The essay today is simply to inform. It is neither to criticize nor to complain. It is in everyone’s best and vital interest to understand how (and when) word of what was to become the most serious pandemic in over one hundred years was first reported. It is also especially important to understand when reports of this new contagious virus first reached public health and political leadership in the United States and abroad, and what action was taken in response. This is not the last pandemic America and the rest of the world will experience. Hopefully, the response to every future pandemic will represent an improvement over the response to whatever prior pandemics have occurred. The timeline that follows was prepared by extracting information from time progressions reported by various government and non-government agencies and press reports originating first in China and then the United States and elsewhere. (Special thanks to Atlantic, Bloomberg News, Brookings Center on Regulation and Markets, Financial Times, New York Times, Reuters, Time Magazine, Wall Street Journal, Washington Post, Wikipedia Free Encyclopedia with further reference to: Axios, BBC, BNO News, Caixin, China CDC Weekly, Chinese Medical Journal, China Youth Daily, Deutsche Welle, Eurosurveillance, Global Times, Lancet, New York Center for Disease Prevention and Control, New England Journal of Medicine, New York Daily News, Science, South China Morning Post, Straits Times, Xinhua News Agency, World Health Organization, US-CDC, and others).
Novel Coronavirus: Novel, meaning this particular virus has never been seen before. Corona, meaning it is shaped like a crown or wreath.
Covid-19: acronym meaning Coronavirus disease first appearing in 2019
When Did China Know:
December 1, 2019: (141 days ago)
A 55-year old man in Wuhan China begins complaining of symptoms now widely recognized as consistent with Covid-19 or Coronavirus, but not diagnosed as such at the time. Doctors estimate the patient contracted the disease mid-to-late November 2019.
December 2, 2019:
A 51-year-old doctor in Wuhan complains of respiratory distress, also possibly consistent with Covid-19.
December 12, 2019:
Thaiger, an on-line news outlet in Thailand, reports (on January 9th) that a new viral outbreak of respiratory illness has broken out in Wuhan China on December 12, 2019
December 16, 2019:
The 55-year old man described in the December 1st reference above is admitted to Wuhan Central Hospital. At this time, both lungs are infected. The patient does not respond to existing anti-flu drugs.
December 20 to December 29, 2019:
The Wuhan Institute of Virology publishes a report identifying seven patients who were admitted with severe pneumonia to intensive care at the Jin Yin-Tan Hospital in Wuhan. Six of the seven were either sellers or deliverymen at the Wuhan Seafood Market.
December 24, 2019:
Doctors at the Central Hospital of Wuhan take fluid samples from the lungs of a 65-year-old deliveryman who works at the Wuhan Seafood Market. The samples are forwarded to a lab in Guangzhou for testing.
December 25, 2019:
China Youth Daily reports that hospital staff at Wuhan hospital “might” be infected with an unknown viral disease. (This is the first published report I found of a suspected new contagion ).
December 26-27, 2019:
The Director of the Department of Respiratory and Critical Care (Dr. Zhang Jixian) at Hubei Provincial Hospital of Integrated Chinese & Western Medicine, examines an elderly couple presenting themselves with fever and cough symptoms on December 26, 2019. He observes a different pattern from other known viral pneumonia. The doctor finds the same pattern in the lungs of the couple’s son who has agreed to be examined although he is symptom-free. Another patient, a merchant from the Wuhan Seafood Market, also arrives at the hospital with fever and cough the same day. Dr. Zhang Jixian, having conducted tests to rule out known respiratory ailments and believing this to be an infectious disease, reports the four cases to her superiors at the hospital on December 27, 2019.
December 28-29, 2019:
Hubei Provincial Hospital (Wuhan is the capital of Hubei) receives three cases similar to those described above. All are associated with the Wuhan Seafood Market. On December 29th, the hospital administration convenes a multi-departmental panel of doctors who conclude the cases are unusual and require special attention, whereupon they report their findings to the provincial Center for Disease Control (CDC). Wuhan CDC staff initiates a field investigation and finds additional patients with similar symptoms all of whom are linked to the Wuhan Seafood Market.
December 30, 2019:
A medical testing lab in Beijing mistakenly identifies the virus as SARS (Severe Acute Respiratory Syndrome). This report is circulated to the authorities and reaches a number of doctors in Wuhan. Among the Wuhan doctors now aware of the outbreak is an ophthalmologist at Wuhan Central Hospital, Dr. Li Wenliang. He then posts a warning to alumni from his medical school class on WeChat that seven patients in Wuhan have been unsuccessfully treated for SARS. News then begins to circulate on social media of an outbreak in Wuhan of “pneumonia of unknown origin.”
December 31, 2019:
The Wuhan Municipal Health Commission informs the World Health Organization (WHO) that twenty-seven cases of pneumonia of unknown cause have been detected in Wuhan and that most were stallholders from the Wuhan Seafood Market. This information is then posted on the Commission’s website with a warning to the public to wear face masks and not to congregate in public places. Chinese state television then posts, throughout the country, the news that a strange and unknown virus has been detected and that a team of experts from the National Health Commission has been dispatched to Wuhan to investigate. WHO was, therefore, notified within six days of the time the existence of a new and unknown virus had been published in China.
2020
When Did The United States Know?
January 1, 2020: (110 days ago)
Dr. Robert Redfield, Director of the United States Center for Disease Control (CDC) is briefed about the viral outbreak and its severity by his Chinese counterpart, Dr. George Gao. This is seven days after the existence of this new and unknown virus was first published in China.
January 2, 2020: Forty-one patients in Wuhan are now confirmed to have contracted the new virus, twenty-seven of whom are, in some way, connected to the Wuhan Seafood Market.
January 3, 2020: Dr. Li Wenliang, the physician who posted news of the outbreak on WeChat, is summoned to the Wuhan Public Security Bureau and required to sign a confession, and is admonished that he had “severely disturbed the social order” by announcing the erroneous confirmation of seven cases of SARS. He is sternly warned that if he continues to spread false rumors he will be severely punished (Dr. Li Wenliang died a short time later from the very disease about which he had warned his medical school colleagues). This same day, US Health and Human Services Secretary, Alex Azar is alerted that CDC Director Robert Redfield had been informed about the new virus two days earlier by his Chinese counterpart, Dr. Gao. This is eight days after the existence of a new and unknown virus has first been published in China.
January 4, 2020: Ho Pak-Leung, head of the University of Hong Kong Centre for Infection warns Hong Kong of the need to implement the strictest possible monitoring system because of mysterious new viral pneumonia spreading on the mainland. On this same day, WHO activates its incident-management system at the country, regional and global level, and stands by to launch a broader response “if needed.”
January 5, 2020: The National Institute of Communicable Disease Control and Prevention at the Chinese Center for Disease Control and Prevention, submits the complete genome of the Wuhan Seafood Market Virus for official publication. It is published in China one week later. Simultaneously, WHO publicly acknowledges that an unknown cause of pneumonia has broken out in Wuhan.
January 6, 2020: Wuhan health authorities investigating the outbreak publicly announce they have ruled out influenza, avian influenza, adenovirus, and SARS and MERS (middle east respiratory syndrome).
January 16, 2020: WHO reports the first case of the new virus in Thailand.
January 17, 2020: WHO reports first case in Japan.
January 17, 2020: US- CDC convenes it’s first media briefing on the Novel Coronavirus.
January 20, 2020: US-CDC begins screening incoming passengers from Wuhan at three US airports.
January 21, 2020: WHO reports first case of Coronavirus in South Korea. On that same day the United States confirms the first case of travel-related Coronavirus in the State of Washington.
January 23, 2020: Taiwan’s Cebu Pacific and China Airlines cancels all flights to Wuhan. Japan’s All Nippon Airways cancels all flights to nine Chinese cities including, Beijing, Shanghai and Guangzhou.
January 24, 2020: Thailand’s Thai Airways cancels all flights to China. Hong Kong’s Cathay Dragon Airline cancels flights to vast parts of China and reduces capacity to all other flights to China by 50%. Malaysia’s Air Asia cancels all flights to Wuhan and other selected cities in China. South Korea cancels Korean Air flights throughout China. US-CDC increases the screening of incoming passengers to five US airports.
January 27, 2020: US-CDC confirms the second travel-related case of Coronavirus, this time in Illinois.
January 28, 2020: The FDA announces its willingness “to speed development of medical countermeasures including test kits” to protect Americans from the Coronavirus.
January 29, 2020: The United Kingdom’s British Airways cancels all flights to Shanghai. Germany’s Lufthansa Airlines cancels flights throughout China. Switzerland’s Swiss International Airlines cancels all flights to Beijing and Shanghai. President Trump’s chief trade advisor, Peter Navarro, warns in a January 29th memo to the White House that there was real and present danger of a catastrophic pandemic because of the Coronavirus outbreak. He all but predicted the current crises and urged immediate action. Health and Human Services, Secretary Azar assures the public that President Trump is receiving multiple briefings every day and that the adequacy of the Strategic National Stockpile is being determined.
January 30, 2020: Canada’s Air Canada and South Korea’s Eastar Jet cancels flights to and from China. Air France cancels all flights to China. Italy’s Neos Airline cancels all flights to China. Israel’s El Al cancels flights to Beijing. Netherlands KLM cancels flights to Chinese cities. President Trump announces that the White House Coronavirus Task Force began meeting on January 27th, led by HHS Secretary Azar and that it would be coordinated by the National Security Council. The President says the National Biodefense Strategy which was signed in 2018 will enable the country to accelerate its response to the Coronavirus outbreak.
January 31, 2020: American Airlines cancels all flights to China and several other countries. India’s Air India cancels selected flights to China. Myanmar’s Myanmar Airways International cancels flights to ten cities in China. Pakistan’s Pakistan International Airlines cancels all flights to China. Turkey’s Turkish Airlines cancels all flights to China. Spain’s Iberia Airlines cancels flights to Shanghai. Scandinavia’s SAS cancels flights to Beijing and Shanghai. Kenya’s Kenya Airways cancels flights to Guangzhou. Morocco’s Royal Air Maroc cancels flights to Guangzhou. Rwanda’s Rwanda Air cancels flights to Guangzhou. President Trump issues Proclamation 9984, suspending entry for foreign nationals who have traveled in mainland China in the past two weeks. The World Health Organization (WHO) belatedly categorizes the Coronavirus an International Emergency.
February 1, 2020: Hong Kong’s Hong Airlines cancels flights throughout China. India’s IndiGo cancels flights to China. Turkmenistan’s Turkmenistan Airlines cancels flights to China. Vietnam’s Vietnam Airlines cancels all flights to China. Egypt’s EgyptAir cancels flights to China. Poland’s LOT Polish Airways cancels flights to Beijing. UK’s Virgin Atlantic cancels flights to Shanghai.
February 2, 2020: Delta Airlines cancels all flights to China. Philippines’ Cebu Pacific cancels all flights to China. Saudi Arabia’s Saudia Airlines cancels all flights to China.
February 3, 2020: Singapore’s Singapore Airlines cuts flights to Chinese cities by half. Qatar’s Qatar Airways cancels all flights to China. Ethiopia’s Ethiopian Airlines reduces flights to Beijing, Shanghai and Guangzhou. Secretary Azar declares a Public Health Emergency enabling the Food and Drug Administration (FDA) to wave cumbersome approval requirements, thereby increasing testing potential throughout the country.
February 4, 2020: South Korea’s Asiana Airlines cancels flights to select Chinese cities. Singapore’s Silk Air cancels flights to various Chinese cities. Ukraine’s Ukraine International Airlines cancels all flights to China. Confirmed Coronavirus cases are estimated to be between 10 and, perhaps,100 throughout the United States. FDA grants emergency-use approvals allowing labs to test patients who meet certain symptom criteria.
February 5, 2020: United Airlines cancels all flights to China. Japan’s Jetstar Airline reduces capacity on flights to Shanghai. U.A.E.’s Emirates Air and Etihad Airways cancel flights to Shanghai and Guangzhou.
February 6, 2020: Japan’s Japan Air cancels all flights to China. Sri Lanka‘s SriLankan Airlines reduces by half flights to various Chinese cities. Finland’s Finnair cancels all flights to China. Thailand’s Thai Airways cancels flights to various Chinese cities.
February 7, 2020: South Korea’s Jeju Air reduces capacity on all flights to Shanghai. US Department of Health and Human Services cites the Public Health Service Act providing immunity from liability for activity related to medical countermeasures against the Coronavirus.
February 9, 2020: New Zealand’s Air New Zealand cancels flights between Auckland and Shanghai. Australia’s Qantas Airways cancels flights to Beijing and Shanghai.
February 10, 2020: Japan’s Peach Aviation cancels flights to Shanghai. The US-CDC issues rule requiring airlines to collect data on passengers and crew entering the United States.
February 11 2020: Australia’s Virgin Australia cancels flights to Hong Kong. President Trump reassures the nation that “we only have about a dozen cases and that we’re in great shape.”
February 12, 2020: WHO officially designates (names) Coronavirus as Covid-19.
February 14, 2020: US-CDC reveals that its testing kits are flawed, seriously setting back testing in the United States.
February 22, 2020: US-CDC releases covid-19 “Hospital Preparedness Tool“ designed to help hospitals prepare for an anticipated onslaught of Coronavirus patients.
February 23, 2020: Singapore’s Scoot Airline cancels flights to 19 Chinese cities.
February 24, 2020: South Korea’s Air Seoul cancels flights to various Chinese cities. US-CDC advises all states that only symptomatic patients who have been to mainland China are to be tested.
February 25, 2020: President Trump requests $2.5 billion in supplemental funding to support vaccine development. The President, who is in India at this time, announces at a press conference that the Coronavirus outbreak “is very well under control in our country.”
February 26, 2020: Vietnam’s Bamboo Airways cancels select flights. US-CDC announces that containment is no longer possible and that the virus will spread throughout the United States and that mitigation programs will be necessary. President Trump places Vice President Pence in charge of the Coronavirus Task Force. US-CDC assures the States that testing capacity is more than adequate.
February 27, 2020: “Community spread” is confirmed to have developed in the United States, meaning the Coronavirus has been sufficiently “seeded” in the country to liberally pose a threat throughout the population. Containment is no longer a workable strategy, and the nation moves into a mitigation phase, which is where we are today. President Trump states that the outbreak in the United States will probably be cut off, suggesting that we could go from fifteen cases to zero cases and that his Administration has done a “pretty good job.”
February 28, 2020: Secretary of the Treasury, Steven Mnuchin, Surgeon General Dr. Jerome Adams and Director of the National Economic Council Larry Kudlow are added to the Coronavirus task Force.
February 29, 2020: US-CDC expands allowable testing criteria to include anyone who has traveled in Italy, Iran, Japan, and South Korea along with those who are in respiratory failure sufficient to cause hospitalization. President Trump suspends entry to the United States to anyone who has traveled to Iran in the prior two weeks.
March 1, 2020: FDA allows private as well as public labs to test for Coronavirus. New York State reports its first confirmed case of Coronavirus.
March 2, 2020: President Trump announces that private pharmaceutical companies are working with the government to develop a vaccine and treatment for Coronavirus.
March 4, 2020: FDA announces that nearly a million tests will be able to be performed by the end of the week.
March 5, 2020: CDC expands testing criteria to enable private physicians to approve tests for patients.
March 6, 2020: Confirmed cases of Coronavirus exceed 100. The Coronavirus Preparedness and Response Supplemental Appropriations Act of 2020 is signed into law which provides $8.3 billion in emergency funding.
March 11, 2020: President Trump states at a press briefing that anyone who wants a test can get a test. Confirmed cases of Coronavirus exceed 1,000. President Trump addresses the nation and announces a ban on travel from Europe and that his Administration has reached an agreement with American insurance companies that copays for Coronavirus testing and treatment will be waived. The president also announces that foreign nationals who have traveled in continental Europe in the prior two weeks will not be allowed to enter the United States.
March 13, 2020: The Administration announces that emergency use of respirators will be expanded, that private testing will be increased, and declares a state of national emergency. The FDA approves the first commercial Coronavirus test which is developed by Roche Pharmaceuticals. Secretary Azar announces that he will allow States to authorize and perform more Coronavirus tests.
March 14, 2020: President Trump suspends entry for foreign travelers who have traveled in the United Kingdom and Ireland during the prior two weeks.
March 15, 2020: US-CDC prohibits operation of all cruise ships.
March 16, 2020: The Trump Administration waives sections of the HIPAA Privacy Rules to facilitate greater approval and administration of Coronavirus tests.
March 18, 2020: The Administration prepares an Executive Order enabling more liberalized use of certain drugs that have not yet been approved by the FDA. He is persuaded by senior FDA scientists not to issue the order. Confirmed cases of Coronavirus exceed 10,000. President Trump invokes the Defense Production Act of 1950 authorizing the federal government to direct and allocate the production of protective equipment.
March 20, 2020: President Trump signs the Families First Coronavirus Response Act of 2020 which provides paid sick leave, free testing, expanded food assistance and unemployment benefits, and which also provides additional protection for healthcare workers. The Department of Health and Human Services issues a rule enabling the CDC to suspend entry into the country of persons from designated countries. Entry into the United States from Canada and Mexico is temporarily limited to essential travel.
March 27, 2020: A series of actions are undertaken to liberalize the production of hand sanitizer, face masks, respirators, and other testing and medical supplies. President Trump invokes the Defense Production Act and directs General Motors to produce ventilators. Confirmed cases in the United States pass 100,000.
Today, most of the country is pretty much dealing with the Coronavirus pandemic as the crises it really is. We are in a place we have never been before. There are voices crying out to restart the country just as there are admonishments from the public health community that a premature start-up will be disastrous. In the past three weeks, the number of confirmed cases has grown, from 1000 to over 690,000, and over 35,000 Americans have died. Barely a month ago, there were but 1,000 confirmed cases in the United States. Today, we have tested barely one percent of the population, notwithstanding the seemingly impressive gross numbers of people tested. Our testing is not and has not been even marginally adequate. While there is plenty of criticism that can be and is being doled out by partisans on both sides of the political spectrum, much of it is excessive and brazenly politically motivated. That is a disservice to the entire country.
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Thank you for this very thorough overview!
Great job, Hal.
While it is always easy and almost costless to connect the dots after the fact, it’s both impossible and very expensive to draw conclusions from very limited data, and to act on those conclusions at the earliest stages.
This set of facts, and what the most knowledgeable scientists project still lead to extremely difficult executive decisions, no matter who has to make those decisions.
The key compounding factor in making a good decision is precisely that we haven’t done enough testing, and – at least in terms of publicly available information – we have no plans to. Do we – the public – know why we cannot produce tests faster? Do we know the ratios of false positives and false negatives?
When the scientists say, as many do, “We don’t know the denominator,” what they mean is the we still don’t understand how infectious or contagious the virus is, or the likelihood of severity requiring hospitalization, or leading to mortality.
We have no earthly idea how many people have been or will be infected. We don’t need to test everyone to figure out all these probabilities. All we need is a well-designed random sample.
What would a great executive do if faced with a critical decision and a very limited fact base? Critical in this case doesn’t just mean really important; it means critical.
Hal, For the sake of completeness, it should be pointed out that the German government produced the first diagnostic “nucleic acid “ test for Covid-19 which was approved and promulgated by the World Health Org. throughout the world in January, I believe. The CDC here refused to adopt the WHO test, insisting that they would provide their own to US labs. Unfortunately this test proved to be useless (giving false positive results when just water was used as the material to be tested). This calamity greatly delayed the ability to test for infection in the USA. The rest is history!
In the course of the virus it remains perfectly clear that the WHO has failed the world. The statements by both parties and
news organizations are fundamentally flawed in their reporting.
Errors can be forgiven but the source is still a mystery Why?
Response To Perry:
WHO, indeed, could have performed much better, and the organization’s delay in declaring an international public health emergency is deplorable. WHO was also excessively deferential to China with respect to China’s handling of the Covid-19 outbreak. Nonetheless, WHO did begin reporting on the outbreak in China and elsewhere in a timely manner. WHO also offered German-developed test kits to our CDC early in the outbreak, which we declined to accept, preferring to develop our own test kits. That was an extremely costly decision by our own CDC, which we are still paying for today. Our government should be the last to be throwing stones at any other government in this crisis.
It is also notable, as the prologue to your timeline, that in May of 2018, Rear Admiral Timothy Ziemer, abruptly left his position on the National Security Council as Senior Director for Global Health Security and Biothreats. Rear Admiral Ziemer was eminently qualified to oversee his division- he had previously served (2006-2017) under Presidents Bush II and Obama as US Global Malaria Coordinator, during which time, the percentage of global malaria deaths reportedly dropped by 40%.
Admiral Ziemer left the very week that John Bolton assumed his position as Director of the NSC.
Homeland Security Advisor, Tom Bossert, who had called for working strategies to combat pandemics and biological warfare, left his position on the NSC during Bolton’s first week as well.
Bolton, as Trump’s proxy, in an epically catastrophic judgment call, was given direction to streamline the NSC, and so dissolved the entire global health division at that time. Some of the staff were absorbed into other departments. But this move left our country without a competent point person or a trained professional team to stay ahead of the curve, to coordinate needed resources and to guide us through this nightmare.
Thanks for a remarkably thorough and painstakingly researched piece.
I am curious why no one has attempted to obtain an explanation from Bolton for his action.. The Global Health Division was established because previous administrations concluded future pandemics were inevitable.
Your analysis should be sent to WP, NYT , and USA TODAY
This timeline brings many reports together and reflects a great deal of effort that helps to tell us how we got to the unfortunate and chaotic mess we are in. As a physician retired from seeing patients I have been contemplating this for weeks. The first notices did not alarm me because the public health experts involved in the SARS, bird flu, MERS and Ebola outbreaks were relatively quickly successful in treating and containing the problems,
The first weekend in March my wife and I flew from Chicago to Atlanta for a family occasion not aware that we were standing on the edge of a volcano. We had close contact with everyone, except my son and his family, from New York City who did not touch anyone! We congregated, we went to museums and we shopped. We got home and that week everything in our public discourse changed. I am still trying to comprehend my ignorance and the events.
I do think our public health experts and our infectious disease experts did not prepare us. Now we are all trying to catch up.
For the next catastrophe we need responsible and independent experts who have a platform from which they can speak out and inform us.