How Has the Coronavirus Crisis Affected Xi’s Power: A Preliminary Assessment
Monday, June 1, 2020
The December 2019 coronavirus outbreak in Wuhan and the subsequent spread of the pandemic throughout the country and the world is the worst political crisis Chinese leader Xi Jinping has faced in his seven years in power. The party-state’s poor initial response, whether due to the cover-up by local officials or Xi’s own inadequate attention or poor judgment, not only reveals some of the well-known systemic flaws in the Chinese state but also exposes Xi to criticisms of questionable leadership. Yet, despite its initial missteps, the party-state managed to contain the viral outbreak quickly, largely due to its formidable capacity to mobilize the resources at its disposal. While sustaining real, albeit limited, damage to his authority for now, Xi is likely to experience greater difficulties in confronting the medium-to-long–term economic and geopolitical consequences of the pandemic.
The outbreak of the coronavirus pandemic in Wuhan in December 2019 and the bungled response by the local authorities to the most devastating public health crisis since Severe Acute Respiratory Syndrome (SARS) in 2002–3 reconfirms some of the well-known institutional flaws and strengths of the Chinese party-state. As in previous scandals, such as SARS or the case of the tainted baby milk formula (on the eve of the Beijing Olympics in 2008), the rigidities of the Chinese governance system, in particular the extreme risk aversion of local officials when confronted with unfamiliar problems in the absence of clear directives from superiors and the strict hierarchical decision-making process on politically sensitive and uncertain issues, significantly limited the capacity of local authorities to respond quickly and aggressively. The routinized suppression of negative information that might reflect poorly on the competence and judgment of local officials or trigger public unease made it impossible to provide a timely public warning or to report full and accurate information to the top leadership. Such enduring institutional flaws of the Chinese regime significantly reduced the odds that timely and aggressive actions could be taken during the crucial initial period to contain the pandemic and to limit its human and economic tolls.
For Chinese leader Xi Jinping, the pandemic outbreak presented a potentially lethal political threat. In recent years Xi has encountered a succession of unwelcome crises, ranging from the U.S.-China trade war, worsening strategic rivalry with Washington, and massive anti-Beijing protests in Hong Kong. His record in managing these crises has already raised doubts among China’s political and business elites about his leadership and the wisdom of many of his signature policies. At the same time, China’s political clock is ticking. The critical Twentieth Party Congress, at which Xi is expected to seek—and get—a third term, is less than three years away. While Xi may be able to rely on sheer political muscle to steamroll over any opposition to his open-ended rule in late 2022, a record of significant policy achievements would nevertheless help bolster his case for lifetime tenure.
In this context, it is no exaggeration to claim that Xi’s political future will depend on how he led the fight against the pandemic. In this essay, we analyze Xi’s response to the outbreak and assess the impact of the crisis on his grip on power. Through a reconstructed chronology, we attempt to show how the systemic flaws in the Chinese system, including the centralized decision-making process instituted under Xi, seriously hampered the Chinese government’s initial response and made Xi vulnerable to potential criticisms of poor judgment and inadequate leadership. Fortunately for Xi, the unrivaled capacity of the Chinese party-state to mobilize massive resources quickly to confront perceived existential threats enabled Xi to turn around the situation and claim credit for a pyrrhic victory.
Xi’s public appearances and travel in early and mid-January show no indication that he took aggressive actions to contain the outbreak after he was notified of a new mysterious virus in Wuhan in early January. He revealed in early February that he gave unspecified instructions on dealing with the outbreak (对新型冠状病毒肺炎疫情防控工作提出了要求) at a Politburo Standing Committee (PBSC) meeting on January 7. However, the central leadership went about its business as usual until January 20. The official news release of the PBSC meeting of January 7, notably, contained stock phrases about the importance of the role of the party and of the centralized leadership, but it made no reference to the outbreak. Xi’s activities in the days immediately following the PBSC meeting on January 7 did not indicate that he or any other top leader was alarmed by the reported outbreak in Wuhan. For example, on January 8, Xi delivered a lengthy speech at a conference on “Don’t forget the original intention” (不忘初心) in Beijing. On January 10, he attended an award ceremony for outstanding scientists. On the same day, Beijing announced that Xi would pay a two-day state visit to Myanmar from January 17 to 18. On January 13, he spoke at a meeting of the Central Discipline Inspection Commission and also attended a performance for retired military commanders of the Beijing garrison. On January 14 he attended a roundtable discussion with a group of non-CCP (党外) luminaries. On January 16, he chaired a Politburo meeting, but again the official news release did not mention the coronavirus outbreak. On January 17 Xi began his visit to Myanmar, and he flew back to Yunnan in the evening of January 18. On January 19, Xi inspected a PLA unit in Yunnan and, according to People’s Daily, he spent January 19 through 21 visiting villages, old towns, wetlands, markets, and patriotic education bases in the southwestern province.
What Xi’s itinerary in the two weeks following the PBSC meeting on January 7 reveals is that he was not in Beijing on January 20, a critical day when the State Council’s Executive Committee（国务院常务会议）met to discuss the outbreak in Wuhan. On the night of January 19, two of China’s leading epidemiologists, Dr. Zhong Nanshan and Dr. Li Lanjuan, returned from Wuhan and met with Ma Xiaowei, head the National Health Commission, to report on the findings from their visit. Judging by the fact that Drs. Zhong and Li were asked to attend the State Council Executive Committee meeting the next morning and to give a report on Wuhan to Premier Li Keqiang, it is reasonable to conclude that their assessment of the situation in Wuhan was extremely serious and that, prior to that point, the central leadership was not fully aware of the unfolding calamity in Hubei province.
It was only after the State Council Executive Committee meeting on January 20 that the Chinese government began to take action. In the afternoon of January 20, the State Council announced measures to contain the virus. Apparently after he was notified of the gravity of the brewing crisis, Xi, still in Yunnan, issued a set of general instructions on January 20, and Dr. Zhong Nanshan, appearing on Chinese Central TV (CCTV) in the evening of January 20, declared that the coronavirus was surely being transmitted from person to person.
Based on the published activities of the top leaders even after the critical State Council Executive Committee meeting on January 20 and after the decision to lock down Wuhan was made on January 22, Chinese leaders did not immediately change their schedules. For example, Premier Li went on a pre-scheduled two-day tour of Qinghai province on January 21. On January 22, as a customary Chinese New Year’s eve ritual, Xi paid personal visits or sent representatives to visit retired senior leaders, including former presidents Jiang Zemin and Hu Jintao, and other surviving former members of the PBSC. On January 23, the annual CCP Center and State Council New Year celebration was held as usual, and Xi gave an upbeat speech, with no references to the outbreak.
Xi did not convene a PBSC meeting to deal with the coronavirus outbreak until January 25, the beginning of the Chinese New Year. Since it is highly unusual for the PBSC to meet on the first day of the Chinese New Year and there were no reported public activities for any top Chinese leader on January 24 (New Year’s eve), one reasonable inference to draw is that the top leadership must have received new and even more alarming information from Wuhan after Vice Premier Sun Chunlan was dispatched there on January 22. Xi’s remarks quoted in a story in the People’s Daily published on May 18 offered some clues. He reportedly said to his six PBSC colleagues at the opening of the meeting on January 25, “I originally thought of letting everyone spend a good New Year. But I have to call you to this meeting to discuss and make decisions because of the urgency of the outbreak…. I couldn’t sleep last night.” (“本来想是让大家过个好年。现在疫情形势紧急，不得不把大家召集起来，一起来研究部署这个问题….大年三十我夜不能寐。”) A senior official who was a member of the Central Guidance Group (中央指导组) later revealed that Sun carried out Xi’s personal instructions to lock down the city after arriving in Wuhan on January 22. Sun apparently returned to Beijing immediately after issuance of the lock-down order and could have given Xi a first-person report on the conditions in the city. (She went back to Wuhan on January 27 to head the Central Guidance Group.
Since the PBSC is the CCP’s top decision-making body, its meeting on January 25 appears to have been a turning point in the party’s response to the crisis. Indeed, the party-state began to mobilize fully only after the January 25 meeting. Specifically, the PBSC meeting decided to form a Small Leading Group for Epidemic Response (应对疫情工作领导小组,SLG) headed by Li Keqiang, and it was decided that the Party Center dispatch to Wuhan the Central Guidance Group, led by Vice Premier Sun, to supervise an emergency response on the ground. Two days after the January 25 PBSC meeting, Premier Li Keqiang visited Wuhan, the epicenter of the outbreak.
Xi’s public appearances immediately following the PBSC meeting on January 25 suggest that he, for unknown reasons, did not seek the limelight and, as a result, was upstaged by Premier Li. Between January 26, the day after the PBSC meeting, and February 10, when Xi conducted a high-profile inspection tour of Beijing, Xi appeared in public only four times during the two-week period. Of his four public appearances, only two were related to the emergency response—his meeting with WHO Director-General Tedros Adhanom Ghebreyesus on January 28 and his chairing of the PBSC meeting on February 3 (Xi met Cambodian prime minister Hun Sen on February 5 and on the same day chaired a meeting that was not related to the coronavirus outbreak). In comparison, Premier Li appeared in public ten times in connection with the response to the crisis during this crucial period. In addition to visiting Wuhan on January 27, Li chaired six meetings of the coronavirus SLG and conducted inspection tours of the Chinese Center for Disease Control and Prevention, a national coordination center of key medical supplies（国家重点医疗物资保障调度平台）, and the Chinese Academy of Medical Sciences.
Most likely aware of the risks of being eclipsed by Premier Li as the face of the Chinese leadership in managing the crisis, Xi began to take a series of actions to regain his image as the leader in charge. Based on the somewhat defensive tone of his speech at the PBSC meeting on February 3, one may speculate that Xi had yet to take full control of the fast-moving crisis. The first week of February coincided with the chaos in Wuhan and the mounting public anger over the revelation of intimidation by Wuhan police of Dr. Li Wenliang, an ophthalmologist at Wuhan Central Hospital, who warned his friends about the SARS-like virus.
Reassertion of Control
The day on which Xi pivoted to center stage was February 10, when he visited two Beijing neighborhoods and two medical facilities. Based on the fact that the official media gave Xi’s public appearance on February 10 unusually prominent coverage (People’s Daily devoted the entire front page on February 11 to Xi’s inspection tour in Beijing), it is reasonable to assume that Xi and his loyalists intended to use Xi’s tour—and the ensuing publicity—to signal that he was now really in command.
Following his highly publicized tour of Beijing, Xi moved quickly to re-assert control. On February 12, he chaired another PBSC meeting at which the body probably decided to replace the party chiefs of Hubei province and Wuhan municipality with Ying Yong (former mayor of Shanghai and a Xi loyalist) and Wang Zhonglin (former party boss of Ji’nan municipality), respectively (the decision was announced the next day). Compared with the two weeks between January 26 and February 10, Xi assumed a much more visible public profile that not only signaled his authority in leading the fight against the outbreak but also highlighted his role as a world leader. Between February 11 and March 10 (when Xi visited Wuhan), Xi chaired one Politburo meeting, two PBSC meetings, two high-level meetings (on deepening reform and poverty reduction), and inspected a medical science research institute in Beijing. In addition, he called a number of foreign leaders (the calls were made on four separate days).
Politically, Xi’s most significant public appearance during this period was the delivery of a long speech at a meeting with senior leaders in Beijing on February 23, which was also attended remotely by 170,000 officials at the county- or regimental-level rank and above throughout the country. The size of the audience, the largest in CCP history, is reminiscent of another historic event, the so-called 7,000 Cadre Conference convened by Mao Zedong in January 1962 in the immediate aftermath of the Great Leap Famine. There are several notable parallels but also crucial differences between these two large gatherings. Most obviously, both were held in the aftermath of what was perceived to be the worst political crisis for the top leader (the Great Leap Famine for Mao and the coronavirus for Xi). A more disputable point in terms of parallels is whether both leaders were regarded by the party’s rank and file as responsible for the debacle. In the case of Mao, there was little doubt that the Great Leap was his idea and his purge of Marshal Peng Dehuai at the Lushan Conference in July/August 1959 had resulted in the continuation of the Great Leap that worsened the famine. The case of Xi’s responsibility is more ambiguous. While his early handling of the crisis left him politically vulnerable, his quick reassertion of control and the party’s full mobilization after the scale of the crisis became clear averted a calamity on the order of the Great Leap Famine.
Perhaps the most critical difference between the two events is that whereas at the meeting in 1962 Mao had to take responsibility, albeit in a roundabout manner, for the Great Leap disaster, Xi vigorously defended his performance and claimed the central role in leading the party in the crisis. Similar to his speech at the PBSC meeting on February 3, Xi first listed his personal involvement in making various decisions concerning the viral outbreak, claiming “I was paying close attention to the work of fighting the epidemic at every moment and giving verbal and written instructions on a daily basis” (我时刻关注着疫情防控工作，每天都作出口头指示和批示). Because the situation in Wuhan had begun to improve by late February, it was politically advantageous for Xi to rally the party and, more crucially, pre-empt criticisms of the government’s poor initial response. The crisis, as far as Xi’s leadership was concerned, ended on March 10 when Xi paid a personal visit to Wuhan. Symbolically, it was the equivalent of a victory lap.
Vulnerabilities and Criticisms
Despite the glowing narrative the party’s propaganda apparatus has tried to construct to laud Xi’s leadership, China’s strongman is vulnerable to plausible criticisms of his initial response to the crisis. First, Xi’s instructions at the PBSC meeting on January 7 almost certainly were communicated to lower levels of the government, so a large number of party officials must have had specific knowledge of what he said about the reported viral outbreak in Wuhan. As our reconstructed chronology demonstrates, the top leadership maintained a normal schedule until January 25. Therefore, it is reasonable to conclude that Xi’s instructions on January 7 were likely general in nature and did not demand immediate or drastic measures. Curiously, the Politburo meeting on January 16 did not address the coronavirus outbreak even though there should have been a follow-up since Xi gave instructions on the matter at the PBSC meeting on January 7. Xi can be subject to criticisms of a delayed or indecisive response. Second, even the cover-up by Hubei authorities may not be an exonerating factor because deception and underreporting of serious problems by local officials are endemic in the Chinese bureaucratic system. Xi may also be vulnerable to charges of poor judgment. Specifically, questions can be raised whether he took reports from Hubei at face value and why he did not take more aggressive actions to verify the truthfulness of the information provided by the Hubei authorities.
Second, Xi’s absence from the command post during the most critical period, January 20–21, and from the frontline from January 26 to February 9 may also be vulnerabilities, even if the lack of an aggressive response prior to January 20 can be blamed on deception by the Hubei authorities. With an epidemic looming, Xi should have cut short his inspection tour in Yunnan immediately on January 20 and headed straight back to Beijing. But he continued his tour and returned to Beijing (most likely in the evening) of January 21. His decision to cede the front-line leadership role to Premier Li between January 26 and February 9 is also problematic as it raises questions about why he chose to lead from behind when his presence on the frontline was sorely needed.
Third, the highly centralized decision-making process established under Xi performed poorly during the initial stage of the crisis on several levels. For starters, such a system stifled bureaucratic initiative, as few underlings dared to risk their careers by venturing outside the scope of the top leader’s directives. The safest thing to do was to follow the leader’s instructions to the letter and nothing more. So once Xi set the tone with his general instructions on January 7, it is difficult to imagine that other leaders or officials would take actions that might appear to contradict or violate the supreme leader’s instructions. The reconstructed chronology of the actions taken by the party shows that the most critical decisions were made only with Xi’s direct involvement or support, including, for example, the public disclosure of people-to-people transmission of the virus on January 20 after Xi gave another second set of instructions on the outbreak, the lock-down of Wuhan (on January 21 or 22), the full mobilization of the party (at the PBSC meeting on January 25), and the dismissal of key Hubei party officials (at the PBSC meeting on February 12). Even though these decisions were not necessarily wrong, the centralized decision-making process seems to have slowed them down.
Lastly, although Xi successfully reasserted control by mid-February, he risked stoking resentment within the party by taking credit for leading the fight against the virus while glossing over the top leadership’s poor initial response. Additionally, he filled the key vacancies in Hubei and Wuhan with two loyalists instead of appointing officials unaffiliated with his faction. The new party chief of Hubei is Ying Yong (who worked under Xi in Zhejiang) and the new mayor of Shanghai is Gong Zheng (who had been appointed a vice governor of Zhejiang province in 2008, executive vice governor of Zhejiang in June 2012, and had worked with some of Xi’s closest associates in the Zhejiang government). Although these personnel appointments reaffirmed Xi’s political dominance, such a raw display of power nevertheless reveals the relative narrowness of his support, if not a sense of insecurity about sharing some power with his colleagues. (Inadvertently, Xi’s selection of these two officials probably reveals some of his personnel decisions to be made at the next party congress, slated for 2022. It is very likely that Ying will be rewarded with a seat on the Politburo and made party chief of a significant province, such as Guangdong. Gong may also be promoted to the Politburo and become the party chief of Shanghai, while the current Shanghai party chief, Li Qiang, a Xi protégé from his days in Zhejiang, will likely also be promoted to the PBSC.)
To be sure, it is impossible for any party officials to voice criticism of Xi openly. Nevertheless, three individuals well-known for their dissident activities or critical views of the party generally and of Xi specifically publicly denounced Xi’s record and, especially, his poor performance during the crisis.
The first shot was fired by Xu Zhiyong, a leading dissident who had completed a four-year sentence in July 2017. While in hiding from Chinese police in late January 2020, Xu published an open letter calling on Xi to step down, citing his autocratic style, wrong-headed policies, poor judgment, and incompetent response to the coronavirus outbreak in Wuhan. Shortly after the letter was circulated on the internet, Xu was secretly arrested by Chinese police in Guangzhou. Xu Zhangrun, a law professor at Tsinghua University, also published a scathing critique of the CCP regime in early February. Although Xu Zhangrun did not name Xi directly in his essay, he did list the trends and policies under Xi that Xu believed are leading China on a path to disaster. (Perhaps because Xu did not attack Xi by name, he was not arrested. Instead, in February he was reportedly placed under house arrest.)
Undoubtedly, the most stinging criticism of Xi was launched by Ren Zhiqiang, the 69-year old outspoken former real estate developer and a “princeling” himself. Ren’s essay focused on Xi’s poor leadership during the crisis by raising important questions about how he had handled the pandemic at the outset. In addition to demanding answers to why and how the initial information about the outbreak in Wuhan was suppressed, Ren pointedly asked why Xi’s instructions on January 7 had not been made public, why several large national conferences were held as scheduled after January 7, and why Xi went ahead with his state visit to Myanmar and his inspection tour in Yunnan after being informed of the outbreak. Ren took strong exception to Xi’s speech at the February 23 conference that was attended by 170,000 nationwide officials. In particular, he attacked Xi for failing to mention the cause of the outbreak and the quick spread of the virus and for failing to take personal responsibility for the government’s early missteps. The most memorable phrase used by Ren in his essay is that Xi is not “an emperor showing off his new clothes, but a clown who insists on being the emperor despite shedding all his clothes” (不是一位皇帝在展示自己的“新衣”, 而是一位剥光了衣服也要坚持当皇帝的小丑). Ren’s criticism of Xi, the most biting of its kind by a prominent Chinese business leader with a wide public following, quickly landed him in trouble. Ren disappeared shortly after his essay was circulated on the internet. On April 7, the Beijing CCP Municipal Discipline Inspection Committee announced that Ren had been detained for unspecified “violations of discipline.”
Although it is impossible to determine how widely these criticisms of Xi were circulated among Chinese officials and party members or the amount of damage they did to Xi’s image, they likely reflect a perceived failure of Xi’s leadership in general, and his role in the government’s initial missteps in responding to the outbreak in particular, among those within the party who have not thrown in their lot with Xi and his group. The immediate arrest or detention of the three critics only underscore the need to silence such voices quickly and to stop further attacks on Xi.
Conclusion and Assessment
The above analysis of the response by the CCP leadership, in particular Xi Jinping, to the outbreak of the coronavirus pandemic in China in January and February 2020 shows that the deception or cover-up by local officials in Wuhan in early to mid-January was responsible for the delay by the central government in taking decisive and timely measures. Although the full mobilization by the party-state after January 25 prevented an even worse disaster, the coronavirus pandemic has seriously dented Xi’s image as a strong and capable leader. Likely criticisms of his leadership could center on the inadequacy of his directives made at the PBSC meeting on January 7, the lack of follow-up on a development with potentially devastating consequences, and his absence from the frontlines during the first two weeks following the PBSC meeting on January 25.
However substantive or serious, such criticisms of Xi’s performance during the coronavirus crisis do not seem to have fatally weakened his authority. One obvious reason is that these are what may be called “second-order” criticisms that draw attention to Xi’s shortcomings in terms of poor judgment in processing false or unreliable information initially reported by local officials in Hubei and Wuhan and in failing to take aggressive precautions immediately. The perceived mistakes made by Xi are errors of omission—steps he should have taken but did not—rather than errors of commission, such as Mao’s decision to launch the Great Leap and to continue it even after it was shown to be a disaster. Another obvious reason why Xi’s authority has not been fatally weakened is the effective, albeit draconian, measures the party ordered to control the outbreak after Xi returned to Beijing on January 21. Despite its early stumbles, the party managed to bring the crisis under control within a month.
Throughout this crisis, Xi’s style of hardball politics was on full display. Instead of conceding mistakes or personal responsibility, he held firm and utilized his power fully, first to appoint trusted loyalists to take control in Hubei and Wuhan (and to fill the mayoral vacancy in Shanghai) and then to mobilize the propaganda machine to portray him as an effective commander-in-chief in the fight against the virus. For good measure, he also apparently resorted to anti-corruption investigations to intimidate potential adversaries. Notably, while no “tigers” (officials of vice ministerial rank or above) were arrested during the first three months of 2020, three were ensnared in April, including a vice minister of public security who had been dispatched to Wuhan in late January as a member of the Central Guidance Group.
Yet, it would be a mistake to dismiss the political impact of the coronavirus on Xi as immaterial or inconsequential. In addition to second-order criticisms, the adverse economic and geopolitical consequences of the coronavirus pandemic have greatly complicated his ambitious agenda and made it nearly impossible for him to present a record of significant domestic and foreign policy achievements as justification for a third term at the Twentieth Party Congress in 2022. Historically, strongmen in solid control of the military and secret police are rarely brought down by a single crisis. Instead, their authority and prestige are progressively eroded by a succession of policy errors and political missteps as doubts about their leadership grow among the ruling elites and the impact of their misrule fuels social discontent. From this perspective, it is reasonable to conclude that for now Xi may have weathered the coronavirus crisis with limited damage to his grip on power, but the longer-term effects of the coronavirus pandemic will most likely weaken, rather than strengthen, his rule.
About the Contributor
Minxin Pei, editor of China Leadership Monitor, is Tom and Margot Pritzker '72 Professor of Government. He is also non-resident senior fellow at the German Marshall Fund of the United States. Pei has published in Foreign Affairs, Foreign Policy, the New York Times, the Financial Times, the Wall Street Journal, Project Syndicate, Fortune.com, Nikkei Asian Review, and in many scholarly journals and edited volumes. He is the author of China’s Crony Capitalism: The Dynamics of Regime Decay (Harvard, 2016); China's Trapped Transition: The Limits of Developmental Autocracy (Harvard, 2006); and From Reform to Revolution: The Demise of Communism in China and the Soviet Union (Harvard, 1994). Pei formerly was senior associate at the Carnegie Endowment for International Peace (1999–2009) and assistant professor of politics at Princeton University (1992–1998). He was the Library of Congress Chair in U.S.-China Relations from January to August 2019.
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 “他们打满全场,”《财新》，April 12, 2020. This long revealing investigative report by Caixin was censored and removed from the publication’s website shortly after it was published.
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 According to a long story in the People’s Daily praising Xi’s leadership, Xi personally made the decision to lock down Wuhan on January 22. “风雨无阻向前进,” http://paper.people.com.cn/rmrb/html/2020-05/18/nw.D110000renmrb_20200518_1-01.htm
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 The Politburo meeting on January 16 was devoted mainly to the party’s anti-corruption inspection tours. “中共中央政治局召开会议,” http://paper.people.com.cn/rmrb/html/2020-01/17/nw.D110000renmrb_20200117_2-01.htm
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 Ren, whose father was a vice minister of commerce in the 1950s, first ran afoul of the party in 2016 after he openly criticized Xi’s call for the Chinese media to be totally loyal to the party. He allegedly was a close friend of Wang Qishan, now vice president of the PRC and Xi’s able lieutenant in charge of the anti-corruption campaign during Xi’s first term.
 The Chinese text of Ren’s essay is available at http://blog.dayabook.com/2020/03/blog-post_6.html
 “北京市华远集团原党委副书记、董事长任志强接受纪律审查和监察调查,” http://www.bjsupervision.gov.cn/ttxw/202004/t20200407_68966.html
Photo by CDC/ Alissa Eckert, MS; Dan Higgins, MAM - This media comes from the Centers for Disease Control and Prevention's Public Health Image Library (PHIL), with identification number #23313.