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A Virus-Hunter’s Advice on

Dealing with China’s Resistance


on Covid
Hardball is the wrong technique to get China to
open up about the early spread of the
pandemic. A successful but little-known global
disease program offers a much smarter
approach.
09/15/2021 07:55 PM EDT

Where did Covid-19 really come from?


:
The origins of the pandemic have huge importance to science, to
medicine and to global security, but nearly two years after the first
known infection, the search is stalled. The high-profile release last
month of the U.S. intelligence community’s report to President Joe
Biden only confirmed how little progress has been made: After a 90-
day investigation, it offered two long-familiar theories. Either the
virus originated from natural human exposure to an infected animal,
or it escaped from a biocontainment laboratory. There was no
consensus on which was more likely.

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There’s a good reason we don’t know more: The government of


China has consistently obscured the events around the early
coronavirus outbreak and resisted providing key information to
American investigators and even to the World Health Organization.

This doesn’t automatically mean China was a malicious actor. Its


leaders may simply be worried about what else turns up along the
way. Perhaps it was human error in the Wuhan lab, which would
injure national pride in China’s top new biocontainment facility. And
Chinese leaders are right when they complain that early finger-
pointing at Beijing, and especially the accusations of bioweapon
development, was nothing more than baseless political posturing.

Right now the impasse shows every sign of continuing. The World
Health Organization is launching a second global investigation of
Covid’s origins, this one led by more qualified investigators than the
first, but China continues to reject further inquiries into what
happened. In Washington, there’s now increasing pressure on the
White House to play hardball with China — to force cooperation by
:
imposing serious new penalties, like sanctions on Chinese
laboratories.

There’s little reason to think these might work. And even if they did,
the hardball approach would be a huge mistake in the long run.
Covid-19 is only one of many pandemics we’re likely to see this
century, and — given China’s vast animal and human population,
extensive surveillance network, unparalleled virus sequencing
capabilities and its massive biomanufacturing capability — we’ll
need China in the future, both to investigate and to help fight the
next one, and the one after that.

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Like it or not, Joe Biden and his successors in the White House need
China as a long-term partner far more than they need it as a
scapegoat.

President Joe Biden visits the Viral Pathogenesis Laboratory at the NIH in Bethesda, Md., in Feb. 2021.
| AP Photo/Evan Vucci

So now what? Given the current impasse, is there a way to work


productively with China on the kinds of problems we’ll need to
tackle in the future?

I’ve been involved in global disease outbreak operations for 22


years, isolating dangerous viruses in the field and treating infected
patients, and have worked inside three U.S. federal agencies under
presidents of both parties. And I can say the answer is yes. It
requires, however, more than hastily assigned and executed
intelligence reports. It requires more than complaining about an
uncooperative China, or cooking up saber-rattling diplomatic
:
pressure schemes.

A more promising solution would involve following the successes of


a little-known 30-year U.S. government effort to root out
bioweapons in dangerous parts of the world, and to secure
dangerous pathogens in foreign laboratories. That effort built a field
corps of U.S. experts skilled in virology, foreign biocontainment
practices and the care of patients infected with highly dangerous
pathogens. Their direct “glove-to-germ” experience, often in
politically inhospitable settings, has generated a range of
successful approaches for sleuthing out human factors that
contribute to an accident, a lab infection or an outbreak.

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Their experiences would expand the breadth of any renewed


investigation into the origins of Covid-19 — and more importantly,
their style of cooperation-building would likely preserve China’s
willingness to help the West in future, possibly more dire,
pandemics.

The roots of this success story lie in America’s approach to


another adversarial power, the Soviet Union.

Following the fall of the USSR, the U.S became alarmed about the
security of that country’s biological weapons program. The U.S. was
concerned what might come out of its biological weapons facilities
and stockpiles — and who might hire the 60,000 scientists trained
to produce these living munitions.

Following the attacks of Sept 11, 2001, and the American anthrax
:
attacks soon afterward, the U.S. increased efforts to prevent Soviet
biological weapons, and the skills to make them, from being
acquired by terrorists. Many U.S. efforts involved redirecting former
bioweapons labs to peaceful purposes like vaccine production. This
leveraged both the Soviets’ scientific expertise and the preexisting
biocontainment infrastructure.

The risk wasn’t gone, though. These labs were still handling
dangerous pathogens, and pathogen escape and infection of
laboratory workers remained a concern of western security
agencies. To counter the risk of laboratory leak or infection, the U.S.
didn’t turn to security forces, satellites or spies. It used infectious
disease experts.

The idea to develop a “special forces” for foreign lab biosecurity


garnered bipartisan support in Congress. In 1991, Sens. Sam Nunn
(D-Ga.) and Richard Lugar (R-In.) co-sponsored a law to counter the
proliferation of chemical, biological, radioactive and nuclear
weapons of mass destruction, and over the years the Nunn-Lugar
programs expanded under an umbrella program called Cooperative
Threat Reduction, known simply as “CTR.”

Sens. Richard Lugar, right, and Sam Nunn, center, are pictured with Defense Secretary Leon Panetta,
left, at the Nunn-Lugar Cooperative Threat Reduction symposium in Washington in 2012. | AP
Photo/Charles Dharapak

The CTR mission had 3 basic parts: to prevent the proliferation of


biological weapons and the skills to produce them; to redirect
foreign pathogen research to improve global health; and to prevent
the escape of dangerous pathogens from foreign biocontainment
laboratories. Over the next 30 years, CTR expanded from the former
Soviet Union into politically unstable regions where dangerous
:
pathogens existed alongside groups capable of weaponizing them.
By 2003, U.S. biosecurity experts were deployed throughout the
Middle East and Africa. In 2004, following the Bali nightclub
bombing, concern that the terrorist group Jemaah Islamiyah might
turn pathogens obtained from local veterinary, hospital and vaccine
laboratories into crude biological weapons prompted the State
Department to expand CTR into Indonesia, Philippines, Malaysia and
Thailand.

The dispersed, field-based approach wasn’t just by necessity — it


was also strategic. These field scientists were infectious disease
doctors, veterinarians and microbiologists recruited from leading
U.S. hospitals and universities such as Johns Hopkins and Harvard,
as well as one of the U.S Navy’s oldest international infectious
disease labs in Jakarta, Indonesia. They built partnerships in each
country not just with governments, but with vaccine companies,
local physicians and public health officials, many of whom had
trained in the U.S. Part of the mission was to help each
biocontainment facility develop a business plan to support peaceful
jobs and produce valuable products. The goal was to ensure that
weapons scientists weren’t tempted to wander, and to keep
pathogens secure behind locks, fences and freezers.

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CTR scientists were routinely the first foreigners to access some of


the world’s most secretive biological laboratories — and to initiate
productive collaborations in countries of concern. For example, in
the former Soviet Union, State Department senior scientist Jason
Rao secured $30 million in emergency appropriations to launch his
novel capacity-building program, the BioIndustry Initiative. Over a
:
four-year period, the BII secured pathogen repositories across the
Ukraine and Russia, awarded grants for drug and vaccine
development, assisted former weapons laboratories to develop
commercially valuable services such as diagnostic tests and helped
fledgling drug companies address unmet medical needs.

When the CTR playbook expanded to Asia, Rao retooled the


program for the region in the form of the Biosecurity Engagement
Program. Where the program in the Soviet Union focused on
retraining weaponeers to peaceful professions, BEP worked to build
Asian capability to increase disease surveillance, to control disease
outbreaks — and to secure pathogen collections. Within 5 years, it
had dramatically improved outbreak surveillance, made bird flu
vaccines safer and helped to build one of world’s leading bat virus
research laboratories in Bangkok.

That program continued to pay off in 2020, as the new coronavirus


spread: Asia’s BEP-affiliated hospitals, universities and companies
include the first public health laboratory to isolate Covid-19 outside
of China. And they helped preserve communication links between
American and Chinese physicians after the Wuhan cases became an
embarrassment, and the risk of Chinese government censorship
made communication with U.S. doctors dangerous.

The basis of the whole CTR model was collaboration, and it was
built on doctor-to-doctor contacts. It paired Western scientific
partners directly with local scientists to help them develop new
diagnostic tests, or vaccines, or disease treatments. It prioritized
working with younger scientists willing to train in the U.S. and then
return to their home laboratories. It used American labs to confirm
:
the work being done overseas, and small grants from American
agencies to seed larger local investments.

This trust-building model proved extremely effective in dealing with


very sensitive, and potentially very dangerous, biological programs.
Examples of early collaborations include Ebola and HIV vaccine
projects at a former biological weapon laboratory in Siberia, and a
program to find new treatments for antibiotic-resistant bacteria at
Obolensk, a lab near Moscow where weapons scientists had
previously engineered anthrax to be antibiotic-resistant. These
programs could have clear payoffs in the host country: In 2003, the
same Obolensk team that made anthrax resistant to antibiotics in
the 1990s worked with CTR to open Russia’s first insulin production
facility. One partnership, the Russian Flu Surveillance program, was
a triple success: It gave the U.S. critical flu surveillance in a denied
area, reduced the probability of laboratory escape by centralizing
dangerous flu work, and offered a local payoff by giving animal
producers better diagnostic tests for veterinary diseases. (It was
also featured in a Discovery documentary, Flu Time Bomb.)

Transforming biocontainment facilities into public health labs, or


biotech companies, wasn’t always easy or smooth. U.S. scientists
traveling in Russia were harassed by the FSB, always received the
same hotel room and were required to receive Russian vaccines in
order to work in Russian laboratories. Laboratories had their own
dangers; a virus lab had already been suspected as the cause of one
pandemic: In 1977 a flu outbreak appeared in northern China and
swept the globe, killing more than 700,000 people, very likely
stemming from an escaped virus from the 1950s that had existed
only in laboratory freezers for two decades.
:
The author at the Ebola biocontainment facility in Novosibirsk, Russia, in May 2004. | C/O. Michael
Callahan

But payoffs have come both from partnerships and new on-the-
ground knowledge. One key finding from CTR work, over the years,
may be directly relevant to the Covid outbreak: In many cases,
infections attributed to biocontainment laboratory activities actually
occurred outside the lab, often during field collection of viral
samples. Squirming, clawed and toothy animals bite and scratch
during collection of body fluids. Teeth and talons easily penetrate
the thin gloves required to maintain dexterity when handling fragile
wildlife. And overhead, angry bats release a fine patina of virus-
laden urine aerosols. As part of CTR field surveillance programs, I
have collected viruses from Asian bats carrying coronaviruses, and
from birds infected with bird flu, and can attest that the margins for
personal protection during these expeditions are razor thin. The fact
that researchers are not infected every time they do a field
collection is a question that continues to stump us.

In cases like this, the actual point when infection occurred in the
field can go unnoticed. In two Asian cases, for instance, “lab-
acquired infections” among researchers were actually acquired
during field collection, but symptoms were delayed for 2 and 3 days,
after the researchers had returned to their home city and gone back
to work in the lab. And there are other human factors at work: In
China, if a researcher develops symptoms and suspects lab
infection, they are inclined to hide the mistake from their superiors.

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In the case of the Covid origins investigation, the timing of Wuhan


:
Institute of Virology field collection trips, which we know occurred
several times during 2019, need to be carefully tracked to pinpoint
opportunities for more intensive clinical investigation. As of now, we
simply don’t have enough information to know whether these might
have been connected to the pandemic outbreak — and China has
told its researchers not to share any data on field collection with
WHO. But this scenario suggests a new target for research into
Covid’s origins: Focus on hospital lab data from anyone who came in
contact with the Wuhan field virologists up to 4 weeks following
their return from field collections.

Given what we still need to learn about Covid-19, how might the
U.S. collaborate with China on health security?

The answer may not lie with China’s leaders, who are disinclined to
cooperate with the West for bigger reasons. Over the last decade,
China has fueled an aggressive expansion of its domestic
biotechnology research and its drug and vaccine manufacturing
capacity, and keeps data and practices secret for competitive
reasons. This secrecy also extends to biosecurity. I’ve been told
directly by a Chinese official: The Communist Party views
biosecurity — including oversight to prevent dual-use research,
where biotechnology could be used to make either life-saving
products or biological weapons — as detrimental to its aspirations to
dominate global biotechnology markets.

Beijing’s strategic priorities help explain why U.S. health security


programs do not exist in China. In fact, with the exception of a small
U.S. Centers for Disease Control and Prevention presence in Beijing,
there is no significant U.S. government health presence in China.
:
This does not mean, however, that there is no U.S. medical presence
to build on. For more than 100 years, the U.S. and Chinese medical
education communities have been closely linked, and their
connections remain strong to this day. Yale University, for instance,
has ties with China that reach back to 1835, when alumnus and
medical missionary Peter Parker opened the first western hospital in
present day Guangzhou. In 1917, the Rockefeller Foundation built
the world-famous Peking Union Medical College, which trained
numerous medical leaders in China and whose graduates have
helped modernize Chinese medicine. Massachusetts General
Hospital, where I work, has a relationship with PUMC that started in
the 1970s, after President Richard Nixon’s trip to China.

The results of a century of U.S. Chinese medical collaborations is


that members of the Chinese medical community, unlike the
Chinese government, have deep relationships with their U.S.
partners. And the relationships are now multigenerational and run in
both directions, with U.S.-born, Mandarin-speaking scientists
rotating through Chinese laboratories. These relationships prove
invaluable when the U.S. needs to learn about a new outbreak in
China. For example, U.S. physicians from St. Jude Children’s
Research Hospital and MGH were collaborating on influenza
research when H5N1 and SARS-1 outbreaks occurred in Hong Kong.
Colleagues at Prince of Wales Hospital and virologists at the
University of Hong Kong were first to share clinical and virologic
data on SARS with their U.S. colleagues. Later, during the deadly
2013-2014 H7N9 outbreak, it was Nanjing physicians that shared
disturbing data regarding the high fatality rates in Nanjing’s modern
intensive care units — and the futility of treatments proposed by me
and other U.S. colleagues. And in very early January 2020, the same
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Nanjing doctors, working with colleagues at Central Hospital of
Wuhan, would share the first evidence that the novel coronavirus
was spreading from person to person.

Medical workers in protective suits at a coronavirus detection lab in Wuhan in Feb. 2020. | Cheng
Min/Xinhua News Agency via AP

This news came as the Chinese government was vehemently


denying community transmission. The information was shared at
significant personal and professional risk to our Chinese colleagues:
In the early weeks of the pandemic, the Chinese government was
actively censoring medical data sharing between Boston and
Chinese clinicians, eventually stopping the flow of data from Wuhan
entirely.

Can this kind of collaboration move up the ladder from individual


doctors to Chinese authorities?

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To be successful, the international community must first incentivize


Beijing to fully participate in the origins investigation. And although
it is clear from China’s statements and behavior that such
participation holds no attraction to the Party right now, that’s not
the end of the story.

Discussion between U.S and Chinese drug and vaccine developers


and their colleagues at Chinese medical centers suggest some
possibilities. Major Chinese biotechnology companies, many with
deep connections to the Party, are interested in selling products in
Western markets. One option proposed to U.S. biotechnology
developers, in a meeting I attended for Chinese investors, was to
:
give provincial health authorities their own incentives to participate
in the origins investigation — rewarding them, for instance, with
access to medical technologies currently unavailable in China.
There’s reason to believe China has data that lies outside of Beijing’s
control — for instance, blood and serum samples from drug trials
analyzed and stored in labs across the country, which might yield
important clues about when and where the new pathogen appeared.
And past outbreaks give us some hope that provincial medical
leaders are willing to take modest risks in defiance of Beijing, though
Covid is a different situation with more scrutiny attached.

The U.S.’s superior capability in use of immune forensics tools might


be of value as well. The technologies could be shared with a
reputable clinical trials research organization or leading academic
medical center, where it would serve China’s future public health
priorities. This could be carefully crafted to address China’s own
interests: Strengthening public health through innovation has been
a major pillar of President Xi Jinping’s Five Year Plans since 2010.
Such an offer, designed in a way that allows China to save face,
would be very hard to refuse.

There are plenty of other points of leverage. Access to American


vaccine technology, especially Western mRNA vaccine technology,
would give China the chance to salvage its global vaccine diplomacy
efforts, currently floundering due to the poor protection provided by
China’s two major exported Covid-19 vaccines. And American
biocrime investigators could help track dangerous under-the-radar
and controversial gain-of-function biotechnology research in Asia —
which, perhaps surprisingly, is a growing concern to China as it
looks across Asia’s red-hot bioindustrial marketplace.
:
A third incentive to encourage Chinese participation is an offer to
help Chinese drug companies enter Western markets through the
use of uniform drug and vaccine test and evaluation capabilities.
China has realistic aspirations of unseating India as the leading
global manufacturer of low-cost generic drugs and vaccines. One
obstacle right now is concern about Chinese research and
development methods, ethical concerns about patient recruitment
into trials, dubious informed consent rules and reliance on smaller,
quickly executed clinical studies. There are also concerns about the
reliability of China’s large-scale drug and biologics manufacturing.
The U.S. could establish a Chinese-U.S. office to help guide Chinese
pharmaceutical companies seeking FDA and EMA approval to enter
western markets. The example has precedent: In now-dated
Russian CTR programs, former U.S. pharmaceutical executives,
former FDA evaluators and other industry experts helped Russian
startup companies meet regulatory milestones for testing drugs in
human trials. And a 2004 vaccine training program in Moscow by
scientists from Massachusetts General Hospital helped lead,
eventually, to Russia’s successful development of the Sputnik V
vaccine for Covid-19.

All of these approaches are built on the underlying insight of


America’s CTR efforts: that biosafety is built on collaboration,
positive incentives and strong scientific and public health alliances.
China is a far more sophisticated, and more resistant, government
than most of our previous collaborators, but that only argues for
more sophisticated forms of collaboration.

There are other approaches as well. One used by CTR to promote


transparency about laboratory risks was to share lessons learned
:
from U.S. accidents. As part of my work, I’ve traveled to several
high-risk countries giving biosecurity workshops on mistakes made
by American researchers — a way to leaven our teaching on
biosecurity practices with a dose of humility. The workshop’s
philosophy is driven by insights from Matthew Syed’s book Black
Box Thinking, which argues that organizations that investigate
failure in objective, unthreatening ways — as the aviation industry
has managed to do — can best avoid repeating mistakes. In the
presentation, we discuss common laboratory acquired infections
such as TB, brucellosis, coccidioidomycosis and influenza; with
researchers from higher containment labs, we include a tragic case
of Ebola that killed a Russian colleague, and an infection from a
bacteria engineered through gain-of-function research to be
resistant to all antibiotics that killed a Moscow graduate student,
both in 2004. As China continues work with dangerous pathogens,
its researchers will be more and more eager to hear how we assess
and prevent those kinds of risks, and how we care for highly
contagious patients with diseases novel to them such as Marburg,
Lassa and Ebola.

The U.S. edge in technology gives us some other carrots we can use
to bring to the table. For example, while China has far surpassed the
genomic sequencing capacity of the U.S. in raw processing power,
our systems remain better at predicting pathogen and tumor
evolution and identifying escaped mutants before they actually
occur. This is an extremely valuable field that is still in its infancy in
China. We are also on the edge of being able to design variant-proof
vaccines, while China is still chasing yesterday’s virus. Several U.S.
companies are now able to construct new antibodies against targets
purely on a computer. The actual manufacture of the antibody is a
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formality.

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Some of these technologies could prove very useful in the origins


investigation itself. For example, some of the most exciting new
forensic immune technologies are those that decipher the history of
individual and community immunity. In China, right now, human
blood and serum samples from 2019 are scattered widely across
both traditional and Western hospitals, as well as medical research
centers and biobank freezers. Academic medical colleagues in the
U.S. and other countries have suggested a number of strategies for
using American technology and Chinese clinical samples to rewind
the tape to find the earliest evidence of Covid infection. Since
Chinese law prevents the export of human samples containing
genetic information, the work could be performed in-country by a
U.S.-Chinese team. If we, or Chinese partners, were to find evidence
of a Covid-like infection in blood samples taken from a sick villager
near a bat cave in early 2019, but none in Wuhan urbanites until
December 2019, that would strongly support natural events as the
cause of Covid-19. This conclusion would be great for China.
Conversely, if the blood sample from villages around bat caves
remained unchanged over the years, but blood samples from Wuhan
citizens started showing evidence of an infection from a Wuhan
Institute of Virology virus, then that data would support the lab leak
scenario.

All these approaches offer a way to find common ground to work


with China, not just on the Covid investigation, but on the
investigations we’ll need to run after that. The alternative approach
is of course some kind of hardball — whatever that means. If the
:
U.S. did decide to cut off partnerships, or technology, or
connections to Western science, we need to worry seriously about
the aftereffects. Those who would be most impacted aren’t Party
officials in Beijing but rather the Chinese researchers who are first
to identify new and deadly viruses, our Chinese physician
colleagues who teach us how to care for victims of new diseases,
and the drug and vaccine developers who we need to manufacture
safe, low-cost vaccines to protect the rest of the world.

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