As Numbers Soar, Here’s Everything We Don’t Know About the Coronavirus

As the death toll tops 1,300, there are still more questions than answers.

By James Palmer, a deputy editor at Foreign Policy.
A Vietnamese woman carries her child to receive free protective face masks at a makeshift distribution center amid concerns of a coronavirus outbreak in Hanoi on Feb. 8.
A Vietnamese woman carries her child to receive free protective face masks at a makeshift distribution center amid concerns of a coronavirus outbreak in Hanoi on Feb. 8. Manan Vatsyayana/AFP via Getty Images

Questions about the coronavirus are coming thick and fast—but not answers. Today China reported a startling leap in cases, adding over 14,000—a third of the existing number—to the total in Hubei, the central Chinese province where the virus started. This seems to be in part the result of a broader methodology that has moved many cases from the suspected column into being clearly counted as confirmed—but much remains uncertain. As the death toll reaches over 1,300, the virus remains wrapped in a cloud of doubt. Some of these issues will eventually become clear. Many won’t.

There are several reasons for this. One is the novelty of the coronavirus, which like any new disease will take months to fully detail through hard and tentative scientific work. Another is the sheer scale of the disaster; there are roughly 1.4 billion people in China, all of whose lives have been touched by the disease or the measures around it. As would happen anywhere, the situation on the ground is chaotic, and much goes unreported or exaggerated.

But there are also specific problems here. The Chinese Communist Party has a record of covering up or underreporting the toll of natural disasters from floods to earthquakes. Information is routinely concealed by officials from the public and their superiors for personal reasons. Top-level politics are almost entirely opaque to outsiders even at their most bloody. There are no independent watchdogs and increasingly few journalists able to report with even a modicum of freedom.

All this leads to an awful lot we don’t know.

We don’t know how many coronavirus cases there are. The Chinese authorities are producing daily figures of confirmed and suspected numbers—but there are clearly many more out there. Just how many is a big question. Neil Ferguson, a prominent epidemiologist, estimated last week that as few as 10 percent of cases could be being detected. Other early modeling also showed the possibility of startling underestimates; one study suggested the number of cases in Wuhan alone had reached 75,000 by Jan. 25.

Many factors could be causing cases to be missed. Some victims appear to have relatively mild symptoms, especially children. (Reassuringly, early details of asymptomatic spreaders appear to be mistaken.) The incubation period for the virus could be 14 days, as is currently generally believed, or it could be 24. There’s a severe shortage of diagnostic kits; while Wuhan itself appears to be catching up with the numbers, doctors elsewhere report having quarantined patients but no ability to test them. The sudden rise in cases today appears to have been a result of shifting – in Hubei but not elsewhere – patients clinically diagnosed by doctors but that had not been able to be fully tested into the ‘confirmed’ group.

Because of fears of being isolated or stigmatized, some people showing symptoms may be avoiding the medical system, which is why the authorities have now restricted the sale of medication. In a country where out-of-pocket payments are the norm, people may be avoiding hospitals due to lack of money: Despite the government’s promise to cover costs, no clear mechanism is in place to compensate them, and some patients are paying many times their monthly income.

We don’t know exactly how deadly the virus is. While the percentage of deaths among all known cases has remained steady in the official number at around 2.1 to 2.2 percent, there are several problems with that. Most of those diagnosed started experiencing symptoms only in the last week, and the disease hasn’t yet run its course. The number of deaths appears to be severely understated, with many reports of victims dying at home and being cremated before being counted in the official total. (Cremation is a contentious issue in China and not just during epidemics.)

Deaths are also, so far, overwhelmingly concentrated in Wuhan itself, with the rate there nearing 5 percent. On the positive side, though, the cases being missed are likely to be the less serious ones, meaning that the fatality rate could actually be quite low.

We don’t know whether the virus confirms immunity or resistance on people who have already had it and recover or whether they’re subject to reinfection—a particular worry as China rounds up patients into concentrated hospitals.

We don’t know whether the virus has reached the internment camps and prisons in Xinjiang where China is holding over a million Uighurs and others, many in poor health.

We don’t know how many health care workers have been infected. The case of Li Wenliang, the whistleblower who died last week, has been widely covered, as has one instance in which 14 health care workers were infected. Medical workers inside Wuhan have told the press that at least 500 of them have caught the virus.

We don’t know when exactly people inside the Chinese government knew the virus could be transmitted between humans and how long they delayed before releasing that information to the public. Some folks, like the eight people threatened for “spreading rumors,” were talking about it in early January. (We don’t know whether Li and another doctor were among the eight counted there.) We don’t know why the Wuhan government admitted to only the initial cluster of 41 cases until Jan. 18, when the numbers suddenly leapt. We don’t know whether the cover-up was the result of local political considerations or, as Wuhan’s mayor has hinted, orders from the top.

We don’t know why the crisis response went from zero to 60 in a few days. By Jan. 20, the numbers showed a significant outbreak; by Jan. 23, the city of Wuhan was shut down; and by Jan. 25, that quarantine had been extended throughout much of Hubei. We don’t know if that was informed action by the government based on estimates of the spread or whether it was what the longtime China watcher Ian Johnson has called “actionism”—a political need to be seen doing something.

We don’t know where the roughly 5 million people who left Wuhan before the quarantine was imposed went. For middle-class Chinese citizens, tracking them has been relatively easy thanks to China’s extensive surveillance networks and the ubiquity of services like WeChat, the mobile pay app used by many people in China. But tracking the poor—especially the roughly 450 million people without internet access—is far harder.

We don’t know exactly what the population of Wuhan was before the virus and quarantine. Chinese cities routinely undercount their populations by not including migrant workers because officials in the megalopolises are supposed to be restricting population there and so are incentivized to exclude people from their totals. In contrast, the rural areas where migrants originate receive extra funding for more residents, so they often keep counting people who spend only a week or less there a year. We don’t know how big the Chinese population really is—perhaps overcounted by 115 million people or perhaps severely undercounted thanks to unregistered births.

All this means we don’t know whether the containment efforts will work. Previous mass quarantines have produced highly mixed results. Yet the extent of China’s lockdown is unprecedented, as is the degree of control the government can exercise. Right now, new infections appear to be diminishing in number each day—but that has been the case for only two days and may be just an illusion.

We don’t know why the World Health Organization, which boasts of its partnerships with Beijing, initially chose not to declare a global health emergency in its early meetings and whether pressure from China—which has leaned on countries like Pakistan and Cambodia to maintain transport links and not evacuate their citizens during the outbreak—was involved.

We also don’t know whether the absence of cases in some countries is a sign that the virus hasn’t spread there through good fortune or that cases are going undiagnosed. That’s especially worrying in countries like Indonesia, where the public health system isn’t prepared for epidemics, and in poorer African nations where commerce with China has grown significantly in recent years.

We don’t know whether the epidemic will remain contained largely within Wuhan, whether the clusters of several hundred cases in other Chinese cities will turn into outbreaks there, or whether outbreaks will strike other countries. We don’t know if this will be a global pandemic.

We don’t know when there will be a vaccine—perhaps in six months, perhaps in a year, perhaps in 18 months.

James Palmer is a deputy editor at Foreign Policy. Twitter: @BeijingPalmer