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.
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.
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.
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 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.
