Initiative for U.S.-China Dialogue on Global Issues

Eleanor M. Albert: Today our guest is Jennifer Bouey. Jennifer is the Tang Chair for China Policy Studies at the RAND Corporation and associate professor and chair for the Department of Global Health at Georgetown University. Her research focuses on health, technology, and social issues. Trained in clinical medicine and epidemiology, Dr. Bouey worked on HIV prevention among migrant workers, cross-border workers, and other marginalized populations in China from 2005 to 2016, with collaborations with the China Center for Disease Prevention and Control, National Center for AIDS/STD Control and Prevention, several Chinese universities, and multiple international organizations.

Welcome, Jennifer!

Jennifer Bouey: Thank you.

Eleanor M. Albert: You're the author of [a] recent report that charts Sino-U.S. cooperation combating HIV and AIDS over 16 years, covering 2002 to 2018. That's a large time span. Could you set the scene for us, and give us a bit of a taste of what the state of HIV and AIDS societally was like in both countries? And then, how did U.S.-China collaboration on this issue start?

Jennifer Bouey: Thank you so much. This report is something I've been thinking about for a long time. Between 2005 to 2014, I [was] actively working on HIV prevention in China, funded by NIH [National Institutes of Health]. And through those 9, 10 years, I worked with many colleagues in China, in academia, in public health agencies, community organizations. That's the time I got to really understand their system and also understand the risks.

I also witnessed, firsthand, the collaborations between public health professionals from the two countries and [saw] how they built strong rapport. To me, that's a critical time in my career as a epidemiologist to work on HIV. And I'm hugely inspired by the work of many of the professionals during that time, from both countries. It's always [been] in my mind that it would be great to document that.

This report came to me: [the] Brookings [Institution] and CSIS [the Center for Strategic and International Studies], they are working on a topic that's focusing on how to rebuild collaborations after the recent years of declining of collaborations, and after all the strategic changes for the two countries. And [the] more larger picture is how to maintain some of the public health professional networks during a conflict, whether it is Cold War-like or a “hot war.” This is also a critical issue at this time.

I jumped on the opportunity. I said I would like to put in my experience not just to review what has been done, but also thinking about what it means in a new era. So that's the background of this report.

Right now, both China and the U[nited] S[tates] continue to experience HIV epidemic. So when we say COVID[-19] as a pandemic has lasted so long, and if we think of HIV as a pandemic, it really has lasted more than 30 years, even longer. It is [an] ongoing battle.

Both countries have about a million people with HIV+ on treatment. The U[nited] S[tates] spent about $20 billion a year on HIV prevention and treatment. China, by the record of 2017, [has spent] about US$7 billion-equivalent on HIV. Both countries, especially in the U[nited] S[tates], has very good statistics showing that every year about 40,000 new infections [are] coming up.

On China, there was an article published by Dr. Ma, from Wuhan University, in 2019, comparing the two countries' incidence rate, age-adjusted, showing the U.S.'s trend is going up. China's trend now is flat, but a recent study, 2021, by Dr. He Na from Fudan University, shows that the mortality rate has [been] going up, which is a very dangerous sign because HIV can have a long period of no symptoms, but if the mortality is going up, that means the detection rate was low. So something is wrong there.

Eleanor M. Albert: Could you give us a comparison of what these current numbers look like, and at least the current dynamics of what HIV infections look like, compared to when you started doing this work more on the ground? How does it compare?

Jennifer Bouey: That's a good point. Just to add on to the current trends, in the U.S. infections, most [of] the new cases are focused on young adults, 25 to 29 years old. In China, which is a very interesting pattern, is very young. The teenagers, 15 to 25, and young adults, 25 to 29, as well as [an] older cohort that's from 65 to 80 years old, mostly men. That's the current trend.

Compared to 2002 when the collaboration started, at that time, [the] U.S. has just [gotten] over a big, I think in the '80s and '90s, that's the peak of the incidence, and then the number of people who died peaked in about 1995. Then, from 1995 to 2002, there’s a drop. That's the time when [the] U.S. [was] already launching successful treatment, as well as prevention.

But for China, that's just the opposite trend at the time. China initially denied it had any HIV infections. Then, there [were] two outbreaks in China in the '80s and '90s that didn't really show up until the late '90s. One of them is the injection drug users in Yunnan, that's bordering the Golden Triangle area. The first epidemic was detected accidentally by an epidemiologic surveillance on hepatitis. Then they found, "wow, there's such a high HIV incidence among the drug users."

Eleanor M. Albert: Was that mostly because of needle sharing?

Jennifer Bouey: Yes. I went to some of these mining towns and there's a very interesting dynamic as why that was the case at that very specific time. But the second epidemic is more worrisome at the time, because of the worries about imported blood products. Then China, because of the fear for HIV; [they] banned blood donations.

But in some of central China, where the villages are really relying on blood donation as income, so they use some of the very illegal process. But somehow, village after village [was] infected. But that has really been trying to be covered up by the local government at the time. So 2002 was just when this second outbreak started to show up.

So it caused quite a lot of panic globally. To say, well, China, given its large population and its lack of surveillance, and its tendency to cover up epidemics, no one knows what's really going on. So that was part of the driver for the U.S. to decide to reach out to China's public health.

They had been working…there have always been some public health collaborations, even before SARS 2002, because UNICEF was in China, World Bank was in China, so U.S. CDC [Centers for Disease Control and Prevention] had been working with World Bank and looking at some of the maternal and child health issues in China.

But, it's not until 2002 when SARS flared up, and the Chinese government admitted they were delayed; there were some mistakes. And Wu Yi, who was a [vice] premier in the Politburo, became the new head of Ministry of Health during the pandemic. She really insisted on building a transparent data system.

The U.S. at time [had] successfully [been] doing their domestic HIV prevention [and] wanted to take a lead on the global HIV work. And then there's also global concern about China's ticking bomb of HIV infections. And Chinese government at the time [was] very open to the global collaboration. It's also right after WTO, right? They're in a very receptive and welcoming stage. So on both sides, there [was] willingness to work together.

Eleanor M. Albert: I think that's so interesting given that a lot of China's engagement tends to follow some type of incident that triggers a reprioritization of certain dynamics, right? And so, in this case, you have the U.S. as a model of success as it relates to HIV; you have the double domestic challenges, health-wise, in China as it relates to the SARS epidemic and HIV.

What started the collaboration? When you say the U.S. reached out to China's public health, what bodies in the U.S. did that?

Jennifer Bouey: There's an official marker, that's 2002: the U.S. Secretary of Health [and Human Services], HHS, Tommy Thompson, visited Beijing, and that was the time the two and met with the head of the Ministry of Health. They built a MOU [memorandum of understanding], agreement to work on HIV and emerging infectious diseases. There's very clear sign. Before that, there was background work.

As I said, the World Bank was a platform. With that platform, UNICEF and U.S. CDC had been engaging their peers in China on different maternal child and infectious disease. But those are very small, usually funded by World Bank and UN, not a direct collaboration between the two. But with the MOU in 2002, then following that, there were specific actions. One is for U.S. CDC, Center for Disease Control and Prevention, for the first time, to set up an office in Beijing.

The office is called Global AIDS Program, GAP program office in Beijing. That office, from [the] very beginning, it was located inside the China CDC. So they basically have an office in the Chinese government agency.

And then, at the same time, NIH [National Institutes of Health] did one, two years of funding to think about, “Okay, if we do a comprehensive CIPRA program [Comprehensive international program of research on AIDS] in China, what this will entail?” Two years later, the CIPRA program, collaborative investment research between the two countries, a five-year program, that covers very comprehensive research, HIV research, capacity building, was set up.

Eleanor M. Albert: Wow.

Jennifer Bouey: The third partner from U.S. is USAID. They also made a plan to build programs specifically helping the southwest China on HIV testing. Once the CDC office [was] set up, that NIH big project started, and USAID program [was] going, then I would say that's the beginning of it. China had been very cooperative at the time. They basically welcomed the U.S. office directly in their office. They really [in] about 20 years rebuilt China's public health surveillance system, as well as the basic science and infectious disease research structure.

Eleanor M. Albert: What an incredible, long-term investment, which I think is not something that we see publicized very much. I think it's an interesting dynamic to this, because it is a long-term effort. Clearly, both parties had things to gain. I'm curious how, over the course of these almost 20 years, how did the collaboration evolve? Did it change significantly? Clearly, there are political dimensions that have reared their heads.

Jennifer Bouey: Great question. There are changes over time, for sure. We often say there was a golden window time when Chinese government [was] really open to collaborations. I need to say it's not just U.S.-China. China actually received lots of support on HIV from many other countries, from Great Britain, Australia, many foundations… it's not just the government, there's Gates Foundation, Merck Foundation, Clinton Foundation—all are critical for China to build its comprehensive HIV system, treatment prevention system.

But I would say the golden time was from 2002 to about 2009. China's HIV agencies [were] most open to foreign collaborations, including the U.S. HIV, it's an infectious disease, but it's chronic. People who have HIV diagnosed on treatment can basically treat it as a chronic disease. And there's also a long period of time that the virus can transmit from person to person, but there's no symptoms, right?

And the third characteristic, I would say, is that HIV is transmitted by blood and body fluid. The high-risk populations are often the marginalized population, marginalized in terms of the culture and so on. We often have to look for high-risk groups in drug users, sex workers. Even at the very beginning, even the gay community in China, which is also a high-risk group, is highly stigmatized. That also changed quite a lot during this time.

So the beginning of the collaboration was building the national reference lab so that HIV can be tested, and building the basic human subject protection for research, building the treatment guidelines. This is the first step to the HIV prevention, but they didn't even have a treatment guideline. So the Clinton Foundation had to bring in infectious disease physicians from [the] U.S. and sitting in the GAP office, working with the China CDC, to build its first treatment guidelines.

They then built all these clinical training programs in rural China, in 13 provinces [that had] higher HIV rates, to teach the physician in rural areas to how to treat HIV. And actually, pediatric HIV treatment had never been launched in low- and middle-income countries. And one of the physicians from the Clinton Foundation was the first one to help build the pediatric treatment guideline. And that guideline later on became a guideline for many African countries, too.

So here, you can see that China definitely benefited. But, I would say the U.S. benefit [was] to be able to build this network, to understand China's public health system, and the firsthand data on most of the infectious disease and health system in China. And then also trained its own experts in a low-income setting at the time.

The world benefited from China's experience: either its treatment guidelines, China's experience with MMT, instead of injection drug use, MMT; or replacement therapy. But that can be done in developing countries, too. So, there's lots of data that collected in China, passing through the U.S. CDC, and then to the global HIV prevention stage

Eleanor M. Albert: Right, it's almost like a natural lab, right? You have this new environment and different circumstances that don't necessarily match a developed U.S. And so, you can gather lessons from there about how you can develop similar types of programs for HIV and AIDS, or perhaps other infectious diseases in the developing world. Now, we talked about this being the golden era, '02 to '09. What happens afterwards?

Jennifer Bouey: The golden era is the time that China quickly built up this from pretty much ground level, nothing. During that time, there are just so many significant changes. I think at one time, China actually got more than $500 million funding from outside, which, at the time, was about one-third of their whole public health, not just HIV, public health budget. That has a huge influence on their public health goal-setting.

And the other thing is the community organization. They didn't really have that, but that's another story. They actually conquered that and build it. But the problem is how things [went] up very quickly and then plateaued. What I see is, after 2016, when gradually all the international organizations, agencies pull out, how that now is actually in a collapse stage.

Eleanor M. Albert: Were those withdrawals in response to the non-governmental organization law that passed, in terms of the funding requirements about how outside money was to be used within China?

Jennifer Bouey: That's one factor. There are many factors. For example, U.S. CDC helped China to secure funding from the Global Fund. The CDC didn't really put lots of funding to China directly. They gave maybe $5 million, pretty small funding in terms of CDC's global aid. But, because of the close relationship between the two agencies, they were able to help China to get other funding.

They called it catalyst funding. China got five or six round of Global Funds. That phased out, ended in 2009. The activity lingered until 2013. But the reason for that is that, partly due to China's becoming a upper-middle income country. Then, there's more pressure for a Global Fund to say, "Well, China, you should be a donor." Right? So that's one factor of why some of these funding and organizations left. China became richer…

Eleanor M. Albert: China just became a different category of country.

Jennifer Bouey: Different category. And also, China had made significant progress on its capacity over these years. The initial fear was, first of all, the blood supply is that safe from HIV. The second one is the drug users; is there a significant issue? At least on these two fronts, by 2009 is well under control. And then HIV didn't stop. But I think once these structures started and the capacity building was so successful, [for] many agencies, it's harder for them to justify big funding. But their presence in China is definitely, in my mind, is necessary. And I can tell you why.

My recent trip, I went back to China. I've been reviewing some of the latest HIV reports from China and it paints a very challenging picture. When talking to my colleagues in China, everyone was saying we're back to 20 years ago. 

The local government are not incentivized to screen out HIV. Community organizations are not allowed to go to Chinese university campus to talk about HIV prevention. We're talking about older men, younger gay men. These are clearly the high-risk group now. It's no longer the drug users, no longer the blood donors, it's this new high-risk group. But I see increasingly more stigma attached to these high-risk groups and the reluctance of the local government to actually work on HIV. That's partly due to the lack of a moral support for the public health researchers and professionals in China to push for HIV. Similar issues with tuberculosis.

I think it's critical to engage China on infectious disease prevention because of this large population, because of its system, in a way, encourages cover-up, right? So it's not that they don't have the capacity now. It's more of helping these professionals to fight within a system that tends to ignore public health risk signals.

Eleanor M. Albert: Why do you think culturally, in the political environment in China, why is it that there is this reluctance or a disincentive to read these public health signals and to report them up? What are the drivers of this tendency to want to mask public health issues?

Jennifer Bouey: I see that happen again and again and again. This is something I hope that we [can] have a better research and also think of a solution for this. What I see for HIV, for even other infectious diseases, COVID, we all see that SARS, right?

At SARS, you can say, "Well, at that time, China didn't have a good surveillance system." But since then, the government and international tech support have helped China build that. But why it still didn't work?

As you said, what are the incentives, right? What's the incentive for the local hospitals and local public health system to be sensitive on this? In China, the public health system and the healthcare system are parallel. They're two different systems. What is the incentive at the grassroots, at the local clinic level, for the two to work together? What are the incentives for the local government not to report a system?

They actually have two systems to find an emerging disease. One is focusing on influenza-like type of new pathogen. Another system is called pneumonia without known etiology. The second of the POD [Points of Dispensing] is the system that's supposed to sense COVID. But even before COVID, there were many research reports showing that that system is not as good, not as sensitive as the influenza one.

And the reason is that the pneumonia system is maintained exclusively by the Chinese CDC. Whereas, the influenza one, China is one of the five global influenza stations. So they routinely work with Asia, Southeast Asia. They're the training center; they have to work with the WHO [World Health Organization] on it.

So on that observation, I would say the system is not sensitive because it's not globally or regionally connected. It's exclusively for the Chinese system. Within the Chinese system, the priority for China's government overall is, first of all, economic, at that time. Now it's different. But at that time, number one is economic development. Number two is stability. So infectious disease can be a disruptive factor for both. If you have an emerging disease, the lockdowns, the investigations will affect economic activities. 

And secondly, the stability. Public health is really the counter factor to the two things that they really want to do at the time. That's why, I think, there's always a tendency for underreporting.

Eleanor M. Albert: This is a very natural segue for me to ask why U.S.-China collaboration on public health issues is so important. What are the implications if channels of cooperation remain closed? Has this collaboration collapsed completely, or are there still some institutional linkages there that could provide a tether from all of this tension between the two countries?

Jennifer Bouey: Last month in Beijing, in a meeting I said, “Give me two minutes. I’ll show you my fantasy.” So my fantasy was in fall of 2019 that the U.S. CDC [was] still sitting in the China CDC Center. The U.S. epidemiologists can walk a few steps into the offices of the Chinese colleagues’ office and say, "What's going on in this system? The POD system that's showing a few pneumonia... We don't know the etiology? We are at the stage that we need to investigate it.”

And then maybe the U.S. CDC and Chinese CDC can send investigators. There were three delegations in January 2020 investigating what's going on Wuhan. The first two failed. So if, at the time, there was still ongoing collaboration, then both agencies can brief their presidents of their countries [about] what's going on. And in March 2020, the fantasy is that the U.S. can send in more epidemiologists and, as well as virologists, to China to help Chinese investigators and start the vaccine development. The two countries can collaborate on a whole wide spectrum of types of vaccine to experiment and think about the manufacturing for the world. And then in March 2020, when the COVID came to New York, then the Chinese can provide firsthand treatment data.

So this is my fantasy, but if you are putting it in the HIV collaboration, especially the golden time window time, it can totally doable. They have worked together not just on the SARS and H5N1, avian flu, swine flu. The two countries worked together for Ebola in West Africa.

After it breaks down, are there still ways to connect? I'd say that after almost 20 years of collaboration, all the people are still there. We're still in the same generation. People still remember how well it worked in the past. So I do think that the grounds are still there, but many of the policies, as you said, China's, first of all, its own capacity is there. They may think, “We don't need the foreign countries to come here. Now we can do it.”

But my argument on that is, yes, you have the capacity, but we still need a global standard so that China will still be part of and on par with the global standards on infectious disease prevention. And the public health professionals in China need moral support from their international colleagues to support the prevention and treatment, especially when it comes to marginalized population, and stigma, and [as] relates to human rights issues. That's the need.

The foreign NGO law definitely put lots of stress and made international organizations difficult to work in China. And I want to say that the China initiative from the U.S. side also discouraged many of the U.S.-based scientists to even think about working with China. Because, when they do that, they know their funding and their own research will be put into an investigation pool. Some of the practice there was not very good either. Multiple reasons that the collaboration really collapsed. But I would say the will is still there; the people are still there.

Eleanor M. Albert: To conclude, it would be great if you could tease out some of the recommendations that you provide in this report. You say the will is still there; the foundation is still there. What are the steps that can be taken to rekindle this, and at what levels should these steps be taken?

Jennifer Bouey: Certainly we now all have different mindset. I think security becomes a priority over other things, in both countries. Based on that, I think the first question is, "Why?" Why [do] we still need collaboration? The number one is to think about preventive collaboration. Preventive collaboration is a term that [is] usually used in military to say, to prevent a disaster. What is the
collaboration?

If preventive collaboration can be used for security and military, why not to think about that concept in public health? If there's a COVID or another pandemic, how to prevent [the] same thing happen again—the coverup, the slow response, the lack of professionals to work together, how to build transparency and trust.

You need trust. You really need trust at that critical moment. So I think preventive collaborative, collaboration and engagement should be, hopefully it'll be unanimous, everyone agree on that principle. Then once you have that principle agreed upon and then the operational steps.

I think it needs to be top-down. The reason for top-down is that the scientists are scared, the professional are scared, because of the security first in both countries. We need the countries' presidents to bring this preventive collaboration in public health into the spotlight.

Then some of the protocols that U.S.-China had: the science and technology agreement MOU, since they reestablished diplomatic relationship back in the 1970s. But recently, this agreement MOU has been renewed, instead of five years or long term, it's been renewed every six months. It's not just a piece of paper. Because based on this MOU, every year the two countries will have agencies to work together to iron out, “Okay, what is the scientific priority for collaboration? What is not on collaboration?”

It's really a system that build an effective dialogue for the two countries to talk about what they can collaborate [on], what they cannot collaborate [on]. Without that system, then there's no next step for operational. Once we have that renewed for maybe a little bit longer time, not six months, so that there will be routine dialogues, then it will be the exchange program. Once you have agreement on what to collaborate on, then it will be easier.

I can tell you, the people are still there. The mechanism that used to work successfully is still there, so we need this higher agreement. Then how to engage the regional and global network? When the U.S. and China are willing to collaborate on health, it's easier for WHO's work. Sometimes, when they don't like each and/or attacking each other, the regional and global network gets more difficult.

The last thing is about soft power. The Gallup poll, at least for U.S., shows that this year, the U.S. public thinking of China as the number one competitor or adversary, that percentage maybe dropped from 80% to 60%? In China, I think there are also polls showing that this anti-U.S. sentiment, that was historically high in the last few years... If we want public health professionals to work together, if we can make sure that the public understands why it's necessary to work together on public health, and build public health soft power, that will be helpful in the current environment.

Eleanor M. Albert: Right. There are knock-on effects not just for the domestic populations in both of these countries, but for around the world, right? Because these regional and global systems and mechanisms work best when there is the greatest ease of collaboration and transparency of data.

The views and opinions expressed are those of the speakers and do not necessarily reflect the position of Georgetown University.

Outro

The U.S.-China Nexus is created, produced, and edited by me, Eleanor M. Albert. Our music is from Universal Production Music. Special thanks to Shimeng Tong, Tuoya Wulan, and Amy Vander Vliet. For more initiative programming, videos, and links to events, visit our website at uschinadialogue.georgetown.edu. And don’t forget to subscribe to our podcast on Apple podcasts, Spotify, or your preferred podcast platform.