Europe / World | Coronavirus

Fighting the Coronavirus Pandemic, East Asian Responses - China: Lockdowns, Digital Tools and Mobilization of Industry

ARTICLES - 30 March 2020

By Viviana Zhu

Key Points

Patient zero has not been found, but the start of the outbreak is now backtracked from December 8 (initially acknowledged) to December 1 and now November 17. Strong national measures are implemented from January 23, 46 days after the first case was initially identified and reported.

By contrast, genome sequencing in China has been very quick - from December 27 for a partial decoding to January 6 for the entire sequence, communicated abroad. International epidemiological investigation in Hubei province is almost entirely prevented, however.

The central government’s turnaround between January 20 and 23 leads to a massive containment effort resting on three pillars: rigorous lock-downs and travel bans; these are enforced with the help of local “mass organizations”, as well as digital surveillance tools with some tracing ability for contacts;

All-out mobilization for the production of medical equipment, a feat unmatched anywhere else.

China’s lockdowns, although varying in local implementation, go beyond what has been implemented elsewhere: patients showing symptoms are put in isolation wards, local committees - and a huge distribution network - have ensured that people do not leave their homes in cities; digital tracing tools have been used to detain travelers from infected regions.

This article was updated on April 9.

China is both the cradle of the Covid-19 epidemic and the country that has taken the strongest measures to contain it, so far with success. This is in spite of a late start, and a remaining deficiency of testing in spite of efforts. The Chinese solutions are distinctive by the rigor of the lockdowns, the use of digital tools and the mobilization of medical industries. The economic cost has been sharp. China now promotes its response and emerges as the world’s major manufacturer of needed medical equipment.

Timeline

November 17, 2019 – First case retrospectively detected in China
December 8 - First confirmed case according to the Chinese official statement to the WHO
December 30 - Li Wenliang, a doctor working at Wuhan Central Hospital, sends a warning to fellow medics. One day later, he is made to write a self-criticism to reflect on the topic of “not spreading misinformation”.
December 30 - An “urgent notice on the treatment of pneumonia of unknown cause 关于做好不明原因肺炎救治工作的紧急通知” is issued by the Wuhan Health Commission, highlighting the increasing number of patients in Wuhan showing symptoms, and urging all medical institutions to report relevant information
December 31 – The Wuhan Municipal Health Commission issues the official communication of pneumonia cases of unknown cause at Wuhan’s Huanan Seafood Market. Arrival of a National Health Commission expert team in Wuhan to investigate the pneumonia outbreak, which is reported to WHO on the same day
January 3 - The work unit at a Wuhan hospital is required to not discuss the diseases through public and private communication channels.
January 5 - The virus from Wuhan is fully sequenced in Shanghai; publication of a report by the Wuhan Municipal Health Commission with updated numbers of cases but "no clear evidence of human-to-human transmission"
January 7 - Xi Jinping gives verbal and written instructions on the outbreak at the CPC Central Committee Political Bureau meeting, as he retrospectively indicated in his February 3 speech.
January 14 - First temperature checks at Wuhan’s airport, train station, coach station, and ferry terminal. Installation of 35 infrared thermometers, complemented by around 300 handheld models of infrared thermometers
January 20 - Start of the Lunar New Year mass migration and first public address of Xi on the crisis situation; COVID-19 recognized as a Class B infectious disease and preventive and control measures of Class A to be applied. The policy allows medical institutions to isolate and observe COVID- 19 patients. China confirms human-to-human transmission of the virus.
January 21 – Establishment of the Joint Prevention and Control Mechanism of the State Council (肺炎疫情联防联控工作机制), composed of 32 departments coordinated by Vice Premier Sun Chunlan
January 23 – Lockdown announcement of Wuhan, followed by other nearby cities (Xiaotao, Chibi, Huanggang, Ezhou). Announcement of emergency construction of the first temporary in Wuhan, operational on February 3. A second project is announced two days after, operational on February 5.
January 24, 2020 - Suspension of group travel within China. First nucleic acid test kit passes legal inspection
January 26, 2020 – First meeting of the Central Leadership Group for Epidemic Response (中央应对新型冠状病毒肺炎疫情工作领导小组), chaired by Li Keqiang. Four nucleic acid test kits approved by the National Medical Products Administration (Speedy approval channel for medical devices)
January 27, 2020 – Suspension of group travel to foreign countries; individual travel remains open
February 08, 2020 - State Council issues the Notice on Orderly Resuming Production and Resuming Production in Enterprises
February 10, 2020 - A guideline stipulates that confirmed and suspected carriers of the virus can be charged with endangering public security if they refuse quarantine or leave before their quarantine time is up, enter public places or use public transportation.
March 16, 2020 - All overseas travelers entering Beijing are transferred to a centralized observation point for 14 days of isolation observation.
March 19, 2020 - China reports zero new local cases for the first time since the outbreak
March 23, 2020 - All international flights to Beijing are diverted to 12 cities, only qualified travelers can then continue their journey to Beijing.
March 25, 2020 - All inbound passengers arriving in Beijing are required to receive nucleic acid tests and undergo centralized quarantine
March 28, 2020 - Temporary entry suspension by foreign nationals holding valid Chinese visas or residence permits,
March 29, 2020 - Each Chinese airline is only allowed to keep one route to each foreign country, while each foreign airline is only allowed to operate one route to China. A maximum of one flight per week per route is applied.
March 31 - Ministry of Commerce, General Administration of Customs and the National Medical Product Administration jointly issue “Notice on the Orderly Conducting of Medical Materials Export”.
April 8, 2020 - End of Wuhan lockdown, after 76 days, but various local control and preventive measures remain in place.

Analysis

Three phases can be identified in China’s overall response: the initial period of denial and lack of proper measures to confine the epidemic; a policy reversal on January 20 defined above all by the strongest lockdown measures in the world on January 23 with corresponding means of residential control and digital tracing tools; and from March 19, the claim of victory against the virus, with the accent on imported cases. As China’s production capacities of personal protection equipment are eagerly sought, China aims to reshape the global narrative regarding COVID-19. Yet any final narrative must start from the epidemic’s initial rise.

The tragic cost of denial

The first phase of responses, or lack of responses, is reported by the cover story of China News Weekly. A number of people at Wuhan’s Huanan Seafood Market (which also sells wild animals) were infected as early as December 8, 2019, but the Wuhan Municipal Health Commission only issued the official communication of pneumonia cases of unknown cause at Wuhan’s Huanan Seafood Market on December 31. The market was only closed the day after, on January 1, 2020. Later investigation will backtrack and find infected patients from December 1, and later November 17, with no identified relation to the seafood market. Patient zero has yet to be found.

The 23 days between the December 8 infection cases and the market closure expose numerous Wuhan residents to the virus, contributing to a major outbreak in Hubei province, in China and then globally. Although national medical authorities are informed very early, neither the provincial nor the central government move quickly enough. Locally, information is withheld. Public gatherings and events continue until January 20. Li Wenliang, a doctor working at Wuhan Central Hospital, is one of the doctors who raises the alarm among his colleagues about this SARS-like disease. He is silenced. After his widely commented death from the epidemic and the January 20 turnaround by the leadership, the cost of denial is reassessed. China’s Supreme Court makes an explicit reference to Li Wenliang’s case on January 28. It tempers the definition of 'false information', noting that some of it may actually be true, or fill a gap left by a lack of public disclosure, and that it may not be malicious.

On January 31, Ma Guoqiang, Wuhan’s party secretary until February 13, acknowledges that if decisions and strict control measures had been taken earlier (such as putting Wuhan under lockdown on January 12 or 13 instead of January 23), the situation would have been contained better. He also blames the central government rules that prevented him from disclosing information related to the disease at an earlier stage, as he had to wait for authorization from Beijing.

The moment of truth and drastic measures

On January 20, the virus is recognized as a Class B infectious disease (which includes SARS and influenza A), requiring preventive and control measures of Class A (plague and cholera) to be applied. The upgrade of measures from Class B to A is crucial, since Class B requires faster reporting and stronger isolation measures. One day after, the Joint Prevention and Control Mechanism of the State Council 肺炎疫情联防联控工作机制 is established, comprising 32 departments under the coordination of Vice Premier Sun Chunlan. Guidelines are issued to medical institutions on January 22 urging them to keep the infection within medical institutions under control.

On January 23, as hundreds of millions have already arrived at their Lunar New Year destinations, a travel blockade begins in Wuhan and is sequentially adopted in other major cities. The Lunar New Year Holidays are now referred to as a “window of opportunity” for mass isolation and mass disinfection (大隔离、大消毒) on the prevention and control plan published by the National Health Commission (NHC) on January 28, and the official holidays period will be extended several times. Much migration has already happened by that time however: the mayor of Wuhan estimates that almost 5 million people had left the city before enforcement of the travel ban A restriction on group travel to foreign countries is only implemented on January 27, three days after the suspension of domestic group travel. The travel ban is also enforced by many informal local blockades. Confinement and complete lockdown follow - with varying degrees of severity according to time and place. Complete isolation of suspected cases is enforced. Emergency hospitals are delivered and put into operation in 10 days. Operated by the Chinese People’s Liberation Army, they provide 2600 beds in total. By February 28, 16 cabin hospitals (方舱医院), which are movable medical spaces, are also built in Wuhan to treat mild symptom patients, adding 13,000 beds. The aim set by the NHC at this point is to concentrate patients, experts, resources, and treatment (集中患者、集中专家、集中资源、集中救治)".

While confirmed patients are subject to hospitalization, all individuals in close contact with confirmed patients, or arriving from a high-risk area, undergo a compulsory quarantine. There is mandatory compliance with the investigation, testing, collection of samples and isolation. Public security organs and digital surveillance tools are massively used. Medical treatment is free for individuals, covered by insurance and other government subsidies. Confirmed and suspected cases face charges of endangering public security if they refuse or do not respect quarantine.

Masks and other medical equipments - A production leap

Several provinces and cities make masks compulsory. In addition, there is major social pressure on individuals to wear masks. The Chinese Center for Control and Prevention’s guidelines also advise wearing medical surgical or N95 masks in public spaces and public transportation, as well as keeping at home as “daily necessities” masks, thermometers, and disinfectant. To ensure the mask supply, duties on mask donations from abroad are waived, and subsidies are provided to companies importing masks.

A key feature of the Chinese response is the mobilization or retooling of production capacities in a short period of time to meet domestic demands for medical equipment.

A key feature of the Chinese response is the mobilization or retooling of production capacities in a short period of time to meet domestic demands for medical equipment. On January 21, the Ministry of Industry and Information on Technology issues a notice to ensure and coordinate emergency supplies for the epidemic. A platform is established to connect suppliers and buyers of critical medical equipment to foster production. To address the worry that this could lead to overcapacity, the government promises later on that it will absorb all remaining products for stockpiling after the crisis. A list is released on February 8, which includes medical protective clothing, various types of masks, nucleic acid test kits, and automatic infrared body thermometers.

The certification process for supplies is also simplified, allowing companies to either purchase new production lines or divert their existing production line to join the mass production of medical equipment. In less than one month (Feb. 1 – Feb. 29), China has multiplied its production capacity of masks by 5.5 times, from the initial 20 million per day to 110 million per day. The number will continue to increase, expected to reach 200 million per day. To put it in perspective, in 2019, China’s total production output was 5 billion pieces (13,7 million per day). The same trend is observed with production capacity of medical protective clothing, which increases from an initial 8700 sets per day on January 28, to 852,000 sets per day on March 12.

For tests, the first nucleic acid kit passes legal inspection on January 24. Two days later, the National Medical Product Administration creates a speedy approval channel for medical devices. Four nucleic acid test kit products are approved on the same day. Two types of test kit are used in China: nucleic acid test kit and antibody test kit. By March 27, a total of 22 coronavirus test kit products are approved. As of March 11, production capacity of nucleic acid test kits is 2.6 million kits per day (up from 773 000 on February 1) , while production of antibody test kits is 1 million per day. The nucleic acid test is the most commonly used detection method of coronavirus, as antibodies take time to develop and are not detected in the early stage of infection. However, the accuracy of nucleic acid tests varies and some of them seem to be on the lower end of the variation. Front-line doctors call for using CT scans instead of the test kit, since in their experience the test kits often fail to identify patients even when the infection is already obvious.

The Social Credit System, which is now referred to as the “master key 万能钥匙” solution of problems by reward and punishment, is also applied to coronavirus prevention and control policies. The scope of punitive measures and their implementation vary greatly, depending on local authorities and there is no national standard. But they often sanction the concealment of health and contact history, the refusal of medical isolation and observation, violation of mask-wearing requirement, or flouting prohibition of gatherings, including at home. There are cases of legal authorities temporarily lifting social credit related restrictions to allow for companies operating in critical sectors but under judiciary investigation to resume production. For instance, the Guangzhou Court unfreezes the bank account of a manufacturer of infrared thermal imagers so that it can resume production.

Reducing the risk of exposure and spread through data usage

The usage of big data is the other key to COVID-19 crisis management. Since January 20, local authorities are requested to report on daily basis development related to the virus, and the National NHC publishes a daily report on confirmed cases since January 21. A list of hospitals with a flu section that is qualified to treat coronavirus is also communicated on local authorities’ websites. Official data has become the source of major COVID-19 update websites and applications. But some tech companies go much further. For instance, Baidu visually pins on the map the location of coronavirus patients (without disclosing their names or personal details), as well as where they have been, allowing users to avoid areas with risk of infection. The platform also provides visibility over the availability of beds at hospitals.

Data and analysis provided by China’s three state-owned telecommunication companies (China Telecom, China Unicom and China Mobile), as well as mapping service providers, are used to monitor domestic population flows and to predict trends, allowing better resource allocation and planning. Electricity usage data is also put into use in a residential area in Hangzhou, due to lack of human resources, for real-time monitoring and control of quarantined residents and elderly living alone. In order to keep users connected, the provision of utilities and telecoms is not cut even if the bills are unpaid.

In sum, the government is able to have an overview of the situation thanks to the data and analysis provided by both local authorities and companies.

China Electronics Technology Group Corporations (CETC) releases a “close contact detector” platform based on the data provided by the NHC, Ministry of Transport, China Railway, Civil Aviation Administration, etc. to identify individuals that have been in close contact with someone infected. The platform has been integrated into existing popular applications such as Alipay, Wechat, and QQ. To facilitate enquiries, users can access the platform by scanning a QR code, and sign up with a mobile number, providing their names and national identification number. Each mobile number account can inquire about a maximum of three people. The platform is also used by authorities, companies, schools, public spaces and residential areas. As has been widely reported, social control of the local community has played a significant role in enforcing quarantine rules and other guidance.

These measures are part of a general attempt to divert movement flows, decrease the number of crowded places, and minimize social contacts as much as possible. At hospitals, automated machines are installed for medicine and disinfectors. To avoid overcrowding hospitals with false-positive visits, online medical service platforms are made available. Public hospitals and private companies start providing free online consultations, lowering the risk of cross-infection which has considerably aggravated the situation in Wuhan and other cities in Hubei.

In sum, the government is able to have an overview of the situation thanks to the data and analysis provided by both local authorities and companies. At the same time, individuals are offered a means to access their own status using various platforms. The horizontal combination of data allows authorities to easily identify individuals at risk (for instance, who traveled to a high-risk zone or who has been in close contact with someone infected) and conduct screening of this targeted group. These use of data for monitoring purposes follows the the prevention and control plan published by the NHC, which emphasizes the importance of “discovering, reporting, isolating and treating in advance ( 早发现、早报告、早诊断、早隔离、早治疗)”.

As some cities are now gradually resuming work and other activities, new tools of control and monitoring are introduced. Both Tencent and Alibaba have developed their own “Health Code (健康码)” System, which provides users with a QR and color (red, yellow or green) code to prove their eligibility of “free movement”. Another example is the “Itinerary Card (行程卡)” that can be used as a proof of “clean” travel history. Mobile users can obtain their travel history of the past 14 days (domestic and abroad), based on the data gathered by the telecommunication companies. Mobile users are coded red if they have been to Hubei, yellow if they have been to 58 listed foreign countries (constantly updated) and the remaining countries are green. The “Itinerary Card” is valid nationwide.

The massive usage of data (such as the collection, storage, and future whereabouts) to tackle the crisis has sparked privacy concerns. In most cases, the developed platform is government-backed and the legality of usage is supported by official government statements. In other cases, the company claims that data are either anonymized to show a general trend or unassociated with a specific identity. There is strong collaboration between the private and public sector in the control and prevention of the virus.

Closing down and supplying the world

As China flattens the coronavirus curve, a third phase begins. On March 17, 41 medical rescue teams dispatched to Hubei Province, the first epicenter of the outbreak, start their home journey, signaling a certain degree of return to normalcy. What follows is the lifting of travel restriction of Hubei starting from March 25, with Wuhan as the only exception, which ended its lockdown on April 8 while keeping various control and preventive measures in place. On March 19, China reports zero new local cases for the first time since the outbreak. The “zero new local cases” has continued for two more days, broken by the one confirmed case on March 22, but the daily number remains low. On March 28, China reports 45 new confirmed cases, among them, 44 imported. However, the fight against the coronavirus continues. In Wuhan, all medical personnel (over 4000) dispatched by the People’s Liberation Army since January 24 are ordered to remain on the ground until “the complete victory of the battle”.

On March 23, Li Keqiang urges officials not to hide cases in order to keep the reported number low, and requests everyone not to let their guard down as the fight against coronavirus is a long-term fight. During a meeting three days later, he also stresses the need of paying attention to asymptomatic carriers. According to a team of Chinese researchers published by Science, 86 % of cases in Hubei before January 23 went undetected, and only complete lockdown has reduced the transmission rate. Overall, as of April 9, China has reported nearly 81,90782,000 cases and 3336 deaths, of which 3216 in Wuhan and other cities in Hubei. Both figures are debated and there are serious doubts whether China’s statistics of cases and deaths are reliable.

China decides on February 7 to stop including asymptomatic patients in confirmed cases. Classified Chinese government data disclosed by the South China Morning Post estimate that one-third of coronavirus cases may be asymptomatic. Asymptomatic carriers, also known as “silent carriers”, can still transmit the virus to others, and with the resumption of normal life in China, preventive and control measures must remain in place to avoid the resurgence of cases. With the growing public fears over spread caused by asymptomatic patients, China decides to report asymptomatic cases starting from April 1.

China has also used its WHO membership and influence to regain some control of the narrative regarding the outbreak, and is launching a major bilateral public diplomacy in countries where the epidemic has shifted - chiefly, Europe and America, but also Africa.

At the same time, efforts are placed on preventing imported cases. As of March 26, there is a recorded total of 541 imported cases. Starting from March 16, all international travelers arriving in Beijing have to fill in a health statement card and are screened. Falsification of health conditions leads to a maximum sentence of three years in prison or detention. After customs screening, at-risk inbound travelers are hospitalized while the rest is transferred to a centralized observation point for 14 days. Travelers have to cover their own isolation expenses. Xiaotangshan Hospital is reactivated for screening and treatment of confirmed and suspected imported cases. The requirement to have all incoming passengers undergoing nucleic acid testing is added at a later stage. Shanghai also applies similar measures.

As days go by, the compulsory quarantine requirement has placed Beijing under huge pressure to handle the increasing number of travelers at their designated accommodation. To relieve the pressure, starting from March 23, all international flights to Beijing are diverted to 12 cities. Upon landing in one of the cities, the traveler is only allowed to continue its journey if the required conditions are met. On March 26, China’s Ministry of Foreign Affairs announces a temporary entry suspension for foreign nationals holding valid Chinese visas or residence permits, effective from March 28. From March 29, each Chinese airline is only allowed to keep one route to each foreign country, while each foreign airline is only allowed to operate one route to China. A maximum of one flight per week and per route is set.

Given the massive production capacity increase of medical equipment and their global shortage, China is now receiving requests from other countries hit by the virus crisis. However, mask producers are still struggling to meet domestic demand, as they only fulfill 70%-80% of it. Now that work and schools are restarting, the demand will further increase. The shortfall is also acknowledged by Li Xingqian, Director of the Foreign Trade Department of the Ministry of Commerce. With the increasing demands and orders from overseas, it remains interesting to see how China plans to fulfill them. On the other hand, the export of medical protective clothing is encouraged as its supply has exceeded the demand since the end of February. The export is facilitated by other policies. For instance, China’s Civil Aviation Administration increases its international air freight capacity and opens a “green channel” for approval of charter flights, in order to ensure shipment of medical equipment. China is using its unequalled capacity to shift production towards required personal protective equipment and other medical supplies to provide these abroad, along with a political line about its superiority against democracies. China starts having bilateral trade agreements with countries having medical equipment shortage. On March 29, a first delivery of 5,5 million masks to France, and on the same day, the US also receives a government-led airlift from China (12 million gloves, 130,000 N95 masks, 1.7 million surgical masks, 50,000 gowns, 130,000 hand sanitizer units, and 36,000 thermometers). China reports to have exported 3.86 billion face masks between March 1 and April 6. However, the quality and reliability of medical equipment exported are being questioned. For instance, both Spain and Slovakia found test kits received from China unsatisfactory. Facing backlash, China’s Ministry of Commerce, General Administration of Customs and the National Medical Product Administration jointly issue “Notice on the Orderly Conducting of Medical Materials Export” on March 31. All listed medical equipment must obtain domestic “Registration Certificate for Medical Device” before being exported, while this was previously not a requirement - and exporters were able to play with different certification processes to obtain licences

Economic consequence and policies

The epidemic arrives in a context where there was already much public and quasi-public debt (circa 2,5 GDP), a trend toward slower growth, an impact of the US tariffs on exports to the US. The government was constrained by these financial risks; it had reduced infrastructure investment and adopted; over the past two years a stop-and-go attitude towards more stimulus, especially with the local real estate bubble.

The impact of the epidemic is unprecedented since the 1960s. Official figures for January-February reflect a very steep decline : -13,5 % YoY for industrial production, - 13 % for services, - 20,5 % for retail consumer sales, - 24,5 % for fixed investment, - 9,6 % for foreign trade, - 9,9 % for fiscal revenue (and -21,4 % for February alone). By mid-March, external forecasts are in the 2-4 % GDP growth for the year 2020.

Resumption in operations starts quickly but without full results so far., since resuming some production does not mean reaching full capacity. Steel and similar industries never stopped, but have even larger stockpiles than usual. 97% of SOEs, often with employees at hand and a command structure, report to have resumed production. High-tech foreign firms, less dependent on SMEs and on migrant labor, are ahead by late March. This is not the case for SMEs so far, with only a work resumption rate of 71,7%. Energy usage, traffic statistics indicate an uptick but not yet a return to normalcy. For example, the use of cars in large cities has increased, but not subway rides; intercity traffic is still slow on March 26 (22 out of 51 trains from Beijing to Shanghai, similar cuts on flights in spite of heavy discounts).

A key interrogation is now on a second economic shock, with the impact of an EU, US, and possibly global recession. There can be no export rebound except in very limited categories (medical equipment) in Q2. Some estimates point to a 21 to 45 % decline of China’s exports in Q2: 21 % is equivalent to the 2008 financial crisis and the impact on GDP would be between - 3,7 and - 8,1 % (according to Gavekal Research). The entry ban, quarantines and general decline in air travel will not favor a rebound of foreign investment and activity in the new quarter. For 2020 as a whole, a GDP decline is entirely possible, given these first two quarters.

Some estimates point to a 21 to 45 % decline of China’s exports in Q2: 21 % is equivalent to the 2008 financial crisis and the impact on GDP would be between - 3,7 and - 8,1 %

The government’s economic response remains on the conservative side. Central allocation to virus responses reached CH¥ 116.9 billion (US$ 16.7 billion) on March 13. There are reduced social contributions, discount loans: CH¥ 500 billion (US$ 71.4 billion) on February 15 at a “discount” rate of 2,5% to 4,5% followed by a special quota of CH¥ 350 billion (US$ 50 billion) lending quota to policy banks. This should be viewed in comparison to an overall CH¥ 36 trillion (US$ 5138 billion) previously loaned to SMEs, however. Export subsidies are put in place in mid-March. Infrastructure spending (which dropped in Jan.-Feb) is meant to increase, but from a low base in 2019, and will not by far reach 2008 levels. “Helicopter money” e.g. cash disbursements to individuals have not happened (although large companies and platforms are instituting large sale vouchers), nor has there been so far an across-the-board interest rate cut by the central bank. However, it has announced on March 30 an interest cut from 2.4% to 2.2% on a reverse purchase agreement for banks.

Much touted international aid by China has so far focused on delivery (or sale) of medical equipment. Xi Jinping’s speech at the March 26 G20 summit calls for “coordination” and for “cutting tariffs, removing barriers, and facilitating the unfettered flow of trade”. In other words, a call to the United States to drop the trade conflict. But he only announces on China’s part “a proactive fiscal policy and a prudent monetary policy”.