I can still see the words splashed across my computer screen in the early morning hours of January 3. Though we were barely into 2020, I was stuck in an old routine, waking well before dawn and scanning news headlines online. On the BBC’s site, one caught my attention: “China Pneumonia Outbreak: Mystery Virus Probed in Wuhan.”
Anytime I see a phrase like “mystery virus” my antennae go up. Anytime that mystery virus is in China, I am even more concerned. I’ve worked my entire life, in one capacity or another, in the fields of immunology, infectious diseases, and public health. My medical specialty is in immunology, and epidemics and pandemics have played a large role in shaping my career—from HIV to avian flu. I was doing work in Asia back in 2002 when the sudden acute respiratory syndrome (SARS) outbreak began. Visceral recollections of the fear that gripped the region and the public health community still haunt me. The numbers of those infected with the virus SARS-CoV-1 weren’t extraordinarily high, as pandemics go, but the rate at which it killed those infected was.
Numbers alone don’t tell the story of a virus. Every viral outbreak is unique and requires some variation of measures in the handbook to overcome it. When it came to SARS-CoV-1 and China, I recalled the outrage the medical and public health fields felt, and continued to feel. China violated one of the most fundamental principles of managing any infectious disease: to share information early and to share everything you know about a new pathogen. China did neither. With SARS-CoV-1, China may have taken the right actions locally, but it certainly did not do so regionally or globally. Even back then, the world was too small for parochial interests to have outweighed our common interest.
During that outbreak, I sat in coach class on one of my frequent flights to Asia. I had empty row after empty row on which to stretch out and sleep. That I had that choice did more to prevent me from resting well than being crammed shoulder to shoulder would have. Nature abhors a vacuum, and those empty seats were, for me, filled with the specter of the virus and its victims. The flight attendants, airport staff, and the few Asians on my flight all wore masks, adding to the ghostly effect.
The phrase “mystery virus” goes back even further for me. In the early 1980s, as an active-duty Reserve officer in the U.S. Army while serving as a medical doctor at Walter Reed Army Medical Center, I treated U.S. soldiers suffering from another mysterious illness. Early on, we knew it as adult respiratory distress syndrome (ARDS). As was the case for SARS, we didn’t know what was causing patients to die from what started as an atypical respiratory infection. We could see their immune systems were being destroyed, but we still didn’t understand why or by what.
We faced a heartrending set of circumstances, seeing previously vibrant, healthy young men being killed by inexplicable, unrelenting immune system deficiencies. With ARDS, too many soldiers died the most terrifying deaths. Their eyes would grow wide as they struggled to breathe. Later, with the soldiers unconscious and medicated to minimize their pain, we could only sit beside them holding their hands and watch as their faces twisted into a rictus of suffering and, despite all our efforts, they essentially drowned in their beds as pneumonia filled their lungs with fluid and starved them of oxygen.
Normally, we could have treated the root cause of the immune deficiency, but for these young men, we had no answers. We saw the evidence of an invasion crippling their body’s immune system with one rare infection after another, but we didn’t know its cause. We were desperate, and we were humbled. Our patients went from one bad moment to the next. Our interventions were temporary. We lived in a world of so many unknowns but one—that these young men were going to die and we couldn’t do anything to prevent that.
Returning to the BBC article about this latest “mystery virus,” I noted that the piece focused on two areas: what little was known about the spectrum of the disease (that is, the progression of its symptoms) and how the Chinese citizens and public health officials were responding to it. It was already the annual influenza season in the northern latitudes. If the Chinese had started tracking this outbreak based solely on symptoms and not on a definitive laboratory diagnosis, their initial presumption was that the virus was a seasonal flu variety. That it was now a “mystery virus” meant it could have been circulating for quite some time already. Were we seeing only the tip of the iceberg?
Using Google Translate, I read Chinese social media entries expressing fear that the new illness could be linked to a SARS outbreak. It was easy to see why some online chatter had made the SARS connection both in China and across Asia. Likely, many of those posting had lived through or lost someone to that earlier SARS and Middle East respiratory syndrome (MERS) crisis. Government officials and citizens across Asia knew both the pervasive fear and the personal response that had worked before to mitigate the loss of life and the economic damage wrought by SARS and MERS. They wore masks. They decreased the frequency and size of social gatherings. Crucially, based on their recent experience, the entire citizenry and local doctors were ringing alarm bells loudly and early. Lives were on the line—lots of them. They knew what had worked before, and they would do it again.
To that end, my heart sank a bit as I read on. The BBC article reported that Wuhan police had already cracked down on those who were “publishing or forwarding false information on the Internet without verification.” Would data be withheld again as it was in 2003? Certainly, I recognized the possibility that some of those reporting could be alarmists. But many of them were equally, if not more likely, truth tellers. People risking jail to share information likely meant one thing: the situation was worse than Chinese authorities were reporting.
I hoped this wasn’t the case. In the two decades since SARS, officials around the world, including in China, had agreed to focus on global health security and ensure transparency and information sharing early, even when the data points were incomplete. Based on what I was reading, though, the outbreak in China was not just worse than Chinese officials said, but it had likely started earlier. This meant that the virus had already had the opportunity to spread widely before they enacted any measures to contain it. This had implications for the rest of the world.
When it comes to handling emerging pathogens, the Chinese government is not alone in being motivated by self-interest. Economic and reputational concerns lead to a pattern of denial and downplaying. I saw this happen during other outbreaks, ranging from Ebola in West Africa in 2014/16; to the 2014 MERS, which originated in Saudi Arabia; to the latest instance of the Zika virus’s spread in the Americas in 2017. Governments always believe they can contain a virus and prevent it from spreading widely in their country and to others. But viruses can change rapidly, viruses move rapidly across borders, and humans are by nature slow and often too arrogant to act when they should, convinced they have the power to control and contain viruses with technology and win.
THE NEXT FEW DAYS after that first BBC story, my early morning internet-browsing sessions quickly turned into my taking a few moments regularly throughout the day—some might say excessively—to check where this new virus was and where it was going. Viral outbreaks evolve quickly, so I’d scour the internet between meetings. I’d use different search terms. I’d integrate data points in my head, turning single-source reports into a two-dimensional picture of the new virus on the move.
Much of my career has been shaped by the desire to be of service in the most effective way possible. In college, I chose medicine over my first loves, physical chemistry and math, for precisely this reason. Helping a company like Kodak develop a new and better green dye that didn’t turn photo paper yellow over time certainly would have made me money, but it wouldn’t have helped change the world.
I switched to medicine when medical research and understanding of our immune system were expanding at an explosive rate. The immune system fascinated me because I saw it as a very sophisticated mathematical equation. It has to strike a very delicate balance and stay within a critical window where it can fight off pathogens while not going too far and destroying the very body it’s meant to defend. That the same system contained both the ability to kill us and to save us enthralled and challenged me.
Throughout my medical/research career—which has taken me from the dawn of broad immunological study to places and organizations like Walter Reed, the National Institutes of Health (NIH), and the CDC; to my role as ambassador-at-large and global AIDS coordinator as part of PEPFAR, at the State Department—the immune system and its role in fighting disease has been at the forefront of my work to mitigate the effects of infectious spread. For many years, this meant the AIDS pandemic, but also other diseases, like tuberculosis.
It has been enormously rewarding work, and I was looking forward to ending my tenure in 2021. I had decided that four decades in public service was a good, round number, and I planned to move on to a second career. I wasn’t quite there yet, and had entered into a very busy time with PEPFAR, when I began to read those first accounts coming out of Wuhan, China. I had no special access to other inside information, just a long-held need to keep informed.
Along with monitoring publicly available sources and journalism, I also watched the information coming from the World Health Organization’s situation reports. As the mystery evolved, I dug deeper, moving beyond mainstream news organizations to new websites and online posts tracking the virus across the globe. Clearly, and as I expected, others saw the need to probe more fully into this developing story. Many in the field of public health began to mobilize, putting together what little data we had to create a more complete picture of what was happening.
On January 6, I read a New York Times story about the same clusters of illnesses the BBC had reported on. It confirmed much of the earlier reporting on them, but also included details about a suspected source. The Huanan Seafood Market in Wuhan had been shut down and decontaminated. The virus that caused SARS and the H7N9 strain of bird flu, which had caused five epidemics of avian flu between 2013 and 2017, had been traced back to similar markets. Close interactions between humans and animals can lead to a virus jumping from one species to another. When animal-to-human transference takes place, and the virus adapts to infect human hosts, we call the resulting virus “zoonotic.”
Novel (new) zoonotic viruses are particularly alarming. All zoonotic viruses are worrying, and the fact that Ebola, SARS, MERS, avian flu, and AIDS were all caused by zoonotic viruses is especially worrisome. (Basically, epidemiology is a field that requires a strong stomach for worrying.) Why? With a zoonotic virus, human beings usually don’t have any preexisting immunity to the pathogen that arises in and adapts to a specific animal. The more rapidly it adapts to the human host and can spread from human to human, especially through the air, the more easily the human population can become relatively easy pickings. This is especially true if we are otherwise immunocompromised (as in the case of people who are HIV-positive) or already have other conditions (known as comorbidities) that lessen our ability to produce a fully effective response to pathogens. Airborne pathogens are also particularly dangerous because of the ease with which they are transmitted. As horrific as Ebola and AIDS are, they are not as easily spread, as they are transmitted through the exchange of bodily fluids.
Along with sharing this detail about the market, the Times piece also confirmed two early suspicions I had, both quite troubling. The WHO had received notification from Chinese authorities about a pneumonia-like cluster of infections on December 31, 2019. Yet, by that date, Chinese authorities already had tracking and containment plans in place at airports outside Wuhan to monitor airline passengers arriving from that provincial capital. For the virus to have risen to a level of infection that necessitated these state actions meant it had likely been spreading for weeks, and the Chinese were now aggressively acting to control the spread within their borders while underplaying the outbreak globally. If the virus had in fact been spreading for weeks, it meant the Chinese were also behind in seeing and responding to the outbreak and their containment efforts would fail.
Furthermore, the Chinese were claiming to the WHO that there had been no human-to-human transmission. The only ones infected, they said, had had direct contact with animals at the Huanan wet market. If there was no human-to-human transmission, then the number of victims of the disease would be very small, restricted to those who had been to that single wet market or other wet markets.
Whether the officials in Wuhan or higher up on the chain of command had delayed the release of information by days or weeks was impossible to know at this point. But I did know that any delay could prove deadly. Whatever lessons the Chinese authorities had learned from SARS, they apparently weren’t frightening enough to inspire a change to full transparency.
The Times article also confirmed that the Chinese were on the hunt for those who were already exhibiting signs of infection. To complicate matters, China was in winter, a period when many other respiratory viruses circulate, including influenza. It would be hard to tell, therefore, who had pneumonia-like symptoms that were not related to this novel zoonotic virus—at least, not without a test to detect that particular virus. From past experience with other viral outbreaks, I was dubious about this kind of containment strategy.
In tracking viral outbreaks, it is critical to account for four types of spread. The first is asymptomatic, which applies to people who are infected but, despite not having symptoms such as fever, cough, and nasal discharge, are indeed infectious and able to transmit the virus to others. The second is presymptomatic. Immediately following initial infection and replication of the virus and before exhibiting any signs of the infection, these individuals are infectious and will transmit the virus to others during this window. The third, mildly symptomatic, are those with symptoms so mild and non-febrile that they either ignore them or pass them off as symptoms of allergies or a hangover; nevertheless, these individuals are infectious and can transmit the virus to others. The fourth, the fully symptomatic, are those currently presenting typical signs of the infection and able to transmit the virus to others.
Asymptomatic, presymptomatic, and even mildly symptomatic spread are particularly insidious because, with these, many people don’t know they are infected. They may not take precautions or may not practice good hygiene, and they don’t isolate. As a consequence, they come in contact with more people than someone who is symptomatic. Sick people with high fevers and body aches often can’t physically work and tend to stay at home. As a result, those in the first three categories often infect more people than the fully symptomatic do.
Placing a major emphasis on the fully symptomatic is typical of the containment strategies devised to lessen symptomatic spread. That’s step one, but if it’s the only step you take, if that’s the only type of spread you feel you have to mitigate, then containment will never work. In my experience, from the earliest onset of any cluster of infections, you have to be alert to the possibility of, and account for the first three types of spread. In my mind, this is job one.
Sure, there are other variables that determine the scope of an outbreak. Knowing how the virus is spread—whether it is airborne or passed on by blood or other body fluids—the length of the incubation period after exposure, and how long a person remains infectious to others is also critical information. For example, a person infected with HIV can remain asymptomatic for as many as ten years, which contributes to that virus’s being such a difficult one to control. Some viruses, like the one for measles, are more easily transmitted than others through aerosols (that is, fine particles). Some mutate at a greater rate, becoming more adaptable to their new host’s changing infectiousness and/or virulence.
However, the one variable that stands out most for me is the type of spread/transmission. After years of experience seeing asymptomatic, presymptomatic, and mildly symptomatic cases being ignored in tabulations, anytime I read a number indicating a confirmed case, I multiply that by a factor of between three and ten. Whatever the number of infected the Chinese had put out, 44 in their first report, I read as between 132 and 440.
The only way to accurately account for all four types of spread is to test as many people as possible early and often. The Chinese weren’t doing this—or, if they were, they were far behind where the outbreak actually was. It seemed highly unlikely that they’d developed a test specific to this novel virus yet. If they didn’t believe (or didn’t want to admit) that human-to-human transmission was going on, and if they weren’t accounting for asymptomatic spread, then they wouldn’t prioritize test development.
Often in pandemics, we focus significant effort on the development of treatments and vaccines, and we neglect the development of tests. This is a fundamental error. In Africa, we had spent years moving from testing only those with AIDS symptoms to testing everyone independent of perceived risk. We’d saved countless lives through active community testing to determine if individuals had been infected with the virus, ensure access to lifesaving treatment, and prevent unknowing transmission to others. This approach was working for controlling HIV/AIDS community by community, and even though the novel virus was not being transmitted in the same way as HIV, the same model could apply in the case of this outbreak.
Without widespread testing, the Chinese were providing inaccurate data. They may not have been intentionally underreporting, but their numbers were wrong nonetheless. Whether this was an error of commission or omission doesn’t really matter. Either way, without testing, you could not see the full extent of the virus and number of people infected.
In the case of this novel virus, I believed that significant asymptomatic and presymptomatic spread (which, together, are also known as “silent spread”) was already occurring in China in early January and had likely been happening for weeks. I didn’t have to wait long to find further evidence to support my contention. In the days following the original news reports, other provinces within China began identifying similar pneumonia-like cases. I also knew this: If this novel virus was related to SARS, then it was already spreading more rapidly than the late 2002/3 SARS-CoV-1 version had. The puzzle pieces were being laid down to create a frightening picture. I worried about the HIV-positive people we were supporting throughout Asia and Africa and their potential susceptibility to this new virus.
All zoonotic viruses aren’t created alike, and they don’t act alike, either. They range from extremely and immediately deadly (Ebola) to deadly over time (HIV), with a longer component of silent infections with HIV. SARS and MERS killed many people quickly. Ironically, the more rapidly a person becomes symptomatic and dies from infection, the less community spread there typically is, because there are fewer chances for that person to infect other people. While this may sound counterintuitive, it occurs because those stricken are sick in bed at home or in hospitals and, therefore, not silently and unknowingly spreading the virus in the community.
As deadly as Ebola is, and as large as it looms in our collective imagination, measures to contain it are relatively effective. It spreads through contact with the body fluids of those infected with the virus. You know immediately who has been infected, so tracking and tracing those who have developed, or might develop, the disease are more straightforward. That’s not the case with SARS and its variant MERS. These diseases are produced mainly when an infected person coughs or sneezes, emitting droplets containing the virus that another person comes in contact with. You know when you’ve come in contact with body fluids. You’re not always aware when you’ve come in contact with aerosols and droplets, which remain unseen and are suspended in the air for long periods, allowing us to unknowingly breathe them in. For the medical community, viruses that can spread through aerosols suspended in air (highly infectious) and that are virulent (deadly) are the most concerning.
The SARS-CoV-1 strain of virus that caused the 2003 SARS outbreak is extremely virulent. Its average 10 percent case fatality rate (or CFR, the number of confirmed infected individuals divided by the number of deaths over a specified period of time) is extremely high. Fortunately, the SARS virus is less transmissible, requiring a higher viral exposure for longer periods in order to spread. As a result, even though SARS had a very high CFR, because it wasn’t as “contagious” and because it moved less silently and undetected from host to host, the number of total cases, and thus deaths, for the 2003 outbreak was fairly low. That being said, the SARS outbreak killed indiscriminately across age groups, rapidly taking out healthy twenty-somethings, forty-somethings, all the way up to eighty-somethings, and struck fear throughout Asia from the end of 2002 through 2003.
I understood just how fortunate we all were that SARS wasn’t both easily transmissible and highly fatal. That was the stuff of nightmares.
WHILE I HAVE LONG been fascinated with the immune system’s response to a pathogen, as a public health official, I’m far more concerned about how governments and health agencies respond to the presence of a potentially new and deadly virus. Alerting the public early and being very aggressive can change the course of an outbreak and prevent it from developing into a full-blown epidemic.
On January 3, the same day the BBC piece ran, the Chinese government officially notified the United States of the outbreak. Bob Redfield, the director of the Centers for Disease Control and Prevention, was contacted by his Chinese counterpart, George F. Gao. At the time, this wasn’t reported, but later, in April 2020, the Washington Post revealed that Alex Azar, the secretary of the U.S. Department of Health and Human Services, directed his chief of staff to notify the National Security Council about the severity of the situation in China. I was unaware of any of these developments.
On January 6, the same day the initial New York Times piece was published, the CDC in Atlanta issued a Level 1 travel advisory, the lowest in its three-tier system. It advised those traveling to a specific region of the world to practice the usual precautions. Unfortunately for many, “the usual precautions” meant traveling nonetheless and doing what they would normally do. During the course of a normal year, the CDC and the WHO offices around the world issue dozens of such advisories. The CDC was following standard operating procedures, indicating that it was monitoring the situation. I continued to follow the WHO status updates, but often, to my dismay, they appeared to be focused on merely tracking the evolving situation rather than taking action or alerting others to take action. It’s like they were passively watching a movie. When it comes to viruses, tracking without action leads to continued spread.
Regardless of the testing status in China, and regardless of the issues with the Chinese numbers, I presumed that China (and other Asian countries) would likely fare better with this first outbreak than they eventually did. From the nature of the symptoms, I thought this was likely a respiratory infection similar to the one caused by the SARS virus. Having been through a viral outbreak of that type before, the governments across Asia had enacted aggressive changes to public health policy and preparedness. They not only had a plan, but they and their populations knew how to implement it when necessary. Their populations would be more compliant because they understood the benefits of behavioral changes. They had lived that frightening nightmare and, as a consequence, had developed a kind of muscle memory that guided their actions. They immediately knew what to do and did what was necessary to protect themselves and their families. They weren’t waiting for guidance from the global health officials.
During the SARS crisis, we in the United States dodged a bullet, mostly because SARS was not as highly transmissible. It also was a fairly “loud” and “visible” disease, meaning it was detectable early, through symptoms that clearly and loudly announced themselves with their severity. This made contact tracing, with isolation (of the infected) and quarantining (of the exposed), more straightforward and possible. Yet, our avoiding that major outbreak also meant that, unlike the Asian populations, we didn’t have a cultural understanding of what the impact of a viral outbreak could do to individuals, families, businesses, and our general way of life. We didn’t have that shared experience that told us that wearing masks and social distancing were effective actions to take.
I felt this acutely because, for as long as I could remember, I understood that the risk of a virus is borne by all. As an eleven-year-old, my grandmother was infected at school during the deadly 1918 Spanish flu epidemic. Her mother, my young, vibrant great-grandmother Leah, from whom I get my middle name, had just given birth to another daughter when my grandmother transmitted the virus to her. When my great-grandmother died from it, the entire trajectory of my grandmother’s life was changed in an instant. For a time, she became the caregiver for her infant sister and the rest of her family. She was racked with guilt until the day she died at age ninety-four.
My grandmother was my touchstone, a woman who believed in me unconditionally. I spent every summer with her growing up, and I have carried her wisdom with me through the years. That one innocent moment of bringing the Spanish flu home changed her life for the next eighty-three years. In a very real way, my life was shaped by a viral outbreak. It was part of my lived experience, and my decision to study immunology and epidemiology was shaped by it. I didn’t want anyone to experience what my grandmother had. I didn’t want any country to reexperience the devastation of the Spanish flu, SARS, or any other pandemic event. Youth, vibrancy—these things do not always protect us, but more important, they don’t protect our families. Nothing about our circumstances can insulate us; only our behavior can.
In the case of the novel virus, on January 13 Thailand reported its first case, then a second case. On January 20, the Korean CDC reported its first case. The infected Korean woman had been in Wuhan but had not visited the suspect market. The medical community knew that it had to have been spread from human to human.
Later in the month, a Japanese businessman who had traveled to the Wuhan area and also hadn’t spent any time in the suspected wet market became sick. He was eventually hospitalized and tested positive for a novel coronavirus infection. All this signaled to me, once again, that in both these cases, human-to-human transmission was going on. I couldn’t see it any other way.
By mid-January, though, Wuhan’s Municipal Health Committee had published a FAQ piece claiming, among other things, that there was no clear evidence of human-to-human transmission. On January 14, the WHO tweeted the same thing: no evidence of human-to-human transmission. Later that day, the WHO held a press briefing during which it was stated that “it is certainly possible that there is limited human-to-human transmission.” The spokesperson went on to say that it was important to “ascertain . . . the presence of asymptomatic or mildly symptomatic cases that are undetected.” I shook my head when I heard this—I knew that politics was at work, at least in China. There had to be human-to-human transmission to account for the approximately five hundred cases being reported there. Fortunately, on January 12, the WHO reported that the Chinese had isolated a novel coronavirus as the cause of the spreading illness. This meant that tests—the first pillar of any twenty-first-century public health response—could now be developed to detect the presence of that particular virus. Crucially, those tests could detect infection before a person developed symptoms. This new information would instigate the development of treatments (the second pillar) and vaccines (the third pillar of an effective response).
Like the SARS virus, the novel pathogen was from the Coronaviridae family of viruses and therefore shared some of its ribonucleic acid, or RNA, with SARS-CoV. Knowing that the genetic sequence of this new RNA virus was related to the SARS virus was worrying—but better the devil you know than the one you don’t. The long-term investment in SARS research following the 2003 outbreak had created a strong platform of baseline understanding of this type of virus and would accelerate the research necessary to develop tests, therapies, and vaccines for the new one.
After identifying the type of pathogen, the Chinese did the right things scientifically: On January 12, the China CDC released three genetic sequences for the novel coronavirus. Two others were posted to the Global Initiative on Sharing All Influenza Data, or GISAID, which provides open access to genomic information. This was critical and a good sign, both within and outside China. Scientists could now ramp up their efforts on multiple fronts. But as is often the case with outbreaks, bad news often follows close behind the good.
Despite the Chinese crackdown on the online spread of information, word was getting out. Hospitals in Wuhan were filling up, an incredibly troubling development. If you are, in fact, effectively mitigating, if you are isolating those infected and quarantining those exposed, you should be preventing hospitals from becoming overwhelmed—what we call “flattening the curve” of the pandemic. Based on what I was reading, though, this did not appear to be happening in Wuhan. This was a bright red warning light. Even with the rules in place, the Chinese were not containing the virus, and it was spreading quickly through human-to-human transmission. The Chinese were missing a critical part of the spread. With hospitals being filled so suddenly, there simply couldn’t have been that many people directly in contact with whatever animal at whatever suspected market was carrying the transmissible virus. I knew then that this virus was worse than SARS. It was spreading faster, and hospitals were filling up quicker than they had in 2002/3.
On January 14, when the WHO had tweeted about the limited possibility of human-to-human transmission, I knew that “limited” wouldn’t adequately account for the five hundred cases being reported in Wuhan. The WHO was trying to thread the needle between science and politics, hoping that its words would be seen as a warning without contradicting the Chinese. But using such tentative language to address such an obvious reality was a serious mistake, one that undermined the central tenets of the organization. By this point, we were already way past caution. Public health officials recommend a very different approach to containing a virus that can be spread only from animals to humans, with no human-to-human transmission; the potential for global spread is dramatically different. Warning the world right then and there of the presence of a highly transmissible respiratory virus with a spectrum of disease ranging from asymptomatic to serious illness would have changed the global response and would have spurred the world to greater action and the manufacturing of tests. In hindsight, I see this as an important, early missed opportunity.
On January 14, we also learned that the incubation period (the time between exposure and symptoms being expressed) of the new virus could be as long as fourteen days. But the data was spotty, and there were still many unknowns. Even so, it seemed apparent that whatever we were seeing now was likely to be vastly different (read: worse) in two weeks.
The Chinese data was suspect and scarce. I turned to other sources to find evidence to support my instinct that asymptomatic transmission was also responsible for the spread beyond Wuhan. The website for the University of Minnesota’s Center for Infectious Disease Research and Policy cited two previous cases I’d read about—the Japanese businessman and the Korean. I felt certain other scientists saw these as evidence of human-to-human transmission.
On January 17, the CDC announced that it would be screening passengers arriving in the United States on direct or connecting flights originating out of Wuhan. The screening at three airports consisted of a temperature check to identify those who were febrile and a verbal self-report of symptoms. Just as the Chinese had initially, and then the WHO, the CDC was looking for symptomatic people and their close contacts coming from known hot zones. Once these people were found, they would be isolated or quarantined. This was the singular focus—containment through symptoms, not testing. Without testing, this would never be enough. Everyone who was coming from “hot zones,” independent of their symptom status, needed to be tested.
On January 20, the CDC reported that the United States had its first confirmed case. Like the infected South Korean woman, the Seattle man who was the first reported and known American infected with the novel coronavirus had neither been to the animal market nor been in contact with anyone who was ill. Clearly, he had been in contact with someone who was carrying the virus, but as far as this first-known infected American knew, he had not been in contact with any symptomatic person in China or upon his return to the United States.
Of the three cases outside China that I was aware of, two fell clearly into this same potential asymptomatic or presymptomatic exposure category. I was feeling more and more confident that there was silent spread at work on some level. Yet, as a trained scientist, I understood that I didn’t yet have enough evidence to support what my gut and my head were telling me. I believed that I was ahead of where the CDC and the WHO were, but I wasn’t far enough through the curve to be able to provide the abundance of evidence I would need to defend my beliefs. I could hear the virus calling out, but as far as I knew, it remained silent to others. Still, I was confident that our scientists, among the best in the world, were likely seeing what I was seeing and that our country’s vast resources would offer us the best protection.
I was hopeful that this wasn’t arrogance talking. I trusted that—though the president said presumptuously on January 22, “We have it totally under control,” and though Dr. Nancy Messonnier of the CDC had characterized that agency’s approach as “cautious”—the United States would recognize the seriousness and rally as needed. So, at that point, my concern loomed larger for Africa, and was amplified further when an online video from a hospital in Wuhan made its way to me.
The video showed a hallway crowded with patients slumped in chairs. Some of the masked people leaned against the wall for support. The camera didn’t pan so much as zigzag while the Chinese doctor maneuvered her smartphone up the narrow corridor. My eye was drawn to two bodies wrapped in sheets lying on the floor amid the cluster of patients and staff. The doctor’s colleagues, their face shields and other personal protective equipment in place, barely glanced at the lens as she captured the scene. They looked past her, as if at a harrowing future they could all see and hoped to survive. I tried to increase the volume, but there was no sound. My mind seamlessly filled that void, inserting the sounds from my past, sounds from other wards, other places of great sorrow. I had been here before. I had witnessed scenes like this across the globe, in HIV ravaged communities—when hospitals were full of people dying of AIDS before we had treatment or before we ensured treatment to those who needed it. I had lived this, and it was etched permanently in my brain: the unimaginable, devastating loss of mothers, fathers, children, grandparents, brothers, sisters.
Staring at my computer screen, I was horrified by the images from Wuhan, the suffering they portrayed, but also because they confirmed what I’d suspected for the last three weeks: Not only was the Chinese government underreporting the real numbers of the infected and dying in Wuhan and elsewhere, but the situation was definitely far more dire than most people outside that city realized. Up until now, I’d been only reading or hearing about the virus. Now it had been made visible by a courageous doctor sharing this video online.
The images amplified everything I’d been learning. All the aggregated data—the news articles, the scientific reports, the WHO status updates, the social media entries, my doubts about the reliability of the Chinese authorities’ figures—everything coalesced for me, forming an image of suffering, frightened, overworked human beings and their suffering and dying patients. That video drew me in, and I sat there literally moving toward it, trying to make out details I couldn’t see from a distance. It put me there, in a place where I didn’t want to be and where none of those pictured wanted to be, either. This was just one scene in one particular location with those specific patients and doctors. I wondered how many other scenes in how many other places involving how many other human beings, in Hubei Province and elsewhere in China, were playing out like this—only, without video evidence. Worse, how many more times would all this be replicated elsewhere and multiplied many times over in the weeks and months ahead?
This question was still lingering when, a few days later, I saw images online of a large plot of cleared land. Dotting it were various pieces of earth-moving equipment, enough of them in various shapes and sizes that I briefly wondered if the photograph was of a manufacturing plant where the newly assembled machines were on display. Quickly, I learned that the machines were in Wuhan and that they were handling the first phase of preparatory work for the construction of a one-thousand-bed hospital to be completed in just ten days’ time.
This move was straight out of the Chinese SARS playbook, when China implemented the same measure in Beijing. Sitting there watching video evidence of a need for an enormous prefabricated hospital drove home for me just how ominous things really were. The Chinese may not have been giving accurate data about the numbers of cases and deaths, but the rapid spread of this disease could be counted in other ways—including in how many Chinese workers were being employed to build new facilities to relieve the pressure on the existing, and impressive, Wuhan health service centers. You build a thousand-bed hospital in ten days only if you are experiencing unrelenting community spread of a highly contagious virus that has eluded your containment measures and is now causing serious illness on a massive scale.
In other words, you build a thousand-bed hospital in ten days only if you need a thousand-bed hospital right now.
I had to make sure Africa was prepared.