Keywords

Background and Introduction

The arrival of the coronavirus, COVID-19, first in China in late 2019 and then in the U.S. in early 2020 put further strain on an already frayed U.S.-China bilateral relationship. The relationship further worsened as accusations flew back and forth over the next three years about the origins of the outbreak. Yet if the world is to deal with future pandemics and other global health crises, such as those related to climate change, zoonotic spillover, and emerging infectious diseases, it is essential that the two nations, the world’s two biggest economies, work together on global preparedness and global response. Richard Haass, the outgoing president of the Council on Foreign Relations, noted in a 2020 talk on the global pandemic that there is a gap between global challenges and global arrangements (Haass 2020) and this gap is nowhere more evident than in the dire state of collaboration between the U.S. and China on global health.

It wasn’t always so. China and the United States (U.S.) have enjoyed several decades of collaboration and cooperation in the realm of public health ever since the two countries normalized diplomatic relations in 1979. In fact, much of the long-term, robust public health infrastructure that China now has was established through initiatives that were financed and directly supported by the U.S. Centers for Disease Control and Prevention (CDC), alongside U.S. philanthropic organizations such as the Rockefeller Foundation, the China Medical Board, the Bill and Melinda Gates Foundation, The Ford Foundation, and others. This long history of successful technical and academic exchanges between scientists and the building of institutional partnerships across both sides of the Pacific, together with multilateral and trilateral cooperation runs counter to the dominant geopolitical narrative that has come to characterize U.S.-China relations in recent years. In fact, against the backdrop of the sharp deterioration in bilateral ties between the world’s two largest economies, cooperation in public health has remained a significant priority issue for both Beijing and Washington, with the COVID-19 pandemic demonstrating the urgency for improving global cooperation on public health issues, especially emerging infectious diseases. In the aftermath of the 2003 SARS epidemic, China made tremendous investments into developing its public health infrastructure by working closely with the U.S. and the international community. As China and the U.S. transition to a post-COVID-19 reality, drawing on the lessons from successful prior collaborative efforts in public health could help move toward at least a partial reset of cooperative efforts and inform policy decisions about future directions for cooperation on global health security.

For most of the last 40 years the U.S. and China have collaborated on health challenges at the government level. This collaboration was most robust during the two decades of the 1990s and early 2000s but came to a near halt during the Trump presidency and has yet to be revived. The strong collaboration after the SARS pandemic of 2003 put in place a variety of institutional mechanisms that should have remained when COVID-19 emerged in 2019 and may have prevented much of the global havoc that ensued. While some collaborative mechanisms through non-governmental channels and university partnerships have remained, these too have been challenged by a worsening geopolitical environment and perception of Chinese security threats related to science and technology.

This chapter briefly reviews the history of U.S.-China health cooperation in the last 40 years with a focus on lessons learned, especially over the last twenty years since SARS, that can be applied going forward to avert the serious consequences that ensued with COVID-19, including better prevention of global spread and working together to share effective interventions in the future.

History of U.S.-China Public Health Collaboration

The U.S.-China public health relationship has been described by scholars such as Huang (2021) and Seligsohn (2021) as being divided into three distinct phases: (1) relationship-building from 1979 to 2001/2002; (2) building long-term public health infrastructure from 2002/2003 to 2016; and (3) the worsening of relations from 2017 through the present day. Phase two was the period of greatest bilateral collaboration and Phase 3 has been characterized by the breakdown of the bilateral partnership that negatively influenced the COVID-19 response and which remains today.

China established full diplomatic relations with the U.S. in 1979. The U.S. and China then signed a Protocol for Cooperation in the Science and Technology of Medicine and Public Health in June 1979, and the U.S. CDC began providing assistance to Chinese health authorities in the 1980s. Early collaboration led to a groundbreaking CDC study in northern China from 1993 to 1995 that demonstrated the role of folic acid in preventing neural tube defects (Berry et al. 1999) as well as exchanges of medical experts in many fields.

Following the SARS pandemic in 2003, collaboration was strengthened. In 2005, a Memorandum of Understanding (MOU) was signed between several technical agencies and ministries on both sides, such as the U.S. CDC, Food and Drug Administration (FDA), and National Institute of Health (NIH) and the China CDC, Ministry Of Health, and the State Food and Drug Administration. This MOU served to greatly expand the scope of collaboration between the respective institutions. The collaborative program enshrined under the MOU aimed to: “enhance capacity in surveillance, laboratory testing, diagnosis, treatment, epidemiological investigation, biomedical research, and control of emerging infectious diseases; exchange of technical experts and materials used to enhance the preparedness and the rapid response to emerging infectious disease threats; disseminate effective public health and clinical practices information regarding emerging and re-emerging infectious diseases and sharing of research findings; and promote strategic research on prevention and control of infectious diseases to strengthen capacity in evidence-based decision and policymaking” (U.S. Department of State 2010, p. 2).

The SARS epidemic that began in China in 2003 and the subsequent global spread demonstrated that novel infectious diseases do not respect national borders and can pose a serious threat to any country around the world. This initiated a phase of building long-term infrastructure for public health to prevent another lapse in the initial response within China, which included both mischaracterization of the disease (initially identified as avian influenza), as well as lapses in transparency, public information, and data sharing. The international community, including the World Health Organization, encouraged the Chinese government to acknowledge its responsibility for the global pandemic, which it did, and then provided assistance to improve China’s ability to identify and address future emerging infectious disease threats. The U.S. elevated public health cooperation with China to the top of its agenda and took several major steps in the immediate aftermath of SARS to jointly combat infectious disease. Following and because of the lessons learned from SARS, China announced its own major effort to combat HIV/AIDS (Kaufman 2010) and as part of the new U.S.-China collaboration following SARS, the U.S. established the “China-U.S. Cooperation-Global AIDS Program,” or “GAP,” a partnership that helped to set up national and local HIV control and prevention programs throughout the country (see below). A Health Attaché was appointed by the United States Department of Health and Human Services (HHS) to the U.S. Embassy in Beijing for the first time, signally a new phase in U.S.-China health diplomacy.

New cooperative agreements were signed, training programs were created to leverage collective expertise, and public–private partnerships increased connections between public health experts in both countries. With the requisite structures put in place for collaboration and greater economic integration between the U.S. and China, this phase has been labeled as the “golden age” of public health cooperation, where the two countries worked in conjunction on all of the major infectious disease outbreaks of this time, including H1N1 swine flu, H5N1 and H7N9 avian influenzas, Middle East Respiratory Virus (MERS—a corona virus in the same family as SARS and COVID-19) and Ebola virus (Bouey 2020). The U.S. CDC and the Chinese National Influenza Center (CNIC) initiated Cooperative Agreements in 2004 with the goal of building China’s infectious disease surveillance capacity. Over a 10-year period through 2014, the U.S. CDC and the CNIC successfully collaborated to develop technical expertise, improve the quality of the influenza surveillance system, strengthen the analysis of epidemiological data, and promote international collaboration and cooperation (Shu et al. 2019).

These agreements helped China’s national influenza surveillance and response systems to be rapidly expanded, its network laboratories to increase their capabilities for virus isolation and nucleic acid detection techniques and strengthened the analysis and dissemination of epidemiologic data. The CNIC would eventually go on to become the 6th World Health Organization Collaborating Centre for Influenza, establishing it as a critical component of the global influenza surveillance and response system. Moreover, China’s real time computerized local level surveillance system for “atypical” pneumonia, set up after SARS with U.S. assistance was a major achievement and has provided the capacity for early detection and intervention for many new viral threats in the intervening years (Kaufman 2009).

In 2004, the U.S. CDC began working with the Chinese Field Epidemiology Training Program (CFETP) to develop the next generation of public health leaders and epidemiologists in China. Modeled off the CDC’s Epidemic Intelligence Service (EIS) but owned and operated by the counterpart country’s ministry of health, the CFETP includes specialized trainings and technical collaborations to provide the necessary skills and education to effectively investigate and respond to disease outbreaks. The CFETP has trained nearly 20 different cohorts of Chinese public health officials who have gone on to hold key managerial positions with China’s various public health agencies, including six directors and deputy directors within the China CDC. CFETP-trained epidemiologists have conducted more than 2000 outbreak investigations throughout urban and rural China, examining a myriad of infectious diseases including HIV/AIDS, human and avian influenzas, and typhoid (TEPHINET 2021; U.S. CDC 2020).

The U.S.-China Strategic and Economic Dialogues were initiated in 2006 by George Bush and President Hu Jintao, strengthened during the Obama administration, and continued through the early years of Xi Jinping’s administration but discontinued by President Trump in 2017. Focusing initially on economic matters (Economic Dialogues), top leaders in both countries met twice a year in the early years, alternating locations in each country. In 2008 the dialogue was upgraded to include a broader range of issues of concern to the bilateral relationship (renamed the Strategic and Economic Dialogues). Jointly managed by the U.S. Treasuries and State Departments, the S&E dialogues continued for eight more years. The strategic track consisted of four pillars: bilateral relations (people-to-people exchanges); international security issues; global issues (health, development, energy, global institutions); regional security and stability issues. Climate change, clean energy and the environment had their own separate dialogues. Senior ministerial level leaders from both countries met regularly to discuss and launch projects on topics of mutual bilateral concern, including health (Georgetown University 2017; Barron et al. 2021; Wikipedia, n.d.).

This “whole of government” approach was an effort to consolidate agreements and press for the advancement of issues and interests in bilateral US-China relations” (Barron et al. 2021). It engaged U.S. and Chinese counterparts on numerous issues, including health collaboration, and spun off additional academic and other programs and exchanges. At its height, in 2013–2014, public health collaboration was a major feature of the dialogues and collaboration, including working together on the Ebola crisis in West Africa and the subsequent establishment of an African CDC at the African Union in Ethiopia (Barron et al. 2021). The U.S. and China coordinated the response to Ebola in 2014, sending medical teams and supplies and using existing relationships to contain the outbreak. The cooperation continued to grow, with both sides recognizing the global threat of infectious disease, culminating in a joint project to establish an Africa CDC that officially launched in January 2017, shortly before the S&ED was shuttered.

At the height of collaboration, there were robust relationships between the main public health institutions in China with those in the U.S.: CDC, USAID, and NIH. In June 2002, the Secretary of Health of the U.S. Department of Health and Human Services (DHHS) and the Minister of Health of China signed a Memorandum of Understanding (MOU) on “China–US Cooperation on HIV/AIDS Prevention and Control.” The “China-U.S. Cooperation-Global AIDS Program,” or “GAP” program was established as one of the first efforts of the new MOU. It was a partnership between the U.S. CDC and China’s Ministry of Health to address China’s HIV/AIDS epidemic. GAP was implemented jointly by the U.S. Centers for Disease Control and Prevention (US CDC) and the Chinese Center for Disease Control and Prevention (China CDC) (Bulterys 2019). The bilateral cooperation program was officially launched in Beijing in March 2004 coinciding with the nationwide scale-up of China’s National Free Antiretroviral Therapy (ART) Program (Zhang et al. 2007), a belated response to the catastrophic HIV epidemic among paid blood donors and their families among poor villagers in central China (Kaufman 2010). In 2006, the collaboration was integrated into the President’s Emergency Plan for AIDS Relief (PEPFAR), the overarching framework for the U.S. government’s response to the global HIV/AIDS epidemic (Fauci and Eisinger 2018). Under the PEPFAR umbrella, U.S.-China collaboration on HIV/AIDS was expanded to include collaboration with the U.S. Agency for International Development (USAID). USAID/PEPFAR budgets for activities in China in 2006 were 9.8 million USD, peaking to 10.3 million USD in 2009. Although USAID ended its China programming in 2012, technical collaboration between the China and U.S. CDC through the GAP continued. The GAP program was part of broader U.S.-China cooperation on health, which also included the U.S. National Institutes of Health through many collaborative research grants on HIV and other infectious diseases and noncommunicable diseases.

Collaborations on technical issues included HIV surveillance which was then integrated into China’s own infectious disease monitoring systems. GAP supported the establishment or strengthening of 649 national or provincial sentinel surveillance sites in 15 provinces. Moreover many of the public health decision-making tools supported by GAP have been integrated into routine public health operations in China: evidence-based decision-making; strengthening systems and capacity at national, provincial, and local levels; prioritizing high-risk geographic areas and populations; developing innovative approaches for scale-up; answering important scientific questions that can be most effectively answered in China but also with global implications for the HIV response; and increasing China’s engagement with the global public health community and sharing critical lessons learned (Bulterys 2019).

Up to 2016, the U.S. CDC maintained a presence in China. In the period between 2010 and 2015 several American staff were also assigned to the U.S. Embassy in Beijing as technical advisors, as well as approximately 30 locally hired staff providing technical, program management, and administrative support to the collaborations. Staff focused on HIV/ AIDS represented approximately one third of this complement of China-based experts, and the capabilities of these staff were complemented by U.S. CDC Atlanta-based technical experts who traveled to China to provide assistance in specific technical areas as requested by the Chinese government.

The CDC’s program in China, previously home to up to ten American specialists and dozens of local staff, was drawn down to three Americans and a small cohort of local staff in the years directly preceding the COVID-19 pandemic. At the time of the COVID-19 outbreak, many of the previously established cooperation mechanisms between the U.S. and China had already been reduced or eliminated under the Trump administration.

Outside of the bilateral government collaboration on health issues between the U.S. and China, several non-governmental partnerships also contributed significantly to global health collaboration, and many continue. The Bill and Melinda Gates Foundation (BMGF) established an office in China in the early 2000s and through partnerships with China’s Ministry of Health and Ministry of Science and Technology has supported capacity building in important areas such as vaccine development, the development and testing of novel drugs, safety and manufacturing of medical products, and numerous projects related to the control of specific infectious diseases like HIV, Tuberculosis (TB), and malaria. Gates Foundation has supported both public and private sector partners to provide vaccines, medicines, and health products in Low and Middle Income Countries (LMICs), providing funding and technical support for research and manufacturing, clinical trials, market access, compliance, and commercialization, as well as strengthening China’s own regulatory capacity and certification mechanisms so that they can enter the global public market through international aid and bulk procurement. BMGF has also played a major role in sharing China’s medical and other (agricultural) know how and products with Africa. More recently, the BMGF has been working with China on “One Health,” an important global initiative linking animal and human health for the identification and control of emerging infectious diseases (Zheng 2023).

The Rockefeller Foundation and its offshoot, the China Medical Board (established as an independent charity by RF a century ago) have supported medical education and health systems improvement in China for over a century, and in recent decades, CMB has contributed to the training of physicians, epidemiologists, and more recently to the training of experts in health policy and administration (Zi and Bullock 2014). The Ford Foundation provided important assistance to build an NGO community that has worked with the Chinese Ministry of Health and CDC on the HIV/AIDS response and to link the Chinese HIV/AIDS NGO community to regional and global transnational NGO networks (Kaufman 2019).

The Deterioration of the Relationship

Although the emergence of the COVID-19 pandemic may have appeared to be the tipping point of mistrust and fragmented coordination between the U.S. and China on public health, collaboration had already been deteriorating for several years. The 2005 MOU on Emerging and Re-Emerging Infectious Disease that had underpinned the “golden age” of collaboration was regularly renewed but was left to expire in 2017 amid political tensions and gridlock over negotiation on the terms. The following year was the year that the U.S. greatly reduced staff of key public health agencies such as the Food and Drug Administration (FDA), the CDC, and the National Institutes of Health (NIH) and also winded down operations of the GAP program. This rollback was partly due to the escalating trade war but also explainable by the fact that China’s need for a high level of cooperation had declined because of China’s own capabilities which had been strengthened by earlier collaborative efforts. The 1979 Science and Technology Cooperation Agreement that led to the 2005 MOU was set to expire in August of 2023 and has so far been renewed twice in six month increments. However if not renewed going forward it will remove the most important bilateral superstructure from which all collaboration in health and technology has been based (Seligsohn 2023).

Not long after the first cases of COVID-19 were reported in China, almost all U.S. staff and experts operating across the various health agencies were evacuated out of the country, further exacerbating the shortage of trained U.S. public health professionals that could have assisted in the tracking, investigation, and containment of the novel coronavirus. Prior staff reductions had removed a medical epidemiologist who was advising Chinese health officials as part of the CFETP, training the field epidemiologists who would be eventually deployed to the virus epicenter. Even if the evacuations did not occur, the greater presence of U.S. public health staff may not have made a difference in the early virus investigation, as there were already restrictions on sharing biological samples. In 2018, the Chinese government had failed to share samples of the H7N9 avian influenza virus with their U.S. counterparts despite repeated requested even though they had consistently done so in the past.

As part of the U.S.-China trade war, in 2018 the Trump administration imposed tariffs on many Chinese goods, including health products such as masks, gloves, goggles, and thermometers, which inhibited the U.S. ability to important critical PPE during the first weeks and months of the pandemic. Although tariffs on some products were temporarily reduced, staff shortages made regulatory efforts such as supply chain inspections difficult early in the pandemic when FDA-regulated products including surgical masks, PPE, and other medical equipment eventually were being imported to the U.S. at unprecedented rates. These concerns illustrated the U.S. outsized dependence on China for PPE and other products and exposed the limitations within its own supply chain (Shirk and Huang 2020).

The COVID-19 pandemic was a clear opportunity for the two countries to put aside their differences and find a middle ground to combat a common enemy, however the situation rapidly devolved into one where collaboration became nearly impossible. Each side attempted to leverage the actions and inactions to blame the other and to retreat from good global governance (in the case of the U.S.) and to assert a new model of global leadership in the resulting void (in the case of China). While health cooperation was previously a relatively uncontroversial subject with ample interest in joint efforts, the frosty relations, prohibitive travel restrictions, and a breakdown in bilateral communication stymied the ability of experts from both countries to work with their counterparts on the COVID-19 pandemic and other issues.

Despite the tenuous relationship, some public health collaboration success stories continued. Modeled off the U.S. CDC’s Morbidity and Mortality Weekly Report and developed in close conjunction with the U.S. CDC staff in Beijing, the China CDC Weekly published its inaugural health bulletin just weeks before the first COVID-19 cases began emerging in Wuhan. This demonstrated the importance of timely dissemination of epidemiological information to an audience of domestic public health professionals and for communicating China’s public health condition to the international community of scientists and policymakers.

But the bad relationship contributed to missed opportunities for collaboration that could have changed the trajectory of the global pandemic. For example, in early 2020 the U.S. became one of the first countries to impose entry restrictions on individuals traveling from China, drawing sharp criticism from the Chinese government. The U.S. also initially offered assistance to China, including donating nearly 18 tons of medical supplies in February 2020 and offering technical expertise to assist the China CDC in characterizing the outbreak. At first, President Trump spoke highly of the Chinese response only to turn instead shortly thereafter to using highly inflammatory rhetoric by referring to COVID-19 as the “China Virus” or “Kung Flu” and eventually targeting his attacks against the WHO for praising China in the same way he had once done.

In July 2020, The Trump administration notified the Secretary General of the UN that it intended to withdraw the U.S. from the World Health Organization, criticizing WHO’s response to the COVID-19 outbreak, referencing its belief in undue influence by China in the organization’s delay in acknowledging evidence of human-to-human transmission and declaring COVID-19 a “Public Health Emergency of International Concern” concern. The hostility toward the WHO not only undermined other important benefits of U.S. membership, such as participation in global influenza early warning activities and viral sharing, but further antagonized global partners working together to address the worsening global COVID-19 pandemic. In fact, the U.S. had gained access to Wuhan in the early days of the pandemic through its own participation in a WHO health team.

In January 2021, the WHO sent a mission of 10 internationally respected scientists to Wuhan to investigate the origins of the pandemic, working together with Chinese scientists and epidemiologists. Their conclusions that the pandemic most likely resulted from a zoonotic spillover at the Huanan live animal market corresponded closely with China’s own narrative and the opinion of many global leading scientists (Worobey 2022). However, as part of the U.S.’s growing criticism of China and interest in deflecting blame from the mishandling of its own raging epidemic, the conclusions of the WHO mission were represented as evidence of a cover up by China, which controlled access to data and site visits by the WHO group. The Trump administration offered an alternative origin theory—that a lab leak occurred at the Wuhan Institute of Virology (WIV), a leading WHO affiliated lab that also received funding from the NIH for collaborative research on bat viruses that were the source of the 2003 SARS pandemic.

The public criticism of the WHO mission to China and the purported cover up led to a full-scale attack of the National Institutes of Health’s collaborative research program with the Wuhan Institute of Virology. Two main targets were the Ecohealth Alliance, a well-respected organization working with WIV with NIH funding to study the potential of bat viruses to spillover into humans, and Anthony Fauci, the longtime director of the NIAID who became the U.S. most senior health advisor to President Trump, and later to President Biden. Fauci was accused of covering up NIH knowledge of dangerous research at the Wuhan lab, an accusation without any scientific merit. The issue of COVID-19 origins and WHO and NIH complicity in a cover up became embroiled in U.S. partisan politics and distracted from genuine collaborative scientific inquiry into those origins that still remains unknown. Moreover, despite Taiwan’s own success in containing the spread of COVID-19, China refused to allow Taiwan to attend WHO emergency meetings and technical briefings, alienating U.S. government supporters of Taiwan. In May 2022, China mounted a diplomatic offensive to block Taiwan’s bid to attend the annual assembly of the World Health Organization, drawing further ire from the U.S. which supported its participation.

Both China and the U.S. donated large quantities of COVID-19 vaccines to many other countries, through bilateral donations but also through multilateral initiatives such as COVAX. This “vaccine diplomacy” was largely tied to geopolitical competition for influence in various regions of the world. The major recipients of U.S. mRNA vaccine donations were Pakistan (42.6 million), Bangladesh (38.4 million), Philippines (24.7 million), and Indonesia (23.7 million). China’s major recipients of its less powerful vaccine were Cambodia (11 million), Myanmar (11 million), Laos (8.5 million), Nepal (8 million), all Southeast Asia neighbors and major Belt and Road Initiative (BRI) partners. China declined the U.S.’s offer of donations of the more effective mRNA vaccines even after the highly contagious Omicron variant began spreading in late 2022 after the lifting of the “zero covid policy” (Kaufman, personal communication 2023), resulting in many deaths among the elderly. And its own local manufacture of the mRNA vaccines has stalled partly due to intellectual property rights protection by U.S. and European manufacturers but also to regulatory delays in China.

BioNTech partnered with Shanghai Fosun Pharmaceutical to commercialize their mRNA vaccine via licensing and distribution throughout Greater China, receiving special import authorization from the Health Bureau of Macau in February 2021 and approval in Hong Kong as early as January 2021. However, foreign mRNA vaccines never received regulatory approval in the mainland, except for a very limited number of doses meant to vaccinate foreigners living in China in late 2022. There were reports of plans to use the BioNTech vaccine as a booster shot on top of China’s domestic vaccines that had already been administered to much of the population, but final regulatory approval stalled. The lack of availability of higher efficacy mRNA to the general public in the mainland inevitably led to many more Chinese deaths after COVID-19 restrictions lifted in December 2022. Since mRNA vaccines like BioNTech were available in both Macau and Hong Kong at that time, many mainland residents rushed to the two Special Administrative Regions to get vaccinated during the massive surge in cases that followed the lifting of restrictions. And noted above, China refused the U.S.’s offer of donated mRNA vaccines in late 2022.

Few probably would have expected the U.S. and China to come together in a meaningful way to address COVID-19-related inequities, but in July 2022 they did just that. Belatedly, (missing the chance to deliver maximum impact) the U.S. and China both agreed to waive patent rights for COVID-19 vaccines for the World Trade Organization’s (WTO) Least Developed Countries (LDCs) at the WTO’s 12th Ministerial Conference. The WTO’s TRIPS Agreement on waiving patent rights for COVID-19 vaccines to expedite access and local production for LDCs is an example of the U.S. and China coming to a multilateral agreement on the issue of intellectual property rights which remains a source of conflict between the two.

Key Elements from Effective Future Collaborations

This long history of collaboration between the U.S. and China reveals many important lessons for working together in the future on common global health challenges. China and the U.S. have an obvious alignment of strategic interests when it comes to controlling infectious disease outbreaks, however this factor alone is not enough to ensure that fruitful collaborations can survive the fluctuations in bilateral ties. We suggest a few important takeaways from the fruitful collaboration in the past that should frame the approach going forward.

Leadership

Having strong leadership commitments from the heads of technical agencies (e.g., both CDCs) and backing from high-level political leaders provides an essential legitimizing force and renewed energy to undertake new initiatives. In the absence of direct dialogue between each country’s respective political and public health leadership, such as occurred during the Strategic and Economic Dialogues, there may be a perceived lack of support that results in hesitancy in proposing projects and data sharing, even when it is not of a sensitive nature. Even while a number of non-governmental track 2 dialogues on health have continued or have been proposed, the disjuncture between geopolitics and technical needs suggests only limited action on recommendations will follow without strong signaling from top political leaders. However, there have been some promising signs that the top brass at both CDCs were beginning to thaw the chilly relations. In January 2022, the annual Directors Meeting between the Chinese and US CDCs, which had been paused since 2017, resumed with a marked change in tone, with Dr. George F. Gao, the director of China CDC, speaking about the remarkable results the two agencies have achieved in public health as long-term partners and Dr. Rochelle Walensky, the director of U.S. CDC, calling for the strengthening of bilateral practical collaborations (China CDC 2022).

Presence on the Ground

During the height of collaboration, the U.S. CDC office in China played a crucial role in jointly identifying and investigating new disease outbreaks like avian flu together with the corps of CDC trained field epidemiologists in China. The importance of on the ground investigative teams for early warning of disease outbreaks is crucial for early action. The CDC’s premier EIS program which has been on the forefront of responding to global health outbreaks should maintain its collaborative investigative processes with China CDC.

Sharing Viral Samples, Including Genomes

Continuing the collection and sharing of viral samples that began with the influenza program, can lead to the early development of vaccines for global use, especially in the case of a severe new strain of influenza or an outbreak of a new emerging infectious disease like COVID-19. At the start of the COVID-19 outbreak in China, the viral genome structure was shared online, leading to the unprecedented rapid development of many effective global and Chinese vaccines within a year, saving countless lives.

With our era of emerging pathogens and the spillover of animal viruses to humans, there is the need to expand virus sample sharing more widely to include animal viruses. A recent article identified 102 virus species from 13 different viral families with potential for zoonotic spillover from wild animals commonly eaten as delicacies in China, 21 of which were deemed as high risk to humans because of spillover in the past (Cohen 2022). Robust collaboration on One Health, especially in hot spots, is therefore urgently needed and initiatives such as those being spearheaded by the BMGF should be strengthened and expanded. In the past, important collaboration on such animal viruses took place through NIH and other collaborative research mechanisms. However, the accusations surrounding NIH’s support for the Ecohealth Alliance and its work with the Wuhan Institute for Virology linked to the lab leak theory of COVID-19 origins has put a halt to this type of productive collaborative research (Quammen 2023). In June 2022, the China CDC and U.S. CDC hosted a teleconference on One Health for the first time where they put forward suggestions and a preliminary plan for cooperation priorities (China CDC 2023). And the U.S. rejoined the WHO in January 2021, and has been actively participating in the initiative to strengthen compliance with the International Health Regulations and the WHO’s Convention on pandemic preparedness and prevention (World Health Organization 2022).

Collaborative Research

Collaborative research between Chinese and U.S. Scientists on multisite clinical trials have led to major global health improvement, including the early study linking neural tube defects to lack of folic acid, the PREP trials on HIV, and many more. China has a well-educated, well-funded, and sophisticated science community of leading researchers on vaccine and new drug development and collaboration with global scientists through mechanisms like the International AIDS Vaccine Initiative, the TB alliance, CEPI, and other global partnerships have led to advances for the international community.

Long Term Capacity Building and Training Programs

Collaborations that have an explicit focus on long-term capacity development and sustainability could help to bolster commitments over a multi-year time horizon, as opposed to shorter term collaborations whose successes, impacts, and lessons learned could easily go overlooked.

Training programs that involve in-person exchanges and field research in both countries help to build reservoirs of mutual respect and good will, while helping to facilitate more candid, informal discussions that are part of the spirit of healthy collaboration. Programs like the NIH’s Fogarty Program have trained numerous Chinese doctors and health researchers over the past decades and those strong people-to-people relationships remain and should be revived for important collaborative research on common health problems. Having mutually well-defined priorities and a shared mission and values surrounding evidence-based research and policy decision-making will hopefully help to mitigate some of the politicization of public health work.

Data Sharing

Data sharing is essential for addressing global threats like emerging infectious diseases, as so sorely demonstrated by the early failings in both the SARS and COVID-19 pandemics (Kaufman 2020). Through establishing realistic consensus and clear standards on data sharing agreements, China and the U.S. can protect their legitimate national security interests without inhibiting essential scientific communication and knowledge exchanges across borders.

Conclusions and Recommendations

Collaboration between the U.S. and China in public health has been a major positive feature of the bilateral relationship over the past four decades and has the potential to create positive impacts in other areas, setting an example of how to manage differences and still drive constructive progress toward mutually beneficial outcomes. Although collaborative efforts suffered major setbacks in the years leading up to and more intensely during the COVID-19 pandemic, extensive ties between public health and academic institutions remain and a history of successful initiatives have helped to buttress ties between the two countries in this area.

The U.S. should not let the S&T agreement signed first in 1979 lapse (Seligsohn 2023). A six month extension was agreed to at the last minute in August 2023 and again in late February 2024 (VOA 2024), but renewal of the agreement is still not certain at this time because of concerns about research data restrictions and military use (Matthews 2023). Despite difficult relations, this core agreement provides an overarching mechanism for collaboration on global health should relations improve. Reviving previous agreements on viral sample sharing, collaborating on One Health initiatives, and joint investigations of disease outbreaks are urgently needed. The U.S. public health agencies that opened offices in China during the height of collaboration, such as the CDC, FDA, and HHS should take action to restaff key technical and advisory positions. Agencies’ heads and high-level political leadership can make public commitments to demonstrate their prioritization of collaboration on emerging and re-emerging infectious diseases. Projects that focus on long-term capacity development with sustainable funding will help to support new knowledge exchange, while potentially enabling timely dissemination of vital new public health information.

As two of the world’s most prominent global health donors, there are important ways the two countries should be working together to support global health in collaboration with the WHO, other bilateral actors, and global actors like BMGF. As with the joint establishment of the African CDC which leveraged each country’s respective strength in management, technical capability, and experiences with development assistance for health, the two countries could collaborate on supporting the newly created African Medicines Agency, which is intended to become the continent’s new regulatory body for medicines and medical devices.

With easier travel to China now resuming in the post-COVID-19 period, technical exchanges and joint ventures between U.S. and Chinese scientists and public health officials can resume through field research, trainings, and conferences. Renewing agreements and MOUs that support collaborative activities should be prioritized to ensure that relations do not further devolve. If the U.S. and China move toward operating in increasing isolation from one another and do not find solutions to responsibly managing their overall relationship, the world as a whole will be much less prepared to deal with emerging health threats and crises. Being able to effectively compartmentalize public health cooperation in order to insulate it from flaring geopolitical tensions would help to pragmatically return public health collaboration to an apolitical endeavor that is rooted in objective, evidence-based research and policy decision-making. Despite the threat of increased securitization of infectious disease research, some forms of cooperation are necessary not just for each country to manage their own strategic interests but is a requisite for revamping the existing global health architecture to better meet the challenges of the twenty-first century.