YOU CAN BE TRUTFUL AND STILL HATE THE PRC:

There is, however, a way to step back to a period before any such bias could have crept in, by considering what happened in the hospitals that first pieced together that a new viral outbreak was underway. Although not mentioned by name in scientific publications (9), media reports reveal that Hubei Provincial Hospital of Integrated Chinese and Western Medicine (HPHICWM) was the first hospital to alert district, municipal, and provincial public health authorities about the mysterious pneumonia cases (see fig. S1). Zhang Jixian, director of respiratory and critical care medicine, noticed on 27 December that an elderly couple had large "ground glass" opacities in computed tomography (CT) images of their lungs, distinct from those she had seen in other cases of viral pneumonia. Zhang insisted that the couple's son, who was not a patient and had no symptoms, undergo a CT scan, and the same unusual lesions were observed. The husband and wife evidently are "cluster 1" in the World Health Organization (WHO)-China report (1): They are the earliest known case cluster and the only cluster admitted by 26 December. They had no known connection to Huanan Market.

Another patient with similar CT imaging, a worker at Huanan Market, was admitted on 27 December. Zhang, concerned about a new, probably infectious viral disease, reported the four cases to hospital officials, who alerted the Jianghan District CDC that same day. Over 28 and 29 December, three more patients, all of whom worked at Huanan Market, were admitted and recognized to have the same unknown respiratory disease. A vice president of HPHICWM, Xia Wenguang, brought together 10 experts from the hospital, including Zhang, for an emergency meeting on 29 December, and they concluded that the situation was extraordinary. Upon learning of similar patients, also linked to Huanan Market, at Tongji and Union (Xiehe) Hospitals, Xia alerted the Wuhan and Hubei CDCs on 29 December.

A notably similar situation unfolded at Wuhan Central Hospital. On 18 December, Ai Fen, director of the emergency department, encountered her first unexplained pneumonia patient, a 65-year-old man who had become ill on either 13 or 15 December. Unbeknownst to Ai at the time, the patient was a deliveryman at Huanan Market. A CT scan revealed infection in both lungs, and he did not respond to antibiotics or anti-influenza drugs. On 24 December, a bronchoalveolar lavage specimen collected from him was sent to Vision Medicals, a metagenomics sequencing company. They identified a new SARSr-CoV on 26 December and relayed the finding by telephone to the hospital on 27 December. By 28 December, Wuhan Central Hospital had identified seven cases, of which four turned out to be linked to Huanan Market. Notably, these seven cases, like those at HPHICWM, were ascertained before epidemiologic investigations concerning Huanan Market commenced on 29 December.

At Zhongnan Hospital in the Wuchang District of Wuhan, 15 km away from Huanan Market and on the opposite bank of the Yangtze River, Vice President Yuan Yufeng asked units on 31 December to search for unexplained pneumonia cases, and the Respiratory Medicine Department reported two. The first lived in Wuchang District but worked at Huanan Market (in Jianghan District). The second did not work at Huanan Market but had friends who did and who had visited his home. On 3 January, three more cases were identified--a family cluster unlinked to Huanan Market. Clearly, hospitals in the first weeks of the outbreak were identifying cases both with and without a known connection to Huanan Market. And Wuhan hospitals were not swamped with unexplained pneumonia cases at the end of December--that would come later.

Thus, 10 of these hospitals' 19 earliest COVID-19 cases were linked to Huanan Market (~53%), comparable both to Jinyintan's 66% (of 41 cases) (4) and to the WHO-China report's 33% of 168 retrospectively identified cases across December 2019 (1). Regarding cases at the Wuhan Central Hospital and HPHICWM, patients with a history of exposure at Huanan Market could not have been "cherry picked" before anyone had identified the market as an epidemiologic risk factor. Hence, there was a genuine preponderance of early COVID-19 cases associated with Huanan Market.

How can this knowledge inform our understanding of the pandemic? If Huanan Market was the source, why were only one- to two-thirds of early cases linked to the market? Perhaps a better question is why would one expect all cases ascertained weeks into the outbreak to be confined to one market? Given the high transmissibility of SARS-CoV-2 and the high rate of asymptomatic spread, many symptomatic cases would inevitably soon lack a direct link to the location of the pandemic's origin. And some cases counted as "unlinked" may have been only one or two transmissions away, as exemplified by the second patient identified at Zhongnan Hospital. That so many of the >100 COVID-19 cases from December (1) with no identified epidemiologic link to Huanan Market nonetheless lived in its direct vicinity is notable (see the figure) and provides compelling evidence that community transmission started at the market.

Additionally, the earliest known cases should not necessarily be expected to be the first infected or linked to Huanan Market: They probably postdated the outbreak's index case by a considerable period (10) because only ~7% of SARS-CoV-2 infections lead to hospitalization (11); most fly under the radar. Similarly, it is entirely expected that early, ascertained cases from a seafood market would be workers who were not necessarily directly associated with wildlife sales because the outbreak spread from human to human. The index case was most likely one of the ~93% who never required hospitalization and indeed could have been any of hundreds of workers who had even brief contact with infected live mammals.

Michael Worobey, an evolutionary biologist who signed a high-profile letter in May urging further study of the theory that the COVID-19 coronavirus accidently leaked from the Wuhan Institute of Virology, reported in the journal Science on Thursday that new research strongly suggests the new virus spread to humans from animals at the Huanan Seafood Market, several miles from the lab. His reconstruction of the early days of the pandemic adds to mounting evidence that the coronavirus has natural origins in bats and infected humans through an intermediary mammal, The Wall Street Journal reports.  

Worobey, a leading expert in tracking the evolution of viruses, pored through all available records and found that 10 of 19 early COVID-19 patients worked at or had been in the Huanan seafood market, around the area where raccoon dogs were slaughtered. His research determined that a World Health Organization report incorrectly identified a 41-year-old accountant who had not been near the market as the earliest known case, on Dec. 8, 2019. Instead, the first confirmed patients was a female seafood vendor who became symptomatic on Dec. 11.

"In this city of 11 million people, half of the early cases are linked to a place that's the size of a soccer field," Worobey said. "It becomes very difficult to explain that pattern if the outbreak didn't start at the market." 

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