3 April 2020– Origin: WSWS
By Benjamin Mateus
The Hong Kong-based South China Morning Post reported last month that a 55-year-old man may have contracted a novel coronavirus infection on November 17, 2019. This individual is the earliest confirmed case of COVID-19, but authorities believe he wasn’t patient-zero. The next confirmed case appeared on December 1, 2019 but had no links to the Huanan Seafood Wholesale Market located in Wuhan. The Chinese state broadcaster CCTV reported on January 9, 2020, that the outbreak had first been detected in Wuhan on December 12. Unusual cases of a pneumonia-like illness appeared at local hospitals.
Fluids gathered from the lungs of these patients admitted to ICUs were evaluated at the Wuhan Institute of Virology. Six of seven patients in the ICU were sellers or deliverymen working at the market. On December 21, the Chinese Center for Disease Control and Prevention published their report on a cluster of patients with a “pneumonia of unknown cause.”
As more patients were admitted for severe pneumonia-like illness linking them to the market, the Wuhan Municipal Health Committee issued an urgent notice on December 30 on its Weibo social media account. The World Health Organization (WHO) was notified that there were 27 suspected cases, seven in critical condition. At this time, the genetic sequence of the pathogen was wrongly believed to indicate it was a Severe Acute Respiratory Syndrome (SARS) coronavirus.
Many physicians shared this information on the internet, including Dr. Li Wenliang, an ophthalmologist at Wuhan Central Hospital, who posted a warning to his medical school colleagues via a WeChat group. When his post went viral, he was severely reprimanded by authorities for “making false comments” and “severely disturbing the social order” and compelled to sign a confession. He contracted the infection on January 12 and died on February 7.
On January 1, Chinese authorities closed the Huanan Seafood Market. On January 2, there were 41 patients hospitalized with laboratory-confirmed infections. They were relocated to the Jinyintan Hospital in Wuhan.
The Chinese scientists at the National Institute of Viral Disease and Prevention determined the genetic sequence of the novel virus on January 3, naming it 2019-nCoV. Health authorities were alarmed by the sudden jump in reported cases with many of them seriously ill. No deaths had been reported but close contacts were being monitored. Incidentally, CDC director Robert Redfield alerted US Secretary of Health and Human Services Alex Azar that same day on his discussions with Chinese physicians about the virus.
Hong Kong’s center for infection warned that the city should begin implementing strict surveillance against a new viral pneumonia that was spreading from human to human. The Singapore Ministry of Health was notified of a three-year-old Chinese girl with pneumonia and travel history to Wuhan. The young child tested negative for SARS and MERS-CoV.
By January 7 the Chinese authorities were clamping down on all social media posting information on the outbreak. The US CDC issued a travel notice advisory to Wuhan. In South Korea, health authorities placed a 36-year-old Chinese woman under isolation after returning from Wuhan and experiencing cough and fever. The World Health Organization confirmed that a novel coronavirus had been isolated on January 9. The first death was also confirmed: a 61-year-old man who was a regular customer at the Seafood Market. He had multiple medical conditions including chronic liver disease.
On January 13, Chinese virologists had posted the genome sequence for the virus on the NIH genetic sequence database, GenBank. Thailand reported the first confirmed case of 2019-nCoV in a Chinese woman who had arrived in Bangkok on January 8. On January 15, the second death of a 69-year-old man in China was confirmed, who had become ill December 31.
The WHO confirmed that a team from the German Center for Infection Research and Virologists at Charité Hospital in Berlin had developed a new lab test that could detect 2019-nCoV. The assay protocol was published. According to Dr. Christian Drosten, director of the institute, “Now that this diagnostic test is widely available, I expect that it won’t be long before we are able to reliably diagnose suspected cases. This will also help scientists understand whether the virus is capable of spreading from human to human. This is an important step in our fight against this new virus.”
By January 21, a total of 291 cases were reported across major cities in China. The MRC Centre for Global Infectious Disease Analysis at Imperial College, London, suggested that their modeling predicted more than 1,700 cases of infection. The Chinese government began warning lower-level officials to no longer cover up the spread of the new coronavirus. It also was later made known that President Xi Jinping was aware of the outbreak sooner than had been indicated. The same day, the US reported its first case in Washington state.
On January 24, more countries outside of China were reporting imported cases. The first confirmed case of a human-to-human transmission outside of China occurred in Vietnam. The Chinese Politburo placed the entire Hubei province under a city-by-city quarantine, affecting almost 60 million people.
Benjamin Mateus of the WSWS had an opportunity in mid-March, through an intermediary, to communicate with four Chinese physicians who were involved from the beginning in the massive response to the COVID-19 pandemic in Wuhan. To assure the anonymity of these individuals, names and locations have been changed. The correspondence has been edited and reformatted for clarity and brevity.
Benjamin Mateus (BM): Good morning. I’d like to thank all of you for sharing your experiences. They are important for readers to understand what happened in Wuhan and hear directly from you on how you worked during the harrowing period. But before we begin, could you briefly tell us in what you do?
Dr. X: I am an anesthesiologist at a provincial tertiary center in Hubei province.
Dr. D: I work in the emergency department. I work in another province at a provincial tertiary center.
Dr. Z: Thank you. Yes, I am an internist with a specialty in respiratory medicine. My focus during the outbreak in Wuhan was to evaluate suspected patients with throat swabs looking for the coronavirus. We also arranged their CT scans. If they tested positive or had findings concerning for pneumonia, we admitted them into the hospital. We called this area the “observation” room.
Dr. W: I do obstetrics and gynecology—deliver babies and take care of women’s health issues. Dr. Z and I are both from Wuhan.
BM: Dr. D, when were you called to Wuhan?
Dr. D: My team and I were dispatched to Wuhan on January 24, when Hubei province was placed in lockdown. That was the Chinese New Year’s Eve. Once we received orders from the government, we immediately organized our teams and medical supply. I worked in a team with 138 workers.
BM: How did you get there?
Dr. D: We flew on a government-chartered flight. Once we arrived, we were quartered in a nearby hotel. All the medical workers, even those from Wuhan, though their homes were just by the hospital, had to stay in the designated hotels. The food was plentiful and nutritious. It was donated by the citizens.
BM: Why were you quartered in this way?
Dr. Z: Mainly, to protect our families. We realized that it would be impossible to be with them and keep them safe.
BM: Can you speak about how the hospitals were supplied?
Dr. D: The government was responsible for coordinating all the necessary supplies. One governmental branch would coordinate through the region’s branch which were then dispersed to the next levels down to the hospitals. There is a network we’ve established for these matters.
BM: Dr. D, where did you work?
Dr. D: My team was assigned to a traditional comprehensive hospital in Hankou which was converted to a COVID-19 patient admission hospital during the outbreak.
[Wuhan city is a conglomeration of “three towns of Wuhan”—Hankou, Wuchang and Hanyang. It stands north of the confluence of the Han and Yangtze rivers.]
BM: Dr. X, can you speak to the number of health care workers that supported Wuhan?
Dr. X: When the lockdown went into effect and our resources were mobilized, I think we had about 40,000 healthcare workers supporting our efforts here in Hubei province. It was difficult at first. Hospitals were becoming overwhelmed with patients and we weren’t able to keep up. We were running short on supplies, but now we have managed to staff the hospitals and have the necessary equipment.
BM: And how did the work on the wards proceed? We have seen pictures of Chinese physicians in full personal protective gear.
Dr. X: We quickly learned to develop the process to put on and take off our protective gear. [They explained they donned full protective gear—instead of just gowns and hair nets—with masks and shields and including four pairs of gloves]. It was very difficult to work in them. We were on shift work. Doctors ran a six-hour shift while nurses ran four-hour shifts. We spent one hour before our shift getting into our gear and another hour after just to remove them. When we intubated patients, we used respirators.
Dr. D: We may have been over-zealous with wearing of goggles and outer protective gears at times when maybe we didn’t. We wore three to four layers of gloves. But it was hard to say if it was necessary or not. But we went into it with an abundance of caution.
BM: Dr. Z, I had read that the Chinese doctors were using CT scans to diagnose patients with COVID-19. Why was that?
Dr. Z: We recognized that patients with mild symptoms sometimes were sent home and they collapsed. We learned that the CT scan had a prognostic value. So, if a patient has tested positive but has mild symptoms, they can go home unless their CT scan shows there are infiltrates [pneumonia]. We admit these patients because we found they may decompensate later.
Dr. D: Even now that the epidemic has passed, we remain guarded. Maybe two or three weeks ago we had a 72-year-old come in without any difficulty breathing or fevers—just dizziness and fatigue. The patient was admitted to the neurology department. When they did a CT scan, the patient had all the hallmarks of COVID-19 lungs. Seventeen doctors and nurses were infected, and the department was closed. So, the CT scan has proven valuable when the patients don’t present with the common signs and symptoms.
BM: How are your families coping with your absence during the outbreak?
Dr. W: My husband works in a shipyard as a manager and we’ve been separated to protect him from becoming infected. But he’s also involved in fighting COVID-19. It isn’t only medical workers. The whole country is involved in the fight—we miss each other but it helps that we understand everyone is involved.
Dr. X: My son is at university, so we know he’s safe. My wife is also a physician and we work in the same hospital. We stay at the hotel but have separate rooms. The situation is tough, but we know the disease is preventable, controllable and treatable if we remain committed and vigilant.
Dr. Z: My husband is a physician and works in our hospital as well. We sent our son to stay with his grandparents before they closed Wuhan. We knew the situation would be very serious and we wouldn’t be able to take care of him.
BM: What difficulties did Wuhan, in your opinion, encounter in their fight against the epidemic?
Dr. X: At the beginning of the outbreak in Wuhan, the local authorities covered up the problem. They didn’t report it to the health department or government. Later, it became impossible to cover it up, but the infection was moving quickly. The health care was short on staff and supplies.
BM: Is that why the fatality rate was so much higher in Wuhan than in other provinces?
Dr. X: We were in a difficult situation. We were short in medical supplies. However, the government was able to allocate medical equipment—protective suits, gloves, masks—even food and more to every hospital. We even built two hospitals in two weeks.
BM: Did any of you work there? That was a tremendous feat.
Dr. W: No, we didn’t.
BM: Hospitals in Europe and the United States are being inundated with cases. How did you cope with the rush of infected patients?
Dr. X: At the hospital I was working in, they had 3,000 inpatient rooms. We decided to have patients with COVID-19 share rooms but keep suspected patients isolated to a single room each. This way we expanded our capacity. But you have to do what is needed. Having the COVID-19 patients together also helped them cope better because they kept each other company. Families weren’t allowed to visit.
BM: Dr. W, did you find pregnant patients with COVID-19 do poorly or have more complications?
Dr. W: We didn’t see extra special risks for pregnancy compared to non-pregnant women. We treated their pregnancy no differently than usual, but their families weren’t allowed to be with them.
BM: So, pregnant woman did well?
Dr. W: Yes, for the most part. We did have a lower threshold for moving the patient back for a cesarean delivery because of the exertional difficulty with breathing during labor.
BM: And what about the newborn?
Dr. W: The newborns were sent to a negative pressure inpatient room, isolated and remained in quarantine for two weeks. The mothers stayed in quarantine an additional two weeks after they became asymptomatic and had a negative nucleic acid test. If both the mother and baby tested negative, then the baby could stay with its mother and breastfeed.
BM: What part of the work did all of you find most challenging?
Dr. X: I worked at the regional admission center ICU. So, all the most severe patients came to us. I know the patients were always very appreciative of our efforts and they knew we were trying our best. You could see they were scared. Sometimes you feel so helpless and that was painful.
I had one patient. He was in his fifties. He had lost his parents to COVID-19. Though he was intubated, he always raised his thumb. He tried to always stay positive. But he wasn’t getting better, so I knew he wasn’t going to recover. Three weeks later he died of respiratory failure. I don’t know why his death affected me so much. I felt crushed. I went back to my hotel room isolated. My wife was in the next room. We would sit against the wall and talk to each other. I will never forget that night.
Dr. D: When we rested—we never really felt rested. It’s hard to explain. It wasn’t numbness or bewilderment. Maybe a sense of pain or fear. In my head all I could think of was how to save these patients—constantly searching references, to look at guidelines, read articles, have discussions and meetings.
Seeing a patient on the ventilator and watching their blood oxygen levels slowly decrease, at this point there is nothing left to do. Seeing them slowly die is very painful. You feel so helpless.
I think 129 patients died in the hospital I was working at just in February—38 of them just in my ward. In the peak of the outbreak, I saw four bodies kept on the ward for over 24 hours, because the morgue was full and short-staffed. It was so overwhelming that fear arose from the tip of my hair to the bottom of my feet. I felt the whole world is sick—the whole world is just sick.
Many of my colleagues told me they were unable to sleep. Many developed severe anxieties when they came on the ward. They were shaking when they had to clean the medical waste. I tried to console them, work with them, calm them.
Dr. Z: I remember that we had lost a patient and I was working up the courage to notify the family. I called and as soon as he answered the phone, he said, “It is my dad?” I said, “yes.” Then he said, “Thank you. I will be there in about an hour. I have to finish treating a patient.” He is my colleague. He told me that his mother had died the day before and his two brothers the week before. He came and signed the papers and left. I called to him and he turned around and said, “Thank you. Bye,” and left.
BM: Can you speak about Dr. Li Wenliang? He died of COVID-19 [on February 7, 2020] but was reprimanded when he warned his colleagues on social media of the outbreak in December. What are your thoughts?
Dr. W: I knew him. I had spoken with him. I am shocked that he died. He was so young. His wife was pregnant when he passed away. It’s difficult to speak about this. It could have happened to anyone. But these are political matters … And his family couldn’t be with him. They just put his body in a bag and delivered it to the funeral parlor.
BM: I read that the Communist Party of China (CPC) exonerated him and offered a “solemn apology” to his family.
Dr. W: It isn’t about exonerating him. Talking about the CPC—I especially so hate to talk about it. Too much meaningless sacrifice. Too many meaningless losses of life. Four doctors died of COVID in their own hospital—two from the same department (ophthalmology). There are also four doctors that are still on ventilators for almost two months. Nobody dares to let them die because the public won’t forgive them.
BM: Dr. D, how many health care workers came to Wuhan and how many became infected?
Dr. D: By the time my team had arrived, we had about 40,000 health care workers in Hubei province. I think about 3,000 became infected, but mostly during the initial phase of the response. We had not implemented a strict infection control policy yet and we were short on medical supplies .
BM: Did any of your team members become infected?
Dr. X: We were involved almost immediately in early January. In my team, four became infected, but only one had to be intubated but they recovered.
Dr. D: None of our 138 medical workers in my team became infected.
BM: What lessons did you learn from this outbreak? What worked well and what didn’t?
Dr. X: It was important to make the diagnosis early. We isolated patients quickly and implemented treatment immediately. But, most importantly, protecting the health care workers was essential. We have around 200 staff in our virus institute and zero in infections.
For the general population, wearing masks and washing hands was key to reducing infections. This also applied to medical workers. But proper donning of protective gear was something we learned quickly. We also found ventilating patient rooms helped infection control.
Dr. Z: We also immediately stopped all clinical rotations for medical students. We repeatedly instructed residents to pay strict attention to personal protection procedures. We climbed stairs instead of using the lift. We limited our time in closed spaces. We had one set of clothes, shoes and hat to wear outside. We sprayed our whole body with medical alcohol before going into our room and then immediately took a shower. We cut our hair very short.
BM: Were there any treatments you found ineffective? In the US and Europe people are using chloroquine because they have heard it may help fight the infection.
Dr. X: We used Arbidol (umifenovir—an antiviral treatment for influenza used in Russia and China). It didn’t help at all and did some liver damage. We also gave lopinavir (antiretroviral of the protease inhibitor class used against HIV) which also caused some liver damage and gave the patients nausea or vomiting. It was also no use. Virazole (also known as ribavirin, used to treat respiratory syncytial virus infections) had no obvious side effects but had no benefit. Steroids didn’t seem to have any benefits either but may have decreased patient immunity.
BM: What were your clinical experience with this infection? The age of the patients, how long it took for them to become ill, how deadly was the infection?
Dr. X: For the elderly it was quite devastating. They didn’t do well, but we saw all ages. Usually, once a person became exposed, it would take a few days or a week before they developed symptoms. Patients with minimal symptoms were isolated at home and health care workers regularly checked on them. After a week or two, they either recovered or presented to the hospital and were admitted. Around 80 percent of the patients that required intubation died—usually by the fifth day of hospitalization. Sometimes they would stay on longer, but chance of recovery grew worse.
BM: I wanted to conclude by asking your opinions on the global response to this pandemic. What would you like to say to the rest of the world—in Europe, The United States, and Africa and Latin America?
Dr. D: Every government must pay as much as attention as possible to this pandemic. Allocate materials, health care workers to the most needed areas. Close the city, even the country early. Isolate susceptible people early.
Dr. Z: I think it’s important we work together. After this huge disaster and material shortage, China sent 300 health care workers to support Italy to include medical supplies.
Dr. X: In under-developed countries, their governments need to use their resources in the most efficient manner as possible. They have to protect the general population and if that means closing the cities or countries, they should do it as early as possible. They should educate the population on washing their hands and keeping their houses ventilated. Protect medical workers.
We didn’t pay enough attention at the early stage.
BM: I want to thank all of you for participating. I thank you for your work. Please, always, stay safe.
On March 18, 2020, Chinese authorities reported no new infections, achieving a milestone in a pandemic that has now affected more than 200 countries and territories with over one million cases and over 53,000 deaths. The fight against the pandemic is being waged at its new epicenters in Europe and the United States. China has seen its numbers hold under 82,000 cases with over 76,000 people having recovered and 3,318 deaths reported. There are presently 1,863 active cases.
On March 25, the strict lockdown in Hubei province ended when the Hubei Health Commission announced it would relax travel restrictions. However, local authorities are refusing to lift travel bans. Despite Beijing’s attempt to get people back to work, there are broad concerns and doubts about the government’s assurances that the epidemic has been brought under control. On March 28, police in the city of Jiujiang set up a blockade to prevent migrant workers crossing from Hubei. The situation turned violent with footage showing police from Jiujiang and Huangmei confronting each other as well as hundreds of people attacking the police.
Henan province in central China, just north of Hubei, placed Jia county into lockdown on Tuesday affecting 600,000 people. All businesses were shut down, except for essential services like utilities, medical suppliers and logistics. The basis for these measures came after a news outlet reported three new infections on Sunday. A physician named Liu was tested positive on Saturday as well as two colleagues to whom he had passed the infection.