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

Eleanor M. Albert: Our guest is Dr. Jennifer Huang Bouey. Dr. Bouey is the chair of the Department of International Health and a tenured associate professor at Georgetown University. She also serves as the Tang Chair for China Policy Studies at RAND Corporation. As an epidemiologist with training in clinical medicine and quantitative research, she has led multiple research initiatives on social determinants of health and global health equity and security. You are currently working on projects to promote global health dialogues, gender equity in health care access in Asia, and global infectious disease response system strengthening. You’ve also served as a consultant to the World Bank Group, UNAIDS, Clinton HIV/AIDS Initiative, Hong Kong Government AIDS Fund, and other international organizations.

Jennifer, it's a pleasure to speak with you today.

Jennifer Huang Bouey: Thank you for inviting me. I'm really honored.

Eleanor M. Albert: I would like to start with asking you about what your own path was into studying international health, and how did the United States and China factor into it?

Jennifer Huang Bouey: I was born in Beijing, China, to a family of physicians; both my parents were cardiologists. So naturally, I was the only child, so I was sort of designated to be a physician or a cardiologist. I turned out to be one and ended up doing medical residency in cardiology in one of the teaching hospitals in Beijing. But at that time, it's the mid '90s. I was very curious about the world. China was just opening up. It's a very different world compared to the China nowadays. In the mid-1990s, the GDP of China was one-fifteenth of that of U.S. Nowadays, U.S is just 1.5 times of China’s GDP.

So back then it was still a low-income country. Before it entered the WTO, [China] was not a major export country yet. But there was lots of energy and interest and outward-looking mindset. So then I decided, similar to many of my colleagues and classmates, that I would like to pursue a graduate school education in the United States. So I chose epidemiology and public health because that's very different from cardiology, but I'm very interested in it. I took a patient in my residency, and he turned out to be the first AIDS patient in the teaching hospital. It took a long time for us to make that diagnosis.

And then afterwards, both, he, a young man, and his mother just disappeared from the hospital. So that incidence has a very strong impression on my early career.

At that time, we have to rely on scholarship to be able to get a visa. Even my cardiology parents could not afford for me to go to graduate school in the U.S. So I came to George Washington University and continued to the Ph.D. program, during that time writing several reports [and] research papers about HIV/ AIDS in China. I was really hoping that I could do my Ph.D. thesis about HIV in China, but that's still in the '90s and before SARS.

China really didn't have a comprehensive public health data system. That was all developed after SARS. And the data secrecy was also different. I couldn't actually get any data to do a thesis on that. So I give up on that idea, but continued to finish the program.

But in 2005, when I was working in the Clinical and Community Research Center at Children's Hospital, I got to know a faculty member at Georgetown University, who was thinking of working on HIV projects in China. So I immediately jumped on it. It ended up being the Department of International Health, where I stayed till this day, almost 17 years.

So I think lots of haphazard things happened. However, I do see there's a pathway, and it's reflecting the U.S.-China collaborations during that time. So after 2005, I joined Georgetown. We ended up working on four NIH-funded projects in China, looking at HIV prevention among migrant populations.

Eleanor M. Albert: That's incredible work and almost baffling to think that there wasn’t data on public health issues. I wonder if you could talk a little bit about the development of the public health sector in China. The contrasts between the medical system in the United States versus the medical system in China are so stark. Are there differences or similarities in the conceptual ideas and then implementation of public health?

Jennifer Huang Bouey: It is a very different system and developed at different stages, for sure. I'm not saying that China's public health system was not as good as any other country; it's just a different philosophy and different hardware. China had been actually quite successful in the '50s and '60s at eliminating most of the infectious diseases and through campaigns on sanitation, vaccination. And you can see it, evidence is that the life expectancy has increased dramatically even before the economy open up.

So there is a public health approach that China did well. However, in terms of sharing data or collecting centralized data, at least before SARS, that was not developed yet. So what we see then was most of the public health are anchored by all these public health stations whose main task is to immunize people or doing surveillance on sanitations, not necessarily a data-driven, centralized, public health system as it is now.

The 2002-2003 SARS was a big event for public health in China. Even before that, the SARS epidemic, there were some experiments, thinking of several different countries’ models. As I said, at that time China is very outward looking. They considered the European model; they considered the U.S. model and other Asian countries’ model. They decided to take the U.S. model because the U.S. model is very good, focused on epidemiology field research and technology. What we know now as China CDC's model really originated from there.

Also after SARS, China really opened, saying “We don't have a great system, but we want to build a system.” And at that time, it was embraced by lots of countries and WHO (World Health Organization) and lots of global health professionals. We saw a huge uptake of collaborations after SARS.

Eleanor M. Albert: I was wondering if you could talk a little bit more about the relationship between China and the WHO? There's a long history. Obviously, people currently have thought about the more fraught relationship as it relates to COVID, but the WHO played a huge role in helping to develop standards that have been not just for China, but international standards of public health. I wonder what the process was? China's first experience of heading a UN agency was also the WHO.

Jennifer Huang Bouey: Certainly, WHO is part of the UN system and China joined UN in the '70s. At that time, it was relatively new initiative for China to really go back to the international to stop the isolation. Partly, I think it's because of U.S. engaging China. So I think that really changed a lot of the dynamics and China's thinking about global engagement. Back in the 1970s, China joined the WHO and actually it was supporting one of WHO's then priorities, which is the health care for all. China's barefoot doctor program was at one time mentioned as a model for strengthening the primary health care for even the rural areas.

So I think China does have that history and a good start with WHO. With SARS, I think both Chinese public health system, as well as WHO, were puzzled between 2002 to 2003. What are these new cases? What do they mean?

So compare COVID with SARS: what we can see is, although there are always some delays at the beginning, chaos and delays, but this time China very quickly provided the genomic [sequence] of the new virus. And so it's very easy to link cases to what's happening in Wuhan. But back in 2003, it took four months for WHO to send in a special team to China, to find out that the cases in Vietnam and Hong Kong are actually linked to the Chinese cases.

To me, as a public health professional, I see tremendous progress of technology and how genomic technology was developed in China. And that contributed to at least the early detection of the COVID-19 cases.

Eleanor M. Albert: It’s remarkable to think how quickly things have changed, not just from the technological perspective. There was a lot of international travel in the early 2000s, but it's nothing like what it is today. What would've happened if we had the travel frequency that we had back in the early 2000s, SARS could likely have been a global pandemic as well.

To shift gears and to think about the U.S.-China dynamic: I wonder if you could characterize or describe the current state of U.S.-China relations as it relates to global public health in two or three words? I know this is always a challenging task, but a quick snapshot?

Jennifer Huang Bouey: That is tough, but I think maybe one word is awakening and maybe another word is of reflection.

So awakening in a way... we know a lot of history are cyclical, repeating. But their arch are usually longer than one generation or maybe two generations. I grew up in China in '70s. All I see has been that the United States has been reaching out to China. That opening up and bringing China into the world. That's very deep rooted in my perception. So that's why I said awakening, is that for many public health professionals or health professionals in my generation, from Chinese Americans even, it's very difficult for us to understand why the U.S.-China relationship can have such 180 degree turn in such a short time. We didn't quite understand why, because it seems to be everything's going okay, but suddenly, a nosedive. But in hindsight, I wouldn't say this is even a unique historical moment, but I think it's definitely awakening to think about global health in the context of geopolitics.

And reflection of course, is to think, “Okay, so now we understand the geopolitics competitions and global health, then how to make it work. Right?” We see many countries, not just the United States or China in recent years, become much more sort of withdrawn, building more borders. And there are political sentiments against the globalization. Our career is global health, and we have seen tremendous progress in health globally by engaging different countries, by building alliances, building standards, and to train public health and health care professionals around the world, and in a way to reduce the health inequity. That's our commitment. So then the reflection is really about how to still continue that type of work, but in a much more complex geopolitics.

Eleanor M. Albert: We couldn't have a conversation about global public health without recognizing that the spread of the coronavirus and the pandemic's impact on international travel and trade has exacerbated these tensions we're talking about, between Washington and Beijing, but at the same time, there are a lot of different types of dialogues when it comes to health care standards, gender equity, public health. Could you talk about some of the successes of some of these dialogues in the past, how have they evolved over time? Where do they stand now?

Jennifer Huang Bouey: First of all, I'm a believer of dialogues. Between 2016 to 2018, I was part of a work group on global health and migration sponsored by Georgetown to build a dialogue between global health researchers in the U.S. and with China. I learned so much from that initiative. We visited the Guangzhou Provincial CDC, and looking at their rapid response system, I got to learn about H7N9, how China at that time built insufficient capacity to deal with surveillance all the way to building a vaccine with their colleagues from the U.S.

And then in 2019, my sabbatical year, I started to work as Tang Chair at RAND. I continue that work to today, to build dialogues and collaborations with China, mostly on health and education. I try very hard to gather the momentum as well as researchers interested in dialogue on a variety of topics. The one that we actually just finished is the climate and energy policy that between RAND and Tsinghua University and the Energy Foundation of China. And we are also starting dialogues on trade, on global health. It's not easy because first of all, the funding is much more difficult now about these topics. Neither country is not overtly supporting these dialogues. And we also need higher-level dialogues to be an umbrella to make sure these dialogues actually can make some difference, right? Otherwise, it's just each side talking about their own things.

The funding is not easy. To find researchers, experts who are willing to engage in these dialogues is also not easy, because each country has their own politics and also paranoia. So the U.S. is much more afraid of IP (intellectual property) loss and China is more [concerned about] political influence. So people who can join these dialogues without a lot of political caution or danger or risks, is difficult.

And then the third difficulty is that we really want to have genuine dialogue, not just one hour of Zoom and each make a statement, but more as what we did in Georgetown. We had a whole week of people coming together and having discussions, talking about priorities, understanding each other's backgrounds. And then we do that for three or four years.

That type of rapport building is much more necessary. But I also think that's very necessary because without dialogue, there will be more distrust or more misunderstanding. I still don't know whether this is the right timing to ask for people's commitment. But in the last few years, we have built this—I think pretty successful—dialogue model, not just with one meeting, but rather have two research teams to work for couple of years to build a project. That's the type of dialogues that we really need to continue.

Eleanor M. Albert: When we think about having dialogue about public health, are there certain topics within that field that are more insulated from some of the political concerns and constraints? Coronavirus is off the table, right? But there's a plethora of issues that both countries face, whether it's urban/rural access to health care, or whether it's gender access to health care, various standards of issues.

Where are there areas where we can have discussions that are that deep dialogue that is necessary? Is it that we need to have these discussions as it relates to places outside of both of our countries? China is training doctors in different parts of the world. Is that something where there could be more engagement? Where is the fruit that can be born from some of these dialogues?

Jennifer Huang Bouey: That's a great question. There's certainly no shortage of topics that the two countries can learn from each other or even come together through a discussion to find a solution of importance to both countries or maybe to other parts of the world. Both countries are facing this increasing cost of health care, right? And both countries are actually both capable, very strong in research and development. And both countries are innovative even though each country has its strengths in almost different type of supply chain for the research. U.S. is very good with theoretical and basic science and China's very good in adaptation and quickly turning that into the consumer products.

I wish there were joint force for the common good of health, but I think the first thing for us as global health professionals, we still need to understand what is the situation. It's not just coming from our own will and goodwill that we can just work together; we need to understand the competition between the two countries. And only when we understand why there are some of these concerns, then maybe we can address these more effectively.

So these barriers are, I say competition, and some other people may say it's war, right? So you have the competition in trade, competitions in technology. You have competitions in currency, in global influence, as well as military.

Eleanor M. Albert: Vaccine roll out…

Jennifer Huang Bouey: That's all about the global influence. So we have to be aware and not to say one country is right or wrong, but these are the facts. These are big power competitions and we cannot just wish it away. So that taught me to think, “Okay, how can we get work done, but without causing these competitions to aggravate”? And also, I think the two countries do have very different system from its political system to its health care system, to how it tries to solve its problem.

I think at the beginning of the COVID-19, I was sitting in testimony at Congress and I was hoping the two country can work together, but that didn't happen. So, I think these competitions are the barriers. Each country's political situation, like polarization in the U.S., and China's own political issues, as well as rising nationalism. Those can all be part of the barriers.

So then where can collaborations on health sit? First, we need to understand these barriers and then to think about, okay, what we want to do is really get work done, not to claim any superiority. If each country can engage more with multilateral institutions, either new ones or old ones, doesn't matter... But if each country can integrate their global health activities more into what is done in different regions, let's say in Latin America or in West Africa, truly work with the locals as well as the multilateral agencies—with WHO, with the Global Fund, with the G20, whichever initiative that has a foot on the ground—and working with them more, rather than thinking about the gains.

The other thought I have is, given the situation, how to engage the collaboration at a multilevel. So not just looking at two countries, say the top leaders need to shake hands. That's important, but also important is at provincial level, province to states, to city to city. United States is not a top-down country. It's a federal system; each province can have its own policies. So targeting different levels of collaboration. I know that California has been maintaining this climate and energy research with China for a while. I think that level of collaboration should get more attention. And also at a professional level, as an epidemiologist, I would love to work with epidemiologists around the world. And I think COVID-19 also [showed the] benefits from the professional network of data sharing. I do think that we need to be a bit more innovative in considering dialogues and collaborations.

Eleanor M. Albert: I know that the top-level national discourse has really been dominant. It's been a shadow over all of these attempted efforts. And of course, nationalism and backlash to globalization, in both countries, has muddied all of this as well. But I think your recommendation on the idea of regional and grassroots levels and professional networks are where one can hope that there would be something to grasp onto.

You laid out some top-level ideas of how things could be done. What are some tangible things that in the past have been great models for how we can get over moments like this? Or if those aren't possible right now, what might be some things that you see or are actively trying to encourage to revive some semblance of U.S.-China global health exchanges?

Jennifer Huang Bouey: So I think there's a couple of urgent issues. Of course, the first, the higher-level dialogues and overall political system atmosphere would be really important to facilitate these dialogues. But, even if it's not a high-profile dialogue, but some communication on these issues, will be tremendously helpful. So one thing, we're all talking about a COVID vaccine. How to vaccinate the whole world. And that is really critical to the whole world, as well as for the economics of two strong countries. So whether the U.S. or China, separately even, can facilitate and help the regional vaccine center and also help with the transfer of the technology to build multiple regional vaccine production centers, not just vaccine, but also on the antiviral treatment. These are critical.

Secondly, how to strengthen the public health delivery system in different parts of the world is also critical. China has been for a long time sending out medical teams, helping with infrastructure building. So they're good at that. And U.S. has been the leader of financing a lot of global health and focusing on specific diseases. I see these are two very different approaches, but both have its advantage. So if there's any way, even if it's not directly connected, but both contribute to certain areas of the world without too much thinking of who gets what credit, then that would be good. Influence is not just zero sum. It's not because one country get credit, the other would not. I think that both countries can get good outcomes and good commitment.

In terms of research: moving forward on health and public health, China has benefitted for sure in the last 20 years from the U.S. being willing to help China to build a surveillance system, to train China's public health professionals. I know many of the Chinese CDCs’ directors are trained in the U.S. So there's a very deep-rooted goodwill to each country. But I hope that door won’t be closed.

At the professional level, I think there's actually a very good connection, but I don't think in either country, public health professionals are at the very forefront of the political phase. I'm very hopeful that those collaborations will continue. That there will be more U.S. CDC staff that goes to China, and there will be more exchange students and scholars for both countries. That type of collaboration is important. But also how United States and China can be part of the regional network of global health. How Asia, in terms of either ASEAN or the other alliances on regional global health that can be supportive. And if U.S. would like to join, why not? We should think about all these innovative ways to engage.

Eleanor M. Albert: I study politics, so I can't help, but ask what you see as the major political constraints, within the Chinese context or comparatively in contrast with the American system? Are there some that are fundamentally a product of the Chinese political system and the American political system?

Jennifer Huang Bouey: Given my background is more on health, I can only talk of my own understanding of these. What I found is the two political system are very different. China, it's a top-down system. So if there's order from the top, then there's not much negotiation for the downstream. Under that environment, you could easily say, “Okay, now this is not the time to talk to U.S.” Whereas in the United States, the political system is much more spread out, and it's more tolerant of people with different opinions. So there will be less restriction for U.S. professionals to want to continue to work with China.

However, we do, at least among the Chinese American researcher scientists, the China Initiative really put a very chilling effect there, because even if there's no ill intent, you can still get all of your life disrupted at one moment. So as you can see that both country can have these barriers for dialogue. So that's why I always still have to insist that, if we could get global health less political, the better.