities for the infected. Because the caseload turned out to be smaller than expected, some of these facilities were repurposed for quarantine. This was the case with Xiaotangshan Hospital in Beijing, which was first built in during the SARS outbreak but was repurposed into a quarantine facility for international travelers when caseload in Beijing turned out to be relatively modest (Xia, ). The surplus in quarantine facilities eventually allowed the Chinese government to pursue the policies of &#;taking in all who should be taken in&#; (yingshou jinshou), which entailed placing confirmed patients, suspected patients, and those who had been in contact with confirmed patients in designated quarantine facilities (Wen et al., ).
As the first country faced with a COVID-19 outbreak, China initially faced a severe shortage in testing kits, even after medical firms began to develop them on January 10, (&#;Yisi Bingren Nanti&#; [&#;The Dilemma of Symptomatic Patients&#;], ). By January 19, however, the National Health Commission had approved testing kit production by three biotech firms, all Shanghai-based, thus enabling mass production of the nucleic acid tests. By January 26, some thirty firms around China had received approval to produce some 600,000 nucleic acid testing kits per day, more or less overcoming the initial bottleneck in testing availability (&#;Yisi Bingren Nanti&#; [&#;The Dilemma of Symptomatic Patients&#;], ).
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While the regime mobilized resources for testing and treating COVID-19, it also simultaneously instituted the strictest quarantine the world has ever seen. This began with the January 23, , lockdown of Wuhan along with fourteen other cities in Hubei, cutting off these cities and their tens of millions of residents from all forms of traffic, including air, rail, and vehicular traffic, allowing only official vehicles to go into and out of the quarantine zone (&#;Xianchangpian: Wuhan Weicheng&#; [&#;Live: The closing of Wuhan&#;], ). This lockdown did not end until a color-coded system designating the risk profiles of residents of all cities and counties in China allowed people from some parts of Hubei province to travel outside of the province starting in late March (&#;Shijianchou: Wuhan &#;Fengcheng&#; Page 74 &#;de 76tian&#; [&#;Timeline: 76 Days of the Wuhan Lockdown&#;], ). Since the airports, the railroads, and the police all had party committees, once the highest authorities in the party ordered the lockdown, it was executed immediately by party cells and committees across China with little time lag between jurisdictions. Also, nationally, the Lunar New Year holiday was extended indefinitely so that most workers and university students remained in their hometowns instead of traveling back to their workplaces and schools in major urban centers (China Central Television, a).
The key to China&#;s success in containing COVID-19 was its draconian stay-at-home policy, which saw nearly all of its 1.3 billion population remain in their homes over the course of four to eight weeks starting in late January. This was enforced at the lowest level by neighborhood committees in the cities and by village committees in the countryside. These committees are parastatal bodies at the neighborhood or village level mostly led by party members and staffed by local activists such as demobilized soldiers and former state-owned enterprise (SOE) workers on a part-time basis (Read, , p. 52). During normal times, they mainly channeled information about potential sources of unrests to the authorities and helped the local governments distribute information and propaganda about the latest policies (Read, , p. 32). In times of emergency, however, they provided additional personnel for the Chinese state authorities to implement policies at the grassroots level.
In the case of COVID-19, the party soon mobilized neighborhood and village committees to implement the quarantine. As a decree issued by the Beijing municipal government (BMG) made clear, neighborhood and village committees were to &#;carry out the task of investigating and recording all the coming and going of residents within their jurisdictions&#; (BMG, ). The neighborhood committees carried out in-person surveillance and contact tracing, which provided much of the underlying data for China&#;s impressive digital COVID-19 surveillance program (Lin, ). Neighborhood committees also regulated or even outright blocked residents from leaving their homes and required residents to check their temperatures on a periodic basis and reported results to local health authorities and to digital surveillance platforms (BMG, ). As more and more households were placed in strict home quarantine because of contacts with confirmed patients, residential committees also delivered food and other supplies to these households and checked their temperature on a regular basis (Zhang et al., ).
Throughout the pandemic, the government also ordered several waves of comprehensive testing, whereby all suspected patients or even the entire population underwent nucleic acid testing. Again, the neighborhood committees either carried out the testing or assisted health authorities to compile lists of households and to notify the neighborhoods about impending testing drives (Wen et al., ). As these tasks multiplied, the party also mobilized staff in local schools and government-controlled civic organizations, as well as state-owned enterprises to augment the neighborhood committees so that twenty-four-hour surveillance and lockdown could be enforced (Wen et al., ). For all the crucial tasks perPage 75 &#;formed by these community workers during the pandemic, the government only compensated them with a modest bonus, free insurance policies, and free meals while on the job (Central Leading Group on Confronting the Novel Coronavirus Pneumonia, b).
Finally, although the government began to release to the public more accurate information about the trajectory of the pandemic and government responses, it continued to deploy a concerted information manipulation campaign, including heavy censorship. First, although the WHC and the National Health Commission began to report a much higher caseload and death rate related to COVID-19 after January 20, , the true infection figures remained undercounted as thousands of suspected cases were excluded from the official figures (Qin, a). Even according to the official media, the COVID-19 death toll for Wuhan was vastly undercounted until the middle of April , when the government suddenly increased the official COVID-19 death toll in Wuhan by 50 percent (Qin, a). As China struggled with economic recovery in March and April , analysts of China&#;s economy also doubted the accuracy of China&#;s economic numbers, including those for electricity use (Qin, b). For several weeks in late January and early February , the government allowed journalists, both Chinese and foreign, relatively unimpeded access to Wuhan, and they provided excellent reporting on the real situation in Wuhan (Wang, ). The authorities likely tolerated such reporting because they had mistrusted the flow of information from the WMG and wanted on-the-ground verification. As the number of central officials in Wuhan expanded, however, the party once again reasserted a monopoly on publicly available information on the epidemic. By the middle of February, the authorities had rounded up 350 people around China for &#;spreading rumors,&#; including famous bloggers Fang Bin and Chen Qiushi (Wang, ). They remained in detention as of September .
Although the mobilization for containment meant that the Chinese government quickly agreed to undertake the full medical costs of COVID-19 treatment and testing, it could not make up for the uneven nature of China&#;s health insurance and social security regimes. Like in the United States, those covered by the most resourceful health insurance and pension schemes and were healthy could go for months without working, whereas those who were not covered or were covered by bare-bone insurance schemes had to fend for themselves during illnesses and periods of unemployment. Anecdotal evidence suggests that this was especially a major problem for China&#;s 290 million migrant workers, who were trapped in the countryside away from their workplaces and had much less access to adequate social insurance coverage. Like more advanced countries, China had a powerful central bank, which began to subsidize government spending via a form of quantitative easing. Yet, in the absence of democratic pressure, the Chinese government Page 76 &#;devoted central bank funds to the government and to firms, rather than toward financing social spending.
Soon after the Chinese government began to acknowledge the potential of a pandemic, the issue of treatment and testing costs emerged. Even after the reform of the medical insurance system in , some 17 percent of the 290 million or so migrant laborers did not have any form of public health insurance (Chen et al., ). Among those with health insurance, out-of-pocket costs for urban residents were still over 50 percent for inpatient care (Huang, ). For patients in rural areas, out-of-pocket costs were even higher. For multi-day inpatient care, the costs, even after insurance reimbursement, can surpass the annual salaries of migrant workers. Thus, in late January , some hospitals in Wuhan actually turned away patients because they had insufficient cash or insurance coverage to pay for the potentially high costs of inpatient care. After receiving reports on this phenomenon, the central government on January 25 made a decision to cover the full medical costs of all patients, both confirmed and symptomatic patients, as well as for testing (&#;Yisi Bingren Nanti&#; [&#;The Dilemma of Symptomatic Patients&#;], ). This eliminated a major treatment bottleneck in the system.
Although the government devoted enormous resources to COVID-19 patients, the lockdown exacerbated existing inequality in the medical system, both geographically and across residency status. Geographically, Hubei province had some of the lowest capacity to treat infectious diseases before the COVID-19 outbreak. It only had 1 percent of the hospital beds for treating infectious disease in China, despite having 4 percent of China&#;s population (Liu, ). Thus, when the COVID-19 surge began, nearly all the other hospitals in Hubei, especially in Wuhan, were converted to COVID-19 care. This left patients with other critical illnesses without any care. The lockdown instituted on January 23, , meant that patients critically ill with other diseases could not seek help from hospitals outside of Hubei province, even though neighboring provinces all had excess capacity to care for patients (Liu, ). Anecdotal evidence suggests that a significant number of patients in Wuhan with critical illnesses such as cancer and HIV died because of the absence of care for one month or more during the lockdown (Qin, c).
Although workers in the government or in state-owned enterprises benefited from a well-funded pension and social security systems, China&#;s traditional social security regime provided little to no coverage to urban workers outside of the state system and especially left out migrant workers, whose household registrations were in the countryside (Frazier, ). Since , nationwide minimal assistance insurance (dibao) has become available to most urban and rural residents who are unemployed or unable to work (Frazier, ). As the quarantine shuttered the majority of economic activities in China, the central government mainly relied on dibao to provide basic necessities to unemployed healthy working-age workers and disabled workers, instead of providing additional fiscal assistance. As the CLGCNCP decree on this issue states, &#;As for those urban residents whose livelihood faces difficulties because Covid-19 prevents them from working in Page 77 &#;other cities, operate businesses, or otherwise engage in gainful employment, they can be included in the coverage of minimal assistance insurance if they fulfill its enrollment criteria&#; (CLGCNCP, b).
Yet this was in a sense the least the government could have done. According to a schedule published by the Ministry of Finance, the minimal assistance insurance standard for rural residents in Hubei province, for example, amounted to $67 a month, which was a paltry sum considering the average per capita rural income of $165 a month for the province and food inflation of over 13 percent in the first half of (Li et al., a; Ministry of Finance, ). For an average Hubei household made up entirely of unemployed rural residents, monthly dibao payments only provided 40 percent of the income it had earned in , which allowed it to buy 34 percent of the food it could have purchased with income. For urban residents in Hubei, the decline was even steeper if they only had received dibao payments. The Ministry of Finance&#;mandated payments to urbanites in Hubei amounted to $90 a month, whereas their per capita disposal monthly income in was $452, representing an 80 percent drop in income (Ministry of Finance, ). To be sure, the majority of urban residents likely had access to other forms of social insurance through their workplaces and thus on average were better off than their counterparts trapped in the countryside, including migrant workers normally employed in cities (Frazier, ).
As the quarantine continued and as more people were placed under quarantine in designated facilities, the central government also did not deploy too many additional resources to look after vulnerable populations typically cared for by the quarantined patients. Instead, the neighborhood committees, already inundated with the demands of the quarantine, were also asked to perform this task (CLGCNCP, b). The central decree on this issue states vaguely that &#;upon notification, the neighborhood (village) personnel should visit and evaluate, and contact relevant persons or organizations to provide care and monitoring of the target population&#; (CLGCNCP, b). The decree never made clear who the &#;relevant persons or organizations&#; would be, leaving the neighborhood committees with the unenviable task of scrambling for resources, or to do nothing. This clearly was one task too far for some of the neighborhood committees as cases of children or elderly starving while their loved ones underwent treatment soon emerged (Li, ). In a widely publicized case, a sixteen-year-old with cerebral palsy died of starvation because his caretaker underwent a prolonged period of COVID-19 treatment (Li, ). The true extent of this public health crisis remains untold because of government censorship.
At a time of widespread firm shutdown and heightened public health expenses, the Chinese government mobilized the state-controlled financial sector to finance various needs. Because the Chinese government owns the vast majority of banks and because state-owned banks were all governed by party committees (Shih, ), the January 20 edict by Xi Jinping and subsequent commands from him and Premier Li Keqiang also were transmitted to the financial sector. By January 31, , the central bank had rolled out an earmarked lending program to Page 78 &#;provide 300 billion yuan to designated firms, mainly state-owned ones, which engaged in priority activities including the construction of makeshift hospitals, the production of vital medicines and PPE, and the procurement of essential food and necessities (People&#;s Bank of China, ). As the containment and recovery effort continued, the central bank unveiled additional programs to finance major policy priorities directly or to subsidize the interest payments of firms affected by the lockdown. In total, the central bank ultimately provided 1 trillion yuan to firms via lending or re-discounting programs (&#;Yiwan Yi Zaidaikuan Zaitiexian Shiyong Mingque&#; [&#;The Usage of the 1 Trillion Yuan in Re-lending Became Clear&#;], ).
Yet little of this was devoted to financing additional government social security spending. Official spending on social security and unemployment for both the central and local governments rose by only 2 percent in the first half of (Euromoney Institutional Investor PLC, ). Given the enormous size of China&#;s supply-side response, the Chinese government certainly could have ordered the central bank to directly or indirectly purchase government bonds to dramatically boost unemployment aid. Yet this was not done.
The trajectory of outcomes in China, the rapid ascent in caseload, followed by a rapid and persistent decline in COVID-19 cases, can be explained by two major factors: the Leninist structure of the party-state and the enormous grassroots mobilization capacity of the regime stemming from the socialist legacy of party control over basic social and economic units in society. These features enabled the top leadership to repress information related to COVID-19 in the first phase. When the leadership saw fit to begin national quarantine, these institutional features also allowed for the total mobilization of state and community resources and personnel. Meanwhile, the complete lack of democratic accountability in China compelled the government to provide the minimum level of social aid to economically stressed households to prevent mass starvation. Despite having a clear capacity to provide more help, the Chinese government refrained from doing so.
Three key features of the Leninist party-state played an important role in shaping China&#;s COVID-19 responses. First, within the CCP, lower-level officials must obey decisions made by higher-level party authorities, or else face punishment (CCP, ). Although the party constitution allows for debates among party members on policies, once higher-level authorities make a decision, all lower-level party members are obligated to carry out these orders. Thus, the dictates of the highest party authority, that of Xi Jinping himself, become laws for all lower-level party officials to follow, superseding most existing laws and regulations. During emergency periods, failure to obey the dictates of higher-level party authorities brought about especially harsh punishment. During the information repression Page 79 &#;phase, for example, some grassroots level officials had called for the cancellation of the &#;ten thousand families banquet,&#; but district party authorities ignored such pleas, and the banquets went ahead (Zhang et al., ). Likewise, the party committees in frontline hospitals in Wuhan were ordered to not disclose caseload numbers to the public and only do so to higher-level public health authorities (&#;Xianchangpian: Wuhan Weicheng&#; [&#;Live: The closing of Wuhan&#;], ). As long as the party center did not reveal a strong preference for fighting the epidemic, local officials did not do much on their own initiative, and the epidemic proliferated without much hindrance.
Once mobilization for containment was ordered, local officials immediately were placed under enormous pressure from higher level authorities to put the quarantine in place both at the provincial level and at the neighborhood level. As Xi Jinping stated at a February 3, , Politburo Standing Committee meeting, &#;for those who are unwilling to take responsibility, who do not take this seriously, who shirk their duties, not only will they be punished. If the consequences are dire, their party and government supervisors also will be held responsible. Dereliction of duty will be punished according to the law&#; (Xi, ). This high-level political pressure was passed down through every level of government down to the grassroots level. As the follow-up order from the BMG reveals, the BMG would &#;thoroughly implement regional responsibility, departmental responsibility, work unit responsibility and individual responsibility&#; (BMG, ). That is, every party committee and individual party member was held responsible for the proliferation of the disease. At the same time, because the party center hardly focused on other health challenges and economic hardship faced by ordinary people, few government resources were deployed to address these issues.
Second, the Communist Party is a hierarchical command structure embedded in all levels of the government, major firms, major social organizations, and nearly all financial institutions in China (Koss, ; Shih, ). Thus, when the highest authority in the party issued a clear order, the formal jurisdictional cleavages between these various institutions did not hinder the implementation. Again, when the party center did not reveal a high level of alarm about COVID-19, the rank-and-file party members across various state institutions, including hospitals and China&#;s public health authorities, did very little to disclose to the public the true extent of the epidemic and at times even suppressed information. Behind the scenes, the top leadership likely was very worried starting in early January , but there was only a limited mobilization effort to investigate the severity of the epidemic. Once the highest authorities publicly mobilized the party, however, decrees from the party center quickly cut through the fragmented institutions in China&#;s party-state. Thus, during periods of emergency at least, China&#;s perennial problem of &#;fragmented authoritarianism&#; suspended as all party cadres set aside bureaucratic interests for fear of harsh punishment to fulfill commands from the highest authorities (Lieberthal & Oksenberg, ).
The formation of the CLGCNCP was the modern manifestation of an old institutional trick from the revolutionary years, which centralized power in the Page 80 &#;hands of essentially one senior official, who also took full responsibility for the outcome. Even in the late s, the party formed &#;frontline committees,&#; which entrusted enormous powers in the hands of a senior party official on the front line, who exercised plenipotentiary power over all communist forces on the front line (Gao, ). In a similar vein, the party not only formed the CLGCNCP at the central level to coordinate nationwide containment effort; it also formed a Central Guidance Small Group (Zhongyang Zhidaozu) headed by Politburo member and Vice Premier Sun Chunlan and top Hubei officials, which directed containment efforts on the ground in Wuhan. Again, the purpose of this Guidance Group was to leverage the high political stature of Sun to cut through jurisdictional cleavages, including the military. The work of the Guidance Group was very granular, including sending leading epidemiologists to neighborhoods in Wuhan to instruct local community cadres on garbage disposal and carrying out nucleic acid testing (Cao, ). Despite the effectiveness of these elite bodies in addressing issues directly related to COVID-19, they did not focus on or devote too many resources on severe welfare challenges caused by the lockdown, such as the cessation of income for migrant workers and care for patients with other critical illnesses. Because these leading groups saw these issues as less urgent priorities, the entire Chinese government also neglected these issues.
Third, the mobilization of resources was sped up by the party&#;s existing control over major assets and institutions in China. Despite decades of reform and waves of restructuring and privatization, the Chinese government, and by extension the CCP, still owned and controlled all of the major oil companies, the largest construction companies, almost all of the banks, the railroad, major electricity producers and the grid operator, as well as the largest industrial and electronics firms in the country (Naughton, ). During the information repression phase, the party&#;s control over all major media allowed it to suppress information fairly successfully, although rumors of the pandemic spread through private chatrooms online. After January 20, , the massive economic resources directly under the control of the party were mobilized immediately.
Moreover, because the party also controlled the police and the courts, other economic actors had no way of refusing government decrees to mobilize resources under their control. By early February , China&#;s economy was under direct state control whereby the CLGCNCP imposed production targets on designated producers for testing kits, PPE, and other essential medical supplies (China Central Television, a). The leading group also ordered priority material to be channeled to Wuhan at state-mandated prices (China Central Television, a). Even if producers had wanted to sell PPE to the highest bidder, for example, in Shanghai, they did not have that option, nor could they have challenged the government&#;s decision in court. In the case of the COVID-19 pandemic, this feature in China&#;s political system facilitated the production and distribution of PPE and testing kits to areas with the greatest needs. The government&#;s total control over the media and the courts also prevented citizens with concerns about their welfare from suing the government or complaining to the media.
Page 81 &#;As the preceding discussion demonstrates, China&#;s massive quarantine effort likely would not have succeeded to the same extent had it not been for the millions of neighborhood and village level committees. The neighborhood committee system was reintroduced by the communist authorities in on the basis of a much older system of local governance, the baojia system (Read, ). Although it languished through much of the Cultural Revolution and deteriorated some more in the wake of mass SOE closure through the early s, by the late s, the increasingly resourceful central government began to experiment with ways of reviving neighborhood committees (Read, , p. 52). By , the central and municipal governments had provided enough funding such that the heads of residential committees in major cities could expect monthly stipends of $100 to $200, which would have been a nice bonus on top of pension payments that many in these positions already received (Read, , p. 53).
Still, in the face of the epidemic, even the neighborhood committees did not provide sufficient personnel. In a large neighborhood in Wuhan, for example, twenty-one members of the Baibuting neighborhood committee oversaw more than ten thousand residents living in dozens of residential buildings (Zhang et al., ). If the entrance of each apartment building needed to be staffed by six community workers, two per eight-hour shift, seventy-two people would be needed to watch over twelve buildings. Clearly, the Baibuting residential committee itself did not provide sufficient personnel. It had to be augmented by SOE workers, teachers, and staff from social organizations (Zhang et al., ). Because all of these organizations were loosely or tightly controlled by the party, the party deployed personnel from these organizations to needed areas. Most likely, millions of party members across China were mobilized to augment the neighborhood committees to enforce the quarantine.
Still in the face of enormous health risks and the multiplication of missions piled on to them by the central government, neighborhood committees in heavily affected regions acquitted themselves surprising well, basically ensuring that the stay-at-home order was carried out and facilitating waves of testing, as well as delivering various essential social services to some extent. They likely did not do as well on addressing other social issues confronting the millions of households in lockdown, but that was due to the government&#;s unwillingness to devote greater resources at the community level. Future works will unravel the puzzle of their effectiveness in instituting the quarantine during the COVID-19 pandemic in China.
In a way, the relative success with which China dealt with COVID-19 was the product of luck. Because so much power is invested in the hands of Xi Jinping alone, had he chosen to delay mobilization even longer for idiosyncratic personal reason, thousands more would have been infected, and more would have died. Page 82 &#;The machineries under the party&#;s control are enormously powerful and resourceful, but they only go into motion when the party center issues a clear signal for mobilization. The initial hesitation by the party center led to a horrendous spike in infection and death in Hubei province and in other parts of China, which was reversed only after the January 25, , Politburo Standing Committee meeting ordered a containment mobilization. The top leadership&#;s singular focus on the pandemic itself, however, led to a systematic neglect of other challenging social and welfare issues confronting vulnerable populations in China, especially the migrant workers.
Certain features of COVID-19 made a strong response by Xi and other senior officials more likely. First, COVID-19 mainly affected urban residents in dense major cities, where the majority of mid-level officials and SOE managers&#;the main constituency of the party&#;lived (Wallace, ). Potential harm to these core supporters of the party motivated the top leadership and the rank and file party members to devote their energy to fighting this pandemic. Second, COVID-19 spread so rapidly and easily that the authorities were compelled to act, or else risk losing control of it entirely. China&#;s reaction to an epidemic with different features likely would have been less successful. For example, because the acquired immunodeficiency syndrome (AIDS) epidemic mainly affected a more marginalized population and was much slower moving than COVID-19, the Chinese government did not even begin to keep accurate statistics on AIDS patients or to have any coherent policy until ten years after cases had begun to appear in China (Huang, ). The dearth of public health response or even basic information campaigns on AIDS led to the rise of AIDS villages in Henan province, which saw the reusing of needles from blood sales causing thousands of infections (Huang, ). Future research should further specify features of diseases that would elicit an effective or delayed response from a Leninist party-state such as China.
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