The Sars experience drove Beijing’s leadership to overhaul its infectious disease control system in a bid to prevent a future epidemic and, according to a former CDC official, in its early years at least the system worked well.

“We spent 730 million yuan to build a reporting and early warning system for the CDC after Sars,” Yang Gonghuan, former CDC deputy director, said.

“It did well for the avian flu and plague, although they were of much smaller scale than the coronavirus.”

Yang said she was dismayed the system had failed to raise the red flag it was designed to when the new coronavirus struck.

“For the whole of December when the disease happened, I have learned that the system was not put into use. I was very surprised [that happened] at the time,” she said.

“This [failure] actually exemplifies a lot of the problems that are happening in China today.”

A leaked document from Wuhan Central Hospital – one of the designated facilities for Covid-19 patients – this week indirectly confirmed that the early warning system was not activated during the early period of the outbreak.

The document showed doctors were under instructions not to report any cases until they had been vetted and approved by their supervisors. They were also forbidden from disclosing any information to the public without permission.

Doctors said they stayed away from infectious disease cases to avoid trouble. Wei Peng, a doctor at a fever clinic in a Wuhan community hospital, said he had no knowledge of the CDC early warning system and would not have bothered to use it even if he had.

“There is no gain for you if you report. No one would blame you if you didn’t,” he said, describing the process of reporting as “tedious trouble”.

Meanwhile, official reports have documented that leading experts from China’s National Health Commission made two separate visits to Wuhan, just a week apart in early January, and reported no evidence of human transmission of the virus.

It has since emerged that there was evidence of human transmission occurring in Wuhan as early as December.

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“Did the experts really tell the truth? Or did they just say what the leaders wanted to hear?” said a Chinese epidemiologist with knowledge of CDC operations.

Speaking at a press briefing in late February, Zhong Nanshan, one of China’s top respiratory disease experts, lamented the weakening of the CDC’s functions in recent years and said the agency had been reduced to a “technical department” with “too low a role” in the system.

“[The CDC] can’t report to the central government directly, and it cannot issue public warnings,” he said. “If that doesn’t change, new epidemics will happen again.”

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In a paper submitted to medical journal The Lancet in February, Zhong and his research team estimated the number of infections could have been halved if China had sounded the alarm and shut down Wuhan just five days earlier.

Professor Chen Zhuo, a former senior health economist with the US CDC and now an associate professor at the University of Georgia, said Chinese doctors lacked incentive to do their jobs properly. In contrast, he said, the US CDC had set up a foundation to encourage doctors to report emerging infectious diseases.

“This is an important incentive reward,” he said. “The importance of public health is not being appreciated in China. Governments at different levels invest little in public health. In some areas, the CDC offices have been downsized, although few have been upgraded during the outbreak.”

Li Jing, a hospital performance consultant based in the south China city of Guangzhou, said doctors in China were rewarded based on their “profitability” and not on the number of hazardous cases they reported.

“[In China], turning in a profit is a top priority for most hospitals because they are largely responsible for their profits and losses,” he said.

“The exceptions are those in first-tier cities because they are subsidised by the government.”

Li said a fever clinic – usually the first line of defence in identifying infectious diseases – at a medium-sized hospital would have a budget of about 2 million yuan a year – about half the size of the oral medicine department.

“The fever clinic is the first, or the only, department of an ordinary hospital to deal with fever patients with symptoms of infectious diseases. It is mainly a cost centre [for the hospital] … as no one really cares about the reporting of new infectious diseases in their daily work,” he said.

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Compared with its American counterpart, the Chinese disease watchdog operates on a much tighter budget. Last year, the total allocation for the National Health Commission – which includes the CDC – was about 22 billion yuan, or roughly a quarter of the US CDC’s budget.

Chen Xi, assistant professor at Yale School of Public Health, said both CDCs had been criticised for their mistakes, but the US body had much greater power to correct its own actions.

“The issue with the US CDC is very different from the issue with China CDC in terms of power. They have enough power to do many things. They can regulate the standards of testing, but the China CDC has no authority,” he said.

Huang Yanzhong, a senior fellow for global health at the Council on Foreign Relations, agreed that the US CDC had far greater autonomy and the ability to quickly change its approach and response depending on the circumstances.

“The important thing is to have the ability to make adjustments in a timely manner. Once the US CDC was criticised for its testing approach, they decided to change their criteria for testing … they have the autonomy to make those changes without having to get [presidential] approval,” he said.

Lu Jiahai, a professor who studies epidemiology at Sun Yat-sen University in Guangzhou, said the epidemic would have been preventable if the system could have functioned as intended.

“The system should have been able to sound the early warning and the disease could have been prevented,” he said.

“The epidemic has caused irreparable harm to people of the whole world. It’s a disaster for human beings. We should all reflect on our responsibilities for this disaster, instead of pointing fingers.”

For Yang, the former deputy director of the China CDC, the new coronavirus reflects a failure of responsibility by some Chinese experts.

“It’s the experts’ job to find out and tell the truth. They should apologise for failing to alert policymakers and the public [about the disease]. I feel so sad about this,” she said.

“No one has the courage to tell the truth and this shows that people have yet to learn the lesson from Sars.”

Despite the criticism, which has been circulating widely in China since the new coronavirus outbreak, Gao and other CDC officials have declined to respond, saying their priorities should be on controlling the disease.

Additional reporting by Simone McCarthy