The End of Zero-COVID in China: What’s Happening and What’s Coming Next

Shockingly low case counts, the Party’s Central Economic Work Conference concludes, thick smoke emanating from Beijing crematoriums, and a closed-door meeting of the National Health Commission…

Amid the endless stream of Tweets and headlines warning of a massive wave of COVID-19 deaths in China, there is no shortage of discussion about how serious the situation in the country might become. However, there has been some confusion, incomplete information, and countless questions circulating about what is known right now. We discussed the rollback of China’s Zero-COVID policies and growing problems like antiviral shortages in last week’s Pandora Report, so check there for more detailed discussion on those topics. This update aims to explain and clarify what is known about the current situation and analyze what might happen as a result of it, covering how China is counting cases and deaths, what vaccines are available in the country, critical threats the healthcare system is facing, and what this means in the current economic and political environment in the country.

The Basics

The current wave in China is being driven by BF.7, which is short for BA., a sub-lineage of the Omicron BA.5 variant (good luck remembering all that!). BF.7 is reported to transmit faster than other variants, have a shorter incubation period, and be better able to infect those who previously had COVID-19 or are vaccinated. Dr. Li Dongzeng, Chief Physician at Beijing YouAn Hospital’s Infectious Disease Department, reported late last month that BF.7 is thought to have an R0 between 10.0 and 18.6. For context, the original strain of SARS-CoV-2 had an R0 between 2.0 and 3.0 and it officially infected 68,150 people as it ripped through Wuhan in 2020, though estimates of the true case count are as much as three times that number. Given what we have discussed previously about China’s Zero-COVID policy, specifically its failed vaccine strategy, this is incredibly dangerous with many models predicting around one million COVID-19 deaths in China in the coming months. Furthermore, with the rollback of Zero-COVID restrictions, a massive, immunologically vulnerable population is likely to be quickly infected, causing national and global economic problems. This policy pivot is also likely to further complicate business for the Chinese Communist Party (CCP) as its credibility is challenged by this spread and as the likely economic and human costs it will bring come to fruition.

What’s Up with China’s Case and Death Counts?

The incredibly low case and death counts China is reporting currently have left many highly skeptical of the government’s truthfulness. For example, there were officially five COVID-19 deaths on Tuesday, December 20, and just two the day before-and zero in the two weeks prior. The government also reported shockingly low numbers of new cases throughout this week. Meanwhile, the World Health Organization reported that China has 26,878 new cases and 78 new deaths, causing some confusion online and in media reporting. So, what gives?

First-What Counts as China in These Numbers?

Regarding the WHO numbers, it is important to remember that they include Taiwan’s counts in the totals for China. While the WHO’s interactions with and stance on Taiwan made global headlines in early 2020, little has been done to address this issue. Taiwan, officially the Republic of China (ROC), initially represented China in the United Nations and its umbrella organizations. This was because China was one of the original UN member states during the organization’s creation in 1945. This predated the Chinese Communist Party’s defeat of the Kuomintang-led government of the ROC, which led to the establishment of the People’s Republic of China (PRC) and the exiling of the ROC to the island of Taiwan in 1949. The ROC (still under the leadership of Chiang Kai-shek) continued to represent China in the UN until the passage of United Nations General Assembly Resolution 2758, or the Resolution on Admitting Peking, in 1971. This resolution recognized the PRC as “the only legitimate representative of China to the United Nations,” giving the PRC its permanent seat on the UN Security Council and expelling “representatives of Chiang Kai-shek from the place which they unlawfully occupy at the United Nations and in all the organizations related to it.”

Though Taiwan has functioned as a self-ruled democracy since 1949, the PRC insists that Taiwan is a renegade province that will eventually be reunified to the rest of the country. As a result, Taiwan lacks proper representation in organizations ranging from those in the UN System to the International Olympic Committee (where it is listed as Chinese Taipei). While this might normally seem like a purely political issue between the countries, it has important implications, particularly in the context of global health. Taiwan is an excellent international player in pandemic response, as demonstrated in its work to support other countries during the COVID-19 pandemic. The WHO has been largely unresponsive, however, which many critics argue is because the PRC forces its view of Taiwan as a province of the PRC on international organizations, irrespective of the potential harm this carries in matters like international development and global health. Earlier this year, there was a movement to allow Taiwan to attend the WHO’s World Health Assembly as an observer, which had support from 13 member states, including the United States. However, this bid was rejected.

Important to also consider is that the WHO counts Hong Kong and Macao in its counts for China, whereas some data sources differentiate between them and the mainland. Hong Kong and Macao are special administrative regions (SARs) of the PRC with their executive, legislative, and judicial powers devolved from the national PRC government. These SARs are the subject of the “one country, two systems” policy in China which came about as Hong Kong and Macao were transferred to the PRC from the United Kingdom and Portugal respectively in the late 1990s. Under this policy, the SARs would continue to have their own governments and maintain functions like overseeing their own legal financial affairs, including foreign trade. This has allowed them to hold onto their distinct cultures and functions with, for example, both SARs maintaining their own currencies separate from the PRC’s renminbi. In recent years, China has aimed to reduce the independence of the SARs, taking aim at Macao’s famous casinos this year and implementing the Hong Kong National Security Law in 2022, which sharply reduced Hong Kong’s autonomy. Importantly, despite these changes, the SARs have separate healthcare systems and have implemented different policies to control COVID-19 than the mainland. As we will discuss later, this has made the SARs an attractive location for mainlanders to seek care and vaccinations. However, the point here is that it is important to take Taiwan and the SARs into consideration when looking at COVID-19 cases and deaths in China.

What Does the PRC Consider a COVID-19 Death?

Irrespective of all this, the low number of total deaths in mainland China is still suspicious given the sudden policy reversals and sub-pay vaccines in the country. This is made worse by reports of funeral homes and crematoriums in the country being overrun by COVID-19 victims. For starters, the Chinese government is very strict in how it identifies a cause of death, which was a point of confusion even before this pandemic in comparing things like influenza mortality rates in the United States and China. However, it is even more important right now. China is only counting deaths from pneumonia or respiratory failure in its official COVID-19 deaths. This does not include deaths of COVID-19 patients who had pre-existing conditions, and proof like evidence of lung damage caused by SARS-CoV-2 is required for confirming COVID-19 deaths. This goes against the WHO’s guidelines and helps explain the shocking discrepancies between China and other countries’ COVID-19 death counts. During the outbreak in Shanghai earlier this year, many also claimed that their elderly family members who tested positive for COVID-19 and then later died were not included in the city’s official COVID-19 death count if they had underlying diseases, for example. Essentially this means that, even without overtly concealing numbers, China will always have a lower mortality rate than countries that count deaths where COVID-19 was a factor as COVID-19 deaths.

What About the Case Counts?

Okay, so it isn’t a COVID-19 death if a person has any kind of underlying condition or did not clearly die of pneumonia or respiratory distress after testing positive for COVID-19–but why are China’s case counts still so low? In the last two weeks, China has abandoned its mass testing strategy completely and even gone so far as to stop counting asymptomatic COVID-19 cases. It has also slashed central quarantine requirements, further reducing opportunities to accurately count cases. In May this year, as hundreds of millions were forced into lockdowns, the government ordered all cities with more than 10 million people to implement routine testing requirements and to ensure that testing facilities were available within a fifteen-minute walk from anywhere in the city. Places like malls, grocery stores, and restaurants required people to show a negative PCR test from less than 48 or 72 hours ago in order to enter, meaning that people were constantly testing even if their city, neighborhood, or building were not locked down.

Large scale mandatory testing was also mandated when cities entered lockdowns after cases were detected. For example, when Shanghai shutdown in March this year, the city tested all 26 million residents as it kept them all at home or in public quarantine centers if they were positive. The disease spread widely again this fall, prompting lockdowns across the country in an effort to control outbreaks ahead of the National Congress of the Chinese Communist Party, further demonstrating that the Party’s Zero-COVID strategy was not working well even with mass testing requirements.

In mid-November, as cases soared in Guangzhou and Chongqing and discontent rose across the country, the National Health Commission announced its 20 rules for optimizing Zero-COVID, which included relaxation of quarantine measures. This coincided with cities like Shijiazhuang, Yanji, and Hefei announcing they would end their mass testing programs. Later, cities like Beijing and Shenzhen relaxed their requirements for negative tests to use public transportation on December 3, which came before the total abandonment of mass testing just days later following the State Council’s announcement of its ten-point plan on December 7. Xinhua News, an official state media outlet, reported on December 7 that the new rules indicate that, “Apart from nursing homes, medical institutions, primary and secondary schools, kindergartens and other special places, people will no longer be required to provide negative nucleic acid test results and undergo health code checks to access public venues or travel to other regions.”

Furthermore, the ten-point plan’s changes in quarantine policies and determination of high/low risk areas are impacting overall case counts. While the previous 20 rules from November cut down central quarantine facility requirements, ended many mass testing requirements, and changed testing and arrival procedures for international flights, the new ten-point plan totally cut central quarantine requirements for mild and asymptomatic cases. It also changed requirements for close contacts to just five days of home quarantine as well, in lieu of being taken to a central facility. While these new requirements are helpful in that people should not be yanked away for an unknown amount of time because they are considered a close contact, these new changes also mean it is not really possible to have a reasonable understanding of the full extent of COVID-19’s spread in the country. While other countries have dealt with similar issues as at-home testing became more common, this is a much more complicated problem as China faces a winter of overwhelming case counts.

However, as we discussed on Sunday, provinces are introducing rollbacks at different paces. Now we are also seeing cities reintroducing stricter measures on their own, with Shanghai ordering schools and childcare facilities to close this Monday as cases climb. This has created a confusing patchwork of different policies and requirements, further adding to the chaos unfolding as China exits Zero-COVID. As we mentioned last time, CSIS has a helpful map tracking where provinces are at in terms of rolling back restrictions, though it is still hard to keep track of how individual cities are responding as the situation progresses.

Finally, in perhaps the most shocking change, many in China are being encouraged to go to work still even if they are positive for COVID-19. Earlier this month, with some hospitals reporting as many as 80% of their staff were infected, healthcare workers were encouraged or required to still come into work in order to keep up with demand. Now several local governments in China have asked workers to continue going to work even if they are sick in what many view as a warning of the coming economic problems that will be discussed later in this post. These complete 180° changes are simultaneously removing virtually all precautions while also overtly encouraging further infections by encouraging or requiring those who are sick to continue going around others.

Announcement of Chengdu’s new “2+3” requirements for people arriving to the city. In this scheme, arrivals will take one nucleic acid test on arrival and one on their first day at a quarantine hotel. They will spend just two days in quarantine before staying home for three days afterwards, in contrast to the 7+3 and 5+3 arrangement previously in place. For context, Chengdu, the capital of Sichuan province, locked down entirely for four days just in September to test its 21.2 million residents after 157 cases were detected.

A Glimpse Into What’s Actually Happening?

Despite the impossibly low official counts presenting by the government, a closed-door meeting of the National Health Commission reportedly offered a much better look into how many are currently infected. Reports claim that Sun Yang, Director of the Chinese Center for Disease Control and Prevention, informed the commission that at an estimated 37 million people, or about 2.6% of the population, are thought to be recently infected. Estimates from this meeting also indicate that about 248 million Chinese were infected between December 1 and 20, making the cumulative infection rate about 17.56%. The provinces with the high single-day new infection rates are Sichuan, Anhui, Hubei, Shanghai, and Hunan. Perhaps most shockingly, both Sichuan and Beijing are thought to have infection rates over 50%. Finally, infections have spread more rapidly in the Jingjinji Metropolitan Region (the megalopolis of Beijing-Tianjin-Hebei), the Chengdu-Chongqing region, Hubei and Central China. In contrast, the Yangtze River Delta (another megalopolis incorporating Shanghai, China’s most populous city), the Pearl River Delta (yet another megalopolis in the Guangdong–Hong Kong–Macau Greater Bay Area), and the Northwest and Northeast regions of the country are less impacted thus far.

Post from popular Twitter account sharing Chinese social media posts and trends, Teacher Li is Not Your Teacher, featuring posts by netizens discussing the National Health Commission Meeting.

Though these reports indicate health officials believe Beijing is past the peak of this phase, this is still very clearly just the beginning of this disaster. Shanghai has already ordered schools to shutdown in anticipation of growing case counts, in contrast to Beijing (which rolled back essentially all of its COVID-19 policies) and Chengdu, the capital of Sichuan province and the producer of the 2+3 quarantine poster above. As we will discuss further down in this post, this situation is likely to get far worse as the disease continues to spread in other major metropolitan centers and, eventually, across rural regions of the country, especially with the country’s subpar vaccines and the approaching holiday travel season.

Don’t Shoot the Messenger(RNA): China’s COVID-19 Vaccine Problem

Earlier in the pandemic, China claimed that it was nearing production of a domestically-produced mRNA vaccine for COVID-19 (even going so far as to announce the construction of a facility to manufacture ARCoVax/AWcorna in late 2020) and that it would approve the mRNA vaccine from Pfizer/BioNTech. Today, AWcorna only has emergency use approval in Indonesia, and the only people who have access to the Pfizer/BioNTech shot in China are German expats. China’s vaccination campaign has instead depended on two domestically-produced inactivated offerings-Sinopharm BIBP and CoronaVac. The country did recently approve and rollout CanSino Biologics’ aerosol offering, Convidecia Air, a viral vector vaccine growing in popularity as more Chinese seek out booster doses.

In mid-2021, the WHO approved the initial two offerings for emergency use based on limited clinical-trial data indicating that CoronaVac was about 51% effective while Sinopharm was about 79% effective. This was alright relative to the 63% efficacy reported for AstraZeneca’s viral-vector vaccine, but it was not as effective as the 90%+ reported for the Pfize-BioNTech and Moderna mRNA offerings. Nature News explained the initial criticism of China’s vaccines, writing “Both the Chinese vaccines are inactivated vaccines, which use killed SARS-CoV-2 virus. Researchers say this type of vaccine seems to be less potent because it triggers an immune response against many viral proteins. By contrast, mRNA and viral-vector vaccines target the response to the spike protein, which is what the virus uses to enter human cells.”

These numbers sound okay, especially with a high number of fully-vaccinated individuals in the country, but these efficacy rates were for the original strain found in Wuhan in 2020 and it has been several months since most people received their last dose of vaccine. 90.3% of the population has received the entire initial protocol, but, as of December 20, just 60.5% of the population has received a booster dose. Worse, those numbers shrink to 65.8% and 40% respectively for those over the age of 80 as of November. During Hong Kong’s outbreak earlier this year, similar hesitancy in elderly people (just 20% were vaccinated at the start of the outbreak in February) contributed to widespread death in the city’s nursing facilities. China announced in late December it would push to vaccinate those over the age of 60, though this is likely too little too late now, particularly given Chinese vaccines’ even more limited efficacy against Omicron and its sub-variants.

Finally, as was hinted previously, Macao and Hong Kong have become popular destinations for mainlanders throughout the pandemic, in large part because Pfizer/BioNTech’s mRNA offering is available in the special administrative regions. The SARs have also largely sold out of cold and flu medications and painkillers after the rollback of Zero-COVID on the mainland as people rush to find these supplies where they could.

Why Isn’t There a Vaccine Mandate?

This issue naturally leads to questions of why the government hasn’t just mandated vaccines already, even if the ones they can offer are not as effective as the mRNA offerings in the West. A vaccine mandate intuitively makes sense at first look, especially as much of the discourse about China’s handling of COVID-19 in the early days of the pandemic centered on the potential benefits of authoritarian rule in pandemic response. However, if it isn’t clear yet, China is playing a unique game and even its brand of authoritarianism is not always black-and-white.

There were attempts to create a mandate, with the Beijing Municipal Health Commission announcing one this summer, for example. Dr. Yangzhong Huang at the Council on Foreign Relations explained the announcement in June, writing “On July 7, Li Ang, the deputy head of Beijing Municipal Health Commission (BMHC) announced that beginning on July 11, those who had not received COVID-19 vaccines would be denied access to public venues including libraries, museums, and cinemas. The mandate also stated that those elderly who live in military and civilian retirement and nursing homes, as well as their visitors, be fully vaccinated.”

Chinese social media was lit up with backlash over the mandate and concerns that citizens’ informed consent was being compromised. Others directly asked the municipal government to reverse the policy, which ultimately did happen the very next day on July 8. Many around the world touted this as a victory for the people, but this is bizarre event points to the difficulty in understanding China’s health policies and to a complicated vaccine hesitancy more than a purely anti-vaccine sentiment. As Huang points out, this reversal came in a city where 98% of the residents were fully vaccinated. Furthermore, that explanation does not explain why the government reversed its policy on vaccines but not on other also unpopular measures like central quarantining. This reversal was also in response to social media posts over the course of a day so, while local governments in China do make similar policy reversals in the face of opposition movements, this usually takes much more time and is the result of backlash that is much more serious in nature. While Huang’s piece focuses on fragmented authoritarianism in the CCP and friction between leaders who supported Zero-COVID and mass vaccination, it also offers very important context for understanding vaccine hesitancy in China.

While there are younger people in China who have openly avoided getting vaccinated for COVID-19, this problem is concentrated in the elderly population. Again using the example of Hong Kong this year, 20% were vaccinated at the start of the outbreak in February, in sharp contrast to the more than 60% in that same group who were vaccinated for seasonal influenza. For reasons discussed earlier in this post, it makes sense for Hong Kong’s elderly to be hesitant to take a vaccine offered by the PRC’s government. However, these low rates were true despite the Pfizer/BioNTech mRNA vaccine being available.

While some point to the initial focus on essential workers as a likely reason why vaccination rates lag in China’s elderly population, a history of scandal is likely in large part to blame. For example, in 2018, Changchun Changsheng Life Sciences was fined ¥ 9.11 billion (about $1.32 billion at the time) after an investigation by the National Medical Products Administration found the company in violation of eight drug regulations. This kind of punishment was at the very least rare and came after some had severe reactions to the company’s rabies vaccine. The incident led many netizens to express their distrust in the country’s pharmaceutical industry, prompting calls from the likes of Xi Jinping and Li Keqiang for severe punishment for the company. However, the effects of this and similar events seem to have stuck around.

John Ruwitch discussed this issue recently in a piece for NPR, writing “It wasn’t always like this, according to Mary Brazelton, an expert in the history of science and medicine in China at the University of Cambridge.​ In the months after the Communist takeover in 1949, the Chinese government launched several successful vaccination campaigns, taking on smallpox, tuberculosis, diphtheria and other diseases.”

He continues, “If you look at earlier periods in the People’s Republic of China’s history…what you see is in some ways almost the opposite in terms of really strong vaccination programs that work quite hard to convince people, particularly elderly people, to receive vaccines against infectious diseases,” Brazelton says. But lax oversight and corruption during recent decades of breakneck economic growth has led to a string of product quality scandals in China — from baby formula cut with industrial chemicals to contaminated blood thinner and tainted vaccines.​”

Now, as the government rushes to try and vaccinate more people, they seem to be pulling out every stop short of using foreign mRNA vaccines, seemingly sticking to the most flawed gun in the safe. Furthermore, this points to a complicated and sensitive situation for Chinese citizens as they try to balance the realities of heavily censored channels of communication, poor signaling and a history of mismanagement from the government, and a desire to protect themselves as best as possible. This situation, unfortunately, is likely to get much worse in the coming weeks as the healthcare system is overwhelmed.

Growing Danger for China’s Broken Healthcare System

Much of the world watched in horror in February 2020 as time lapse footage of Wuhan’s nearly overnight construction of two temporary hospitals to manage COVID-19 cases as the city’s normal hospitals became overburdened dominated news coverage. This wasn’t unique in the government’s epidemic playbook, as it had similarly erected the Xiaotangshan Hospital in Beijing amid the outbreak of SARS in 2003. However, it highlights an important flaw in the playbook. This kind of construction doesn’t really do much in the absence of an appropriately sized and prepared healthcare workforce. China faced a shortage of physicians and nurses well before the pandemic, a fact made much worse once case counts soared in 2020. Furthermore, as diseases spread across the country, Chinese rural citizens are typically left much less protected than their urban counterparts. These are central issues to the looming COVID-19 crisis unfurling in the country today.

The PRC has undergone significant healthcare reforms in the last decade or so, in large part through the Healthy China 2020 initiative, which sought to cut healthcare costs by increasing the percentage of care covered by insurance. Furthermore, as of 2020, about 95% of the population has at least some form of health insurance, though it typically covers only about half of medical costs. Coverage is split between employee medical insurance for employed urban residents, and resident medical insurance for unemployed urban and rural residents. About 75% of those insured in the country are insured by the resident medical insurance program, pointing to the sheer portion of the population that is either rural and unemployed.

This is an especially concerning fact as the healthcare system is overly reliant on urban hospitals for basic healthcare. The United States-China Economic and Security Review Commission (USCC) notes that hospitals account for 3.5% of medical institutions in China despite handling 45% of all outpatient visits. So, while the Party views quality healthcare delivery as an important part of its political agenda and there have been improvements in coverage and care, there are still serious issues in providing quality care nationally. As is often the case, corruption is a large part of this problem. As the USCC explains:

“Corruption among China’s hospitals and doctors is a widely acknowledged problem that has contributed to a low level of public trust in the country’s healthcare system and at times led to violence against Chinese doctors. In many cases, doctors accept illicit payments, known as hongbao, from patients in exchange for a higher quality of care. The practice of hongbao is widespread in China: in a 2013 survey of residents of Beijing, Shanghai, and Guangzhou, nearly one-third of respondents said they or a family member had given hongbao to physicians between 2000 and 2012. In addition to accepting these payments from patients, doctors and hospital officials also receive kickbacks for purchasing certain types of medical equipment or pharmaceutical products, a practice that has been described as “endemic” in China. In a 2010 survey of Chinese doctors, 78 percent of respondents said healthcare companies could not compete in China without paying bribes.”

This seems to bleed into patient distrust of medical clinics, interestingly, contributing to the over-reliance on hospitals to treat minor conditions. Beyond simple perceived incompetence of clinic physicians, there is a cycle of patient-physician mistrust at this level, as Nie at al. have discussed in Developing World Bioethics. They write, “Mistrust (particularly physicians’ distrust of patients and their relatives) leads to increased levels of fear and self-protection by doctors which exacerbate difficulties in communication; in turn, this increases physician workloads, adding to a strong sense of injustice and victimization. These factors produce poorer healthcare outcomes and increasingly discontented and angry patients, escalate conflicts and disputes, and result in negative media coverage, all these ultimately contributing to even greater levels of mistrust.”

This is worse at small clinics, with providers enduring verbal and physical abuse at the hands of patients’ loved ones. There is even a recently coined term, zhiye yilao that describes a “medical mob”, or “people who support families and their relatives in demanding financial compensation from hospitals following medical disputes, as Nie et al. highlight. While many of China’s elites can afford to simply seek care at a private hospital, this is not the case for the majority of Chinese who rely on public hospitals and clinics for their care, particularly those who live in rural areas.

Rural citizens typically either use small clinics or travel to wait in lines in an attempt to get into a hospital, further burdening the system. These rural clinics are often understaffed and poorly equipped, and the national health insurance scheme creates incentives to hospitalize people with relatively minor problems, which is especially problematic for these rural populations. Socioeconomic determinants associated with rural living and resources also contribute to the stark difference in health outcomes between China’s urban and rural populations. Rural residents also are at higher risk of developing many chronic conditions like heart disease, putting them at increased risk during outbreaks of infectious diseases like COVID-19.

As cases climb in urban centers, there are distressing signs that the much better-equipped urban hospitals are becoming overrun. As we discussed, many hospitals are requiring sick staff to still come into work as individual patient loads continue to swell. We and others have also stressed, too, that China does not have the kind of ICU capacity needed to deal with what it faces. This is true in urban centers, but even more so in rural areas, where there are also 30% fewer healthcare workers available. Furthermore, retired physicians and other professionals across the country are currently being called upon to help support efforts to combat the current surge in Beijing. All these signs point to major trouble in urban centers, indicating it is likely to be much worse for rural regions of the country.

As the Spring Festival travel rush, chunyun, approaches, many will travel from urban centers to their rural hometowns, likely spreading COVID-19 to these vulnerable areas. While many are currently opting to stay home on their own and a number of universities have given students the option to finish the semester virtually to cut down on travel, these factors might not be enough to protect these places from becoming overwhelmed in the coming weeks. As a result, the Party has urged local governments to upgrade their facilities and prepare for the oncoming waves. South China Morning Post reports that, “In a directive on Sunday, the Joint Prevention and Control Mechanism of the State Council asked rural hospitals and clinics to ensure pandemic medical services and timely treatment for high-risk patients, such as the elderly and people with underlying diseases.”

The directive reads in part, “Rural areas should…improve the ability of county-level hospitals to treat severe cases, and give full play to the role of health monitoring in township hospitals and village clinics to minimise the severity rate and mortality rate.” However, there is clearly no overnight fix for the kinds of deficiencies rural healthcare facilities struggle with. Despite this, Ma Xiaowei, Director of the National Health Commission, demanded on Wednesday that hospitals address swamped emergency rooms and get patients admitted to different departments. Ma also requested that medium and large hospitals accept more severe cases while promising that regulators will not hold them accountable for increasing fatality rates, according to the Financial Times.

Imploring under-equipped rural healthcare institutions and swamped urbans ones to suddenly improve their ability to treat an onslaught of severe cases is almost an unimaginable request, even for the State Council, as the country had over two years to get ready for its Zero-COVID exit. This complete failure of policymaking and pandemic management will almost certainly cost an unimaginable number of lives, irreversibly harm many people who do survive, further damage China’s and the global economy, and leave many demanding to know why the government did not prepare for this during the years the country spent shutdown.

What Does All This Mean Long-Term?

Just a couple weeks ago, testing positive for COVID-19, even if symptoms were mild or non-existent, was an express ticket to a government quarantine center for however long it took until the government decided one could leave. Shanghai shutdown for all of April and May just months ago, wreaking havoc on the local and national economy and causing global supply chain disruptions. The Party spent the last couple years pushing the message that this “devil” virus was so incredibly dangerous that it was worth it to continue these lockdowns and economic hardships. Today, however, the government insists COVID-19 is basically a cold, that nothing much will come of being infected, and that everything from herbal supplements to canned peaches are good remedies for it. This complete turnaround has many anxiously waiting for the economic consequences and wondering what this means for Xi Jinping and the Party in the long-run.

It’s the Economy, Shagua!

The CCP and State Council recently wrapped up the annual Central Economic Work Conference (CEWC), a meeting that sets the Party’s national economic agenda and directives for the financial and banking sector for the next year. At the meeting, Xi Jinping, who has been remarkably quiet since the end of Zero-COVID, gave a speech in which he indicated that China’s economy is expected to recover and improve in 2023, a tall order given the situation. A number of other critical points were made in an attempt to address the intense downward pressure the national economy is under, explicitly recognizing that the domestic economy has weak prospects coupled with unstable supply chains and shrinking demand.

Another critical point of the CEWC was that, “The meeting urged efforts to deepen the reform of state-owned enterprises (SOEs) while improving their core competitiveness, requiring that legal and institutional arrangements must be made to ensure the equal treatment of private enterprises and SOEs.” While China’s 2001 accession into the World trade Organization was contingent on achieving predominantly “market economy conditions,” the Chinese economy never truly transformed into a market-based one. Rather, despite some reforms in the 1990s and early 2000s, the government has maintained large SOEs in strategic and financial sectors while also maintaining policies that strongly favor these companies. Nicholas Borst explained the logic behind this succinctly for the Lowy Institute, writing “Rather than allowing the private sector more space, Beijing wants a tool for the implementation of government policy.”

In 2021, China had over 150,000 SOEs, with most of its Fortune Global 500 companies under state control. In 2019, SOEs accounted for more than 60% of the PRC’s market capitalization while accounting for 40% of its national GDP. For context, in 2019, Chinese SOEs made up more than 4.5% of the global economy–and now they are going to be treated equally with private businesses in China. This marks an important change as the Party also looks to increase demand by ensuring higher quality supply, and get a better hold on the deleveraging of the country’s real estate industry, stating that bail outs will come only if companies have well-founded plans for recovery. Just last month, amid further reduced apartment sales, the cabinet urged banks (again, most of which are SOEs) to increase loans for completion of unfinished apartments, with the central People’s Bank of China going so far as to reduce “by $70 billion the money that the country’s commercial banks are together required to hold for emergencies, freeing them to lend that money instead.”

Is This China’s Lehman Moment?

The current real estate crisis in China offers a particularly concerning look into just how damaging the sudden removal of Zero-COVID policies in the country could be both domestically and internationally. In recent years, it has been clear China’s real estate market was heading for trouble, with many people paying mortgages on apartments that are not even finished contrasting with the estimated 65 million units (1/5 of the homes available in the country) sitting completely open in China’s ghost cities. In late September last year, China Evergrande Group, China’s second largest property group, was forced to begin payments on its hundreds of billions of dollars in debt amid new regulations on developers’ debt limits. This started the current real estate sector crisis as when it caused several stock market indices to drop on September 20, 2021.

In the last year, it seemed that the Party was concerned the crisis would worsen in the absence of Zero-COVID restrictions. As Keith Bradsher explains in the New York Times, “Real estate development plays an outsize role in China’s economy, representing about a quarter of economic output and a quarter of its bank loans. Housing represents at least three-fifths of household assets in China, and many Chinese regard apartments as the only reliable way to build wealth.” This seemed to leave the Party locked into the restrictions in an effort to protect such an important but struggling part of its economy. Today, however, Zero-COVID is dead and the Party has indicated it wants less borrowing overall and that companies will only be bailed out if they present “well-founded” plans.

In the last year, the government has spent heavily on new railways and other infrastructure investments to try and help the economy amid low confidence, but that was with consistent COVID-19 policies in place. Furthermore, there have been concerns that injecting too much credit too quickly would be counterproductive to the goals of getting companies to borrow less and strengthen their balance sheets. In the real estate sector, the country has to somehow balance achieving sustainable growth and lowering prices, but that is not going to happen if sales keep falling. For example, in Shanghai this year, luxury apartment prices fell as much as 40% after the Party Congress because of concerns about the economic and political direction the country will take in Xi Jinping’s third term.

The CCP is Anything but a Party Right Now

Today, it is hard to fault those in Shanghai for selling off their multi-million dollar properties while they could. Models range in their estimated COVID-19 deaths in China in the absence of Zero-COVID, with some predicting under one million and some going over two million. This high of a number of deaths so suddenly, particularly as a result of the sudden end of virtually all precautions after years of constant testing and lockdowns, will be politically difficult to manage.

This also does not touch on how many Chinese will likely suffer from Long COVID and other long-term conditions if they do recover from COVID-19, something many other countries have had to learn the hard way. In the US, it is estimated that Long COVID costs the economy $3.7 trillion. While the US certainly has struggled with its COVID-19 response, it at least has effective vaccines. In September, Chinese state media was full of pieces talking about the “West’s hidden pandemic” of Long COVID and, now, it is nearly impossible to find any PRC official discussing this condition. The narrative has done a complete 180° on all fronts.

The threat of suddenly losing one million people completely and leaving an untold number burdened with long-lasting symptoms should be enough to make anyone reconsider their policy decisions. However, this is difficult for someone like Xi Jinping who has spent years building an image of infallibility while also championing Zero-COVID the last two years. He has often relied on rhetoric describing pandemic response as a war and continuously touted China’s unique approach as a better alternative to the “chaos of the West.” It is hard to believe what is happening in Xi’s China today is anything but complete chaos, and no amount of internet censorship and state media pieces about the supposed correctness of this new approach can keep the population totally unaware of that fact.

It still is not clear why Xi Jinping suddenly reversed course on Zero-COVID, even in the face of protests against the largely unpopular policy. Furthermore, as Xi begins his historic third term, he does so coming off a year of remarkable failure. As James Palmer recently pointed out in Foreign Policy, the once seemingly boring, safe choice in Chinese politics has proven to be anything but in the years since he took power, eliminated competition, and doubled down on state control over every facet of life in his country. Now, with mass death and further economic turmoil on the horizon, what will happen next for Xi Jinping and the CCP?

Event Summary: Building Capacities for Addressing Future Biological Threats

Defining Convergence

By Geoffrey Mattoon, Biodefense MS Student

On Tuesday, 20 September, the Council on Strategic Risks (CSR) hosted the “Building Capacities for Addressing Future Biological Threats” webinar, which included keynote speaker Dr. David Christian (Chris) Hassell, Deputy Assistant Secretary for Preparedness and Response at ASPR, speakers Dr. Pardis Sabeti, Professor at the Center for Systems Biology at Harvard University, and Dr. Akhila Kosaraju, CEO and President of Phare Bio, and was moderated by Dr. Yong-Bee Lim, Deputy Director of the Janne E. Nolan Center on Strategic Weapons and George Mason Biodefense Program alumni. Together they discussed the evolving biological threats landscape and the means that exist to improve preparedness and response. This event follows the previous webinar “The American Pandemic Preparedness Plan: One Year of Progress & The Path Forward,” also hosted by CSR on 8 September, and focused heavily on the need for greater cooperation, collaboration, and innovation to prepare for the next pandemic.

             Dr. Hassell began the event by highlighting the misconceptions associated with the terms “convergence” and “bioconvergence” within the field. His concern was that these terms have become buzzwords within biodefense and their use implies that the different fields and disciplines necessary for biodefense are converging or cooperating organically. Such a misconception leads those within and outside of the field to assume that unity of effort is common and effortless, which is not the case. Barriers to convergence are prevalent and numerous, both in government and private sectors. Dr. Hassell provided an example from his previous experience in the Department of Defense developing chemical detectors, comparing a lack of higher-level convergence to the lack of standardized interfaces on different detectors preventing operators from gaining competency on all systems after mastering any single system. Such stove-piping of systems and efforts prevents convergence and is common across biodefense. The solution is a greater degree of crosstalk between disciplines working towards a unified solution or goal. Providing another example of this failure of convergence, Dr. Hassell highlighted the recent Pentagon appropriations for biodefense failing to account for the need for cyber funding to be successful against future threats as that discipline becomes more critical.

            Dr. Hassell also indicated that biological threats, in addition to the biodefense, are converging. As biotechnology and other life sciences continue to advance, the line between chemical and biological threats blurs. Previous research has demonstrated this growing convergence, from opioid-producing yeast conducted by Galanie et al. published in Nature to chemical synthesis of toxins conducted by Matinkhoo et al. in the Journal of the American Chemical Society. He urges a greater convergence of chemical and biodefense disciplines to effectively overcome these threats in the future. Such efforts would come at a substantial cost and require the reorganization of numerous government agencies, but it may be necessary to respond to the evolving threat landscape and enable more efficient use of future funding to unify efforts.

            Dr. Hassell then commented on the need for greater inclusion of data sciences, data technologies, and nanotechnologies in future biodefense efforts. The necessity of greater convergence between chemical and biodefense and the inclusion of these disciplines is a key requirement identified in Biodefense in the Age of Synthetic Biology, a report prepared by the National Academies for the Department of Defense in 2018. The addition of these technology-based disciplines is indicative of a greater requirement for technology convergence in chemical and biodefense efforts to combat the rising technology integration in the threat landscape. Modern biotechnology has created significant risk of dual use to create ever greater biological threats. Dr. Hassell pointed to the recent “Dual Use of Artificial-Intelligence-Powered Drug Discovery,” published by Urbina et al. in Nature Machine Learning, that indicated how easy it may be for a machine learning system designed with the best of intentions to identify new therapeutic disease inhibitors to be reprogrammed to instead identify novel toxin molecules. In that report, the MegaSyn system was able to generate 40,000 novel VX molecules in less than 6 hours. Dr. Sonia Ben Ouagrham-Gormley, Associate Professor at George Mason University and author of Barriers to Bioweapons, indicated such results do not directly equate to actionable threats on the Radiolab episode 40,000 Recipes for Murder that covered this journal article, but they still are indicative of the evolving chemical and biological threat landscape. Dr. Hassell also indicated the convergence of other disciplines critical to future biological threats, including climate change, which is enabling greater zoonotic spillover events, generating new and often novel biological threats.

            Dr. Pardis Sabeti underscored deadly infectious diseases as an existential threat to humanity during her remarks. She agreed with Dr. Hassell’s call for greater convergence and stated we must aspire to use technology to outpace the evolution of diseases so that we can be more anticipatory and less reactionary in the face of future outbreaks. She emphasized that COVID-19, though a recent a traumatic pandemic, is not the biggest threat we have faced or could face in the future. She argued we are on the precipice of cataclysm if we do not relentlessly pursue these efforts of convergence to enhance biodefense. Infectious disease is an existential threat that we can address because the tools necessary for biodefense are not bespoke or esoteric. Effective current and future biodefense tools, she argued, must be broad spectrum, offer daily value, contain transferrable benefits and knowledge, and be embraced at a cultural level to be effective. In line with the previous CSR webinar on COVID-19, Dr. Sabeti called for a greater commitment to community engagement as a key effort to combat future biological threats.

            Dr. Akhila Kosaraju then emphasized the need to take novel technologies required for biodefense out of the lab and into the field. She also supported the need for greater convergence, stating such efforts must be intentional to be successful. Her company, Phare Bio, exemplifies such efforts, employing AI and deep learning to enable rapid antibiotic discovery to overcome rising drug resistances. This approach provides Phare Bio a strategy to overcome the drug development “valley of death” where most current pharmaceutical development fails and presents an opportunity for other organizations like it across biodefense.  Modern biodefense efforts must emphasize biotechnology, relying on computational biologists, bioengineers, and other technical experts to maximize advances in the field.  She also indicated a need for organizations like The Audacious Project, a backer of Phare Bio, to effectively unify disciplines to solve intractable problems like drug resistance. The Audacious Project is a “collaborative funding initiative catalyzing social impact on a grand scale” across a broad range of disciplines that seeks to de-risk and encourage innovation. Injection of philanthropic, grant, or even government funding sources to adequately de-risk the “valley of death” and other obstacles is essential to future preventative and treatment therapeutics. Additionally, biodefense must strive to recognize small players in the field that often offer bespoke technologies and solutions that can accelerate efforts beyond that of the usual bigger players, as demonstrated throughout the COVID-19 pandemic. Efforts like Operation Warp Speed serve as foundational examples to the benefits such efforts can provide to the future of biodefense.  

Event Summary: The American Pandemic Preparedness Plan: One Year of Progress & The Path Forward

By Geoffrey Mattoon, Biodefense MS Student

On Thursday, 8 September, the Council on Strategic Risks (CSR) hosted “The American Pandemic Preparedness Plan: One Year of Progress & The Path Forward” webinar, which included speakers Dr. Matthew Hepburn, White House Office of Science and Technology Policy (OSTP) Senior Advisor, and Dr. Carly S. Cox, CSR Fellow for Ending Bioweapons, and was moderated by journalist Janet Wu of Bloomberg. Dr. Hepburn and Dr. Cox discussed the recently released “First Annual Report on Progress Towards Implementation of the American Pandemic Preparedness Plan,” which they both played a central role in developing, and considered the current state and future goals of pandemic preparedness in the U.S. The lack of COVID-19 in the title of the event and report is intentional and the overarching message of both; do not fail to see the forest for the trees. A more apt statement in this instance may be “do not fail to see the future threats of pandemics and biological attacks for COVID-19 alone.”

This message was emphasized throughout the event, refocusing attention from COVID-19 to all pandemic response, and mirroring the call for greater broad-spectrum protection in biodefense as made by Dr. Gregory Koblentz in his book Living Weapons. Such efforts, according to Dr. Koblentz, transcend the historical “one bug, one drug” paradigm and provide a biodefense countermeasure strategy for both biological weapons and natural diseases. Broad-spectrum efforts such as these have already demonstrated their value in the response to other threats, including the adaption of existing mRNA vaccines for COVID-19 or the JYNNEOS smallpox vaccine for the ongoing monkeypox outbreak, and could prove critical in the event of any future disease outbreak or biological attack.

Dr. Hepburn opened the event with a call to action, stating all the progress we have made is good, but we still have much more work to do. He pointed to the first section of the Annual Report as a reminder of all the government has accomplished in pandemic preparedness. When asked by Ms.Wu if he believed we had learned enough from COVID-19 to prevent the next outbreak from reaching the same level, Dr. Hepburn emphatically replied “Yes.” He cautioned that the hard part is learning the right lessons and making the changes necessary to prepare. Dr. Cox stated she hoped he was right, but we also thought we were prepared for COVID-19.

Speaking on the importance of a diversified public health workforce, Dr. Hepburn highlighted the need for technologically savvy professionals. He asserted future public health workers must be trained in data analysis, program management, and human empathy to be successful. Dr. Cox then stressed the benefit of fellowship opportunities to provide professionals in the field a broader perspective to address biological threats that enhance disease outbreak prevention.

A diverse workforce is not the only ingredient needed for preparedness success. Dr. Hepburn and Dr. Cox also discussed the essential nature of interagency and private sector cooperation to overcome COVID-19 and future pandemics. This message aligns with both the 2018 National Biodefense Strategy Goal 1 and the 2021 Biodefense Vision Memo that call for greater coordination and unity of effort across all biodefense organizations in response to natural and man-made pathogens. This message is also supported by the broad range of organizations and their accomplishments throughout COVID-19 response outlined in the first section of the Annual Report. Such unity and diversity of effort is critical to maximize biodefense; including biosurveillance efforts like that of the Center for Forecasting and Outbreak Analytics, biodetection efforts from agencies like NIH RADx, and preparedness guidance from agencies like ASPR. Such multifaceted preparedness and response are essential to provide broad-spectrum protections against future threats.

A specific topic of discussion during the event was efforts in rapid production of medical countermeasures (MCM). Operation Warp Speed demonstrated we now possess the capability to produce effective vaccines within a year, enabling us to respond rapidly to emerging threats. Dr. Shulkin provides a concise summary of the essential lessons learned by Operation Warp Speed that should be applied to future vaccine development in his commentary, “What Health Care Can Learn from Operation Warp Speed.” The speakers emphasized that such efforts must become routine and require global cooperation to be effective in facing current pathogens like malaria as well as future threats. The development of vaccines is a balancing act of cost and innovation which may require government agencies to de-risk programs to incentivize innovation when the cost prohibits private sector interest. They also discussed the importance of novel vaccines that offer shelf-stable solutions as well as varied delivery methods (microneedle, oral, skin patches) to enhance distribution capabilities and capacity. Such technologies would directly benefit defensive efforts nationally and may even enhance defensive deterrence of biological weapons based on a more robust strategic stockpile.

            When asked what efforts give the panelists the greatest hope for the future, they highlighted the need to engage at the local health system and community level. Such efforts enable the establishment of trusted networks that can effectively disseminate critical health information and work to deter misinformation and disinformation. This mobilizes the population in response to threats and provides an added means of innovation that can guide future MCM and biodefense efforts. It is also critical that trust is built in advance within communities, it is not a resource you can “surge” at the time of need and COVID-19 has demonstrated the effects mistrust can have on response. Vaccine hesitancy and anti-vaccine sentiments proved to be a serious obstacle in COVID-19 response and must be addressed in a vaccine-agnostic manner to enhance current and future disease prevention and eradication.

The key messages throughout this event were consistent with those throughout the biodefense community. Interagency and international unity of effort, MCM innovation, and community involvement efforts in pandemic preparedness will enhance national biodefense. The COVID-19 pandemic is a world-changing event that may be key to reinvigorate pandemic preparedness and response efforts and, as a result, biodefense as well. As the speakers emphasized, what is critical is that the entire community applies these lessons to the whole of pandemic preparedness and response, not just COVID-19 specifically, to truly benefit from lessons learned. We cannot fail to see the forest for the trees.  

­­The Hidden Pandemic: COVID-19’s Impact on Antimicrobial Resistance

By Theresa Hoang, Biodefense MS Student


The COVID-19 global pandemic has threatened public health security by adversely altering the health of patients and overwhelming hospital systems throughout the world. Not only is COVID-19 a global health threat, but antimicrobial resistance (AMR) is a public health crisis too. AMR happens when microbes become resistant to antimicrobials that are designed to kill them.[1] AMR contributes to healthcare-associated infections (HAI)­ in patients, which spreads within healthcare facilities and throughout the community and environment.[2] The CDC reports that “each year in the U.S., at least 2.8 million people are infected with antibiotic-resistant bacteria or fungi, and more than 35,000 people die as a result.”1 AMR is a serious public health concern, especially during the pandemic, because experts have noted that COVID-19 may have reversed the progress on reducing AMR by creating a “perfect storm” for antibiotic-resistant infections in healthcare settings.[3] How has the COVID-19 pandemic impacted AMR in clinical patients, and why is it important? This issue is important because it affects patients, who are undergoing antibiotic treatments, and healthcare systems that are trying to prevent the spread of AMR. The current literature has discussed extensively the direct and indirect effects of the COVID-19 pandemic on AMR. A group of authors focuses on the increase of secondary drug-resistant infections and how they are affecting COVID-19 patients. Another group discusses the deterioration of healthcare systems allowing AMR transmission to escalate. Other authors analyze the disruption of antibiotic stewardship and its adverse effects during the pandemic. To fight against this growing pandemic, patients should work together with their healthcare providers to learn about the troubling effects of AMR and how to prevent it from spreading by practicing enhanced antimicrobial stewardship.

Secondary Drug-Resistant Infections from AMR

The surge in AMR during the pandemic has resulted in a rise of secondary drug-resistant infections. The three drug-resistant microorganisms that will be discussed are methicillin-resistant Staphylococcus aureus (MRSA), carbapenem-resistant Enterobacterales (CREs), and Candida auris.

Scanning Electron Micrograph of MRSA (from CDC)

Methicillin-resistant Staphylococcus aureus

MRSA is commonly spread in healthcare facilities and communities, and it can cause staphylococcus infections that are usually difficult to treat because of its resistance to some antibiotics.[4] Segala et. al explain that, during the pandemic, MRSA co-infections have increased significantly in COVID-19 patients who were admitted to intensive care units (ICUs).[5] “Up to 86.4% of all COVID-19 patients admitted to the ICU received a wide spectrum antibiotic therapy,” which helps treat against a vast majority of co-infections, including MRSA.5 However, exposing patients to these unnecessary antibiotics in a combination therapy can induce AMR. In another case study completed in Italy on mechanically ventilated patients, researchers compared the proportion of ventilator associated pneumonia (VAP) due to MRSA, between COVID-19 patients and non-COVID-19 patients.5 They found VAP rates were significantly higher in COVID-19 patients due to receiving a broad spectrum antibiotic therapy. Their findings also suggest there is higher rate of MRSA colonization and environmental contamination in COVID-19 ICUs.5 MRSA has not only evolved to become more resistant to antibiotics, but it continues to spread and colonize in healthcare facilities and other communities, in addition to infecting COVID-19 patients at increasing rates.

Infographic of the Risk of CRE Infections (from CDC)

Carbapenem-Resistant Enterobacterales (CREs)

Carbapenem-resistant Enterobacterales (CREs), formerly known as CR Enterobacteriaceae and nicknamed “Nightmare bacteria,” are a large group of different types of Gram-negative bacteria, such as Escherichia coli (E. coli) and Klebsiella pneumoniae, that commonly causes multiple infections in humans and in healthcare settings. CREs also develop resistance to a group of antibiotics called carbapenems.[6] CRE infections are spread from person-to-person by infecting or colonizing people (without causing infections or symptoms), specifically contact with wounds or stool, and through medical devices that have not been properly cleaned.[7]

CREs are a threat to public health because they are difficult to treat and are resistant to almost all available antibiotics.6 Their resistance comes from producing carbapenemases, which are enzymes that spread to other germs and cause resistance in carbapenems, rendering them ineffective.4 The CDC states that high levels of antibiotic resistance in CREs necessitate more toxic and less effective treatments, harming patient outcomes.7

Studies have shown that CRE infections are increasing among COVID-19 patients. According to a recent review on CRE infections during the pandemic, “secondary infections caused by CR-Klebsiella pneumoniae (Cr-Kp) show high prevalence of co-infection in COVID-19 patients.”5 Researchers have noticed that CR-Kp colonization and infections were associated with a high mortality rate in COVID-19 patients and increased use of antimicrobial agents.5 This represents a significant challenge for both infection control and clinical practice because as new antibiotics continue to be overused, CRE infections continue to rise and manifest in healthcare facilities and throughout communities.

Candida auris on CHROMagar Candida after Salt Sab Dulcitol Broth enrichment (from CDC)

Candida auris

Candida auris is an emerging multidrug-resistant (MDR) yeast that brings severe infections and spreads easily between hospitalized patients and nursing home residents through skin-to-skin contact.4 It can also cause invasive infections by entering the bloodstream, and even cause wound and ear infections.[8] Moreover, C. auris can trigger outbreaks in healthcare settings by contaminating hospital surfaces and medical equipment, especially if they are used for COVID-19 critical care. This indicates that patients are at high risk of C. auris colonization and infections.[9]

C. auris is an extreme public health threat to communities, and it has become a more serious concern during the pandemic. Since some patients with severe COVID-19 have required intubation and other invasive devices, they are put at a higher risk of C. auris infections; the pandemic may have contributed to an increase in these cases.[10] In another report from the CDC, 39 cases of C. auris have appeared in Florida during the pandemic that were attributed to “unconventional personal protective equipment (PPE) practices and environmental contamination.”[11] Risk factors like these have caused critically ill COVID-19 patients with C. auris infections to stay longer at ICUs and require antifungal drugs for long periods of time.5 This proves that improper and extended use of PPE has played a role in self-contamination and transmission of C. auris among COVID-19 patients.5 To prevent C. auris from spreading, especially among COVID patients, it must be detected immediately and IPC practices must be implemented.

Overall, the three different pathogens share a common goal, which is to induce AMR and increase secondary infections among patients. These drug-resistant microorganisms are a few out of the many other agents that have impacted patients during the COVID-19 pandemic.

AMR Implications for Healthcare Systems

Additionally, during the COVID-19 pandemic, the exacerbation of healthcare systems has increased transmission of AMR. Studies have shown that the rise of AMR in healthcare facilities was caused by a variety of factors, such as prolonged stays in the ICU,[12] overcrowding,[13] “contaminated PPE, increased workload among hospital staff, and prolonged glove usage.”[14] Furthermore, “shortages of PPE, staff shortages, fatigue, and deployment of inexperienced staff members with only basic training” are other factors that may contribute to the increased risk of AMR.[15] These determinants not only led to a surge in AMR, but also increases in morbidity, mortality, and healthcare costs for patients.14

To reduce AMR from escalating any further, Rawson et. al propose that social distancing, increased hand hygiene practice, and pre-emptive discharge of patients and cancellation of routine procedures are potential interventions that healthcare systems can implement during the pandemic.13 In addition, Knight et. al mention “enhanced infection prevention and PPE usage and control measures, in response to the COVID-19 pandemic, will help prevent infections and limit the spread of AMR.”15 Therefore, better health infrastructure and enhanced IPC measures set in place mean minimization of AMR amongst patients.

Disruption of Antimicrobial Stewardship

Disruption of antibiotic stewardship is another problem that needs to be addressed with the rise of AMR driven by COVID-19. Antimicrobial stewardship (AMS) is “promoting the appropriate use of antimicrobials, improving patient outcomes, reducing AMR, and decreasing spread of infections caused by multidrug-resistant organisms (MDROs).”[16] However, AMS has not been emphasized enough during the pandemic. For instance, researchers are concerned that increased antibiotic use during the pandemic could enhance the long-term threat of AMR.[17] Popescu states that “misuse and overprescribing of antibiotics, poor stewardship, and generalized lack of surveillance,” are some reasons why AMR continues to be a public health problem.[18]

Moreover, misinformation on antibiotic use (whether it is low public awareness or increased consumption of them) is another factor that may enhance the rise and spread of AMR.[19] For example, Arshad et. al explain that 44% of respondents to a population survey in Australia assumed that antibiotics could treat or prevent COVID-19, and university students in Jordan who believed in conspiracy theories around COVID-19 also thought antibiotics can cure it.[20] Additionally, clinical uncertainty about the disease process and pathology of an infection can increase antibiotic use. “When clinicians do not have all the necessary information to truly understand what is happening to the patient, they tend to prescribe more antibiotics.”17 Altogether, these factors can increase the spread of AMR and disrupt AMS.

In contrast, Toro-Alzate et. al argue that “telemedicine consultations could be useful to educate patients on improving antibiotic use.”19 But at the same time, they mention how telemedicine can also increase over-prescription of antibiotics due to physicians’ decision making.19 Because they are not with patients in-person, healthcare providers tend to misdiagnose more often and not order as much lab tests with these remote services.

#BeAntibioticsAware: Do I really need antibiotics? (from CDC)

Another AMS strategy is using social media to manage online media campaigns that combat misinformation of antibiotic use. Some organizations, such as WHO and Nigeria Centre for Disease Control, correct antimicrobial misinformation and discuss ineffectiveness of antibiotics as a treatment for COVID-19 by using their digital platforms.20 Taking everything into consideration and how the pandemic impacted the public health community, AMS must be further improved and emphasized among patients and healthcare providers to reduce AMR.

Are Hospital Stays of COVID-19 Patients (with AMR) Longer than Those of Non-COVID Patients?

The literature does not yet analyze the question of whether the length of hospital stays for COVID-19 patients with AMR are longer compared to hospital stays of non-COVID-19 patients. One study has claimed that AMR has led to adverse consequences for patients, including “more prolonged hospital admissions.”[21] Srinivasan mentions and compares the patient discharge data and AMR rates between patients with influenza-like illness and COVID-19.11 Yet, the data between patients with flu and COVID-19 were collected at different time frames.

Source: CAPT Arjun Srinivasan, MD, USPHS (CDC PowerPoint)

In the current literature, there is no evidence and comparison recorded between hospital stays of COVID-19 and non-COVID patients during the pandemic, over the same time period. Considering that the surge in AMR has been driven by the pandemic, and that it has caused ill patients to stay at hospitals based on their conditions, it is hypothesized that COVID-19 patients with AMR have stayed at the hospitals much longer than non-COVID patients during the pandemic. To examine this gap, further research needs to be conducted by attempting to gather data through a survey and compare hospital stay rates between COVID-19 and non-COVID patients from different hospitals in the Northern Virginia area. This would also explore the critical steps needed to treat patients with AMR and to mitigate its transmission before discharging patients.


Antibiotics save lives but any time antibiotics are used, they can induce side effects and lead to AMR.4 Along with the rise in AMR, COVID-19 has compounded this issue, creating more challenges for patients and hospital systems to overcome. The surge of secondary infections among patients, the exacerbation of hospital infrastructures, and the disruption of antimicrobial stewardship are the results of COVID-19’s impact on AMR.


Arshad, Mehreen, Syed Faisal Mahmood, Mishal Khan, and Rumina Hasan. 2020. “COVID-19, Misinformation, and Antimicrobial Resistance.” BMJ371 (November): m4501.

CDC. 2021. “Candida auris.” Centers for Disease Control and Prevention. July 19, 2021.

CDC. 2021. “CRE: Healthcare-Associated Infections (HAI).” Centers for Disease Control and Prevention. April 7, 2021.

​​CDC. 2021. “Patients | CRE | HAI”. Centers for Disease Control and Prevention. February 18, 2021.

CDC. 2020. “What Exactly Is Antibiotic Resistance?” Centers for Disease Control and Prevention. March 13, 2020.

CDC. 2020. “Where Antibiotic Resistance Spreads.” Centers for Disease Control and Prevention. March 10, 2020.

Centers for Disease Control and Prevention (U.S.). 2019. “Antibiotic Resistance Threats in the United States, 2019.” Centers for Disease Control and Prevention (U.S.).

Jul 27, Chris Dall | News Reporter | CIDRAP News | and 2021. n.d. “CDC Reports Two Outbreaks of Pan-Resistant Candida Auris.” CIDRAP. Accessed October 6, 2021.

Chowdhary, Anuradha, and Amit Sharma. 2020. “The Lurking Scourge of Multidrug Resistant Candida Auris in Times of COVID-19 Pandemic.” Journal of Global Antimicrobial Resistance 22 (September): 175–76.

“COVID-19 & Antibiotic Resistance | CDC.” 2021. June 8, 2021.

Hsu, Jeremy. “How Covid-19 is Accelerating the Threat of Antimicrobial Resistance.” BMJ: British Medical Journal (Online) 369, (May 18, 2020).

Knight, Gwenan M., Rebecca E. Glover, McQuaid C. Finn, Ioana D. Olaru, Gallandat Karin, Quentin J. Leclerc, Naomi M. Fuller, et al. 2021. “Antimicrobial Resistance and COVID-19: Intersections and Implications.” ELife 10.

Majumder, Md Anwarul Azim, Sayeeda Rahman, Damian Cohall, Ambadasu Bharatha, Keerti Singh, Mainul Haque, and Marquita Gittens-St Hilaire. 2020. “Antimicrobial Stewardship: Fighting Antimicrobial Resistance and Protecting Global Public Health.” Infection and Drug Resistance 13: 4713–38.

Manning, Mary Lou, Edward J. Septimus, Elizabeth S. Dodds Ashley, Sara E. Cosgrove, Mohamad G. Fakih, Steve J. Schweon, Frank E. Myers, and Julia A. Moody. 2018. “Antimicrobial Stewardship and Infection Prevention—Leveraging the Synergy: A Position Paper Update.” American Journal of Infection Control 46 (4): 364–68.

Popescu, Saskia. 2019. “The Existential Threat of Antimicrobial Resistance.” Bulletin of the Atomic Scientists 75 (6): 286–89.

Rawson, Timothy M, Luke S P Moore, Enrique Castro-Sanchez, Esmita Charani, Frances Davies, Giovanni Satta, Matthew J Ellington, and Alison H Holmes. 2020. “COVID-19 and the Potential Long-Term Impact on Antimicrobial Resistance.” Journal of Antimicrobial Chemotherapy 75 (7): 1681–84.

Segala, Francesco Vladimiro, Davide Fiore Bavaro, Francesco Di Gennaro, Federica Salvati, Claudia Marotta, Annalisa Saracino, Rita Murri, and Massimo Fantoni. 2021. “Impact of SARS-CoV-2 Epidemic on Antimicrobial Resistance: A Literature Review.” Viruses 13 (11): 2110.

​​Srinivasan, Arjun. “The Intersection of Antibiotic Resistance (AR), Antibiotic Use (AU), and COVID-19.” Centers for Disease Control and Prevention. February 10, 2021.

Sun Jin, Louisa and Fisher, Dale. 2021. “MDRO Transmission in Acute Hospitals during the COVID-19 Pandemic.” Wolters Kluwer Health, Inc. (34) 4: 365–371.

Toro-Alzate, Luisa, Karlijn Hofstraat, and Daniel H de Vries. 2021. “The Pandemic beyond the Pandemic: A Scoping Review on the Social Relationships between COVID-19 and Antimicrobial Resistance.” International Journal of Environmental Research and Public Health 18 (16): 1–20.        

Vidyarthi, Ashima Jain, Arghya Das, and Rama Chaudhry. 2021. “Antimicrobial Resistance and COVID-19 Syndemic: Impact on Public Health.” Drug Discoveries & Therapeutics 15 (3): 124–29.

[1] CDC. 2020. “What Exactly Is Antibiotic Resistance?” Centers for Disease Control and Prevention. March 13, 2020.

[2] CDC. 2020. “Where Antibiotic Resistance Spreads.” Centers for Disease Control and Prevention. March 10, 2020.

[3] “COVID-19 & Antibiotic Resistance | CDC.” 2021. June 8, 2021.

[4] Centers for Disease Control and Prevention (U.S.). 2019. “Antibiotic Resistance Threats in the United States, 2019.” Centers for Disease Control and Prevention (U.S.).

[5] Segala, Francesco Vladimiro, Davide Fiore Bavaro, Francesco Di Gennaro, Federica Salvati, Claudia Marotta, Annalisa Saracino, Rita Murri, and Massimo Fantoni. 2021. “Impact of SARS-CoV-2 Epidemic on Antimicrobial Resistance: A Literature Review.” Viruses 13 (11): 2110.

[6] CDC. 2021. “CRE: Healthcare-Associated Infections (HAI).” Centers for Disease Control and Prevention. April 7, 2021.

[7] CDC. 2021. “Patients | CRE | HAI”. Centers for Disease Control and Prevention. February 18, 2021.

[8] CDC. 2021. “Candida auris.” Centers for Disease Control and Prevention. July 19, 2021.

[9] Chowdhary, Anuradha, and Amit Sharma. 2020. “The Lurking Scourge of Multidrug Resistant Candida Auris in Times of COVID-19 Pandemic.” Journal of Global Antimicrobial Resistance 22 (September): 175–76.

[10] Jul 27, Chris Dall | News Reporter | CIDRAP News | and 2021. n.d. “CDC Reports Two Outbreaks of Pan-Resistant Candida Auris.” CIDRAP. Accessed October 6, 2021.

[11] Srinivasan, Arjun. “The Intersection of Antibiotic Resistance (AR), Antibiotic Use (AU), and COVID-19.” Centers for Disease Control and Prevention. February 10, 2021.

[12] Vidyarthi, Ashima Jain, Arghya Das, and Rama Chaudhry. 2021. “Antimicrobial Resistance and COVID-19 Syndemic: Impact on Public Health.” Drug Discoveries & Therapeutics 15 (3): 124–29.

[13] Rawson, Timothy M, Luke S P Moore, Enrique Castro-Sanchez, Esmita Charani, Frances Davies, Giovanni Satta, Matthew J Ellington, and Alison H Holmes. 2020. “COVID-19 and the Potential Long-Term Impact on Antimicrobial Resistance.” Journal of Antimicrobial Chemotherapy 75 (7): 1681–84.

[14] Sun Jin, Louisa and Fisher, Dale. 2021. “MDRO Transmission in Acute Hospitals during the COVID-19 Pandemic.” Wolters Kluwer Health, Inc. (34) 4: 365–371.

[15] Knight, Gwenan M., Rebecca E. Glover, McQuaid C. Finn, Ioana D. Olaru, Gallandat Karin, Quentin J. Leclerc, Naomi M. Fuller, et al. 2021. “Antimicrobial Resistance and COVID-19: Intersections and Implications.” ELife 10.

[16] Manning, Mary Lou, Edward J. Septimus, Elizabeth S. Dodds Ashley, Sara E. Cosgrove, Mohamad G. Fakih, Steve J. Schweon, Frank E. Myers, and Julia A. Moody. 2018. “Antimicrobial Stewardship and Infection Prevention—Leveraging the Synergy: A Position Paper Update.” American Journal of Infection Control 46 (4): 364–68.

[17] Hsu, Jeremy. “How Covid-19 is Accelerating the Threat of Antimicrobial Resistance.” BMJ: British Medical Journal (Online) 369, (May 18, 2020).

[18] Popescu, Saskia. 2019. “The Existential Threat of Antimicrobial Resistance.” Bulletin of the Atomic Scientists 75 (6): 286–89.

[19] Toro-Alzate, Luisa, Karlijn Hofstraat, and Daniel H de Vries. 2021. “The Pandemic beyond the Pandemic: A Scoping Review on the Social Relationships between COVID-19 and Antimicrobial Resistance.” International Journal of Environmental Research and Public Health 18 (16): 1–20.          

[20] Arshad, Mehreen, Syed Faisal Mahmood, Mishal Khan, and Rumina Hasan. 2020. “COVID-19, Misinformation, and Antimicrobial Resistance.” BMJ 371 (November): m4501.

[21] Majumder, Md Anwarul Azim, Sayeeda Rahman, Damian Cohall, Ambadasu Bharatha, Keerti Singh, Mainul Haque, and Marquita Gittens-St Hilaire. 2020. “Antimicrobial Stewardship: Fighting Antimicrobial Resistance and Protecting Global Public Health.” Infection and Drug Resistance 13: 4713–38.

Army Training Emphasizes the Importance of Education in Preventing Chemical and Biological Attacks

By Danyale C. Kellogg, Biodefense PhD Student

In October of 2021, I had the privilege of attending the Medical Management of Chemical and Biological Casualties course (MCBC), offered by the U.S. Army Medical Research Institute of Chemical Defense (USAMRICD) and the U.S. Army Medical Research Institute of Infectious Disease (USAMRIID) at USAMRICD’s facility in Edgewood, MD. I learned from instructors at these two legendary institutions how to identify chemical and biological warfare (CBW) agents, diagnose the conditions they cause, and mitigate their impacts. When I applied to the Biodefense PhD program at the Schar School of Policy and Government at George Mason, I could not have predicted that during the first semester of my doctoral studies I would be cutting a classmate out of Mission Oriented Protective Posture (MOPP) gear in the Maryland woods as part of a hands-on training exercise. This course was an incredibly informative, fascinating, and fun opportunity that was an excellent supplement to my graduate education. As an aspiring scholar-practitioner, understanding how the boots-on-the-ground manage these types of events and how such an event could impact broader operations and foreign policy is invaluable.

As the course was hosted entirely at USAMRICD due to the ongoing COVID-19 pandemic, the course felt a bit more focused on chemical warfare (CW) than biological warfare (BW). However, I found this almost more enjoyable as I had virtually no understanding of CW, making this an excellent opportunity to be immersed in learning about these agents. While I understood major concepts like the supposed chemical weapons taboo and global nonproliferation efforts from my prior studies in international relations, this course offered much more in-depth, niche knowledge. For example, I learned at MCBC that mustard-lewisite (military designation HL), two chemical weapons used together, might be a desirable agent for an actor to use, depending on the target and situation in question. This is because HL has certain properties of both agents, such as a lower freeing temperature, making it better suited for both aerial spraying and ground dispersal. Understanding concepts like these are useful from an academic perspective since it provides a better understanding of how an enemy might think about using chemical weapons and how we might prioritize defensive measures in light of such threats.

Bridging the divide between academia and practice requires scholars to learn what real-world elements of their fields look like, which this course provided through its classroom and practical portions. Though this course is explicitly targeted at healthcare providers, I think the in-depth knowledge I gained about chemical and biological agent identification and attack mitigation will improve my work, which lies at the intersection of global health and defense policy. Because of this course, I now have a deeper understanding of how difficult it is to triage victims in a CBW mass casualty event and how time-consuming and complicated it would be to manage decontamination, evacuation, and treatment of victims. I now know how many autoinjectors personnel usually carry in their gas mask carrier to use for buddy aid, what types of drugs different types of military hospitals normally have supplied, and what that all means for their response capabilities in a mass casualty scenario. While the specific, little details may not be critically important to my work, having this context is extremely helpful and, hopefully, will allow me to conduct more rigorous research and make more-informed recommendations over the course of my career.

Finally, deterrence in the CBW realm is dependent on the existence of effective countermeasures and would-be attackers perceiving that their targets are able to successfully mitigate potential attacks. Having attended this training, I am confident that USAMRICD and USAMRIID are succeeding in helping strengthen that deterrent through this and other courses. While our class had about fifty people (the vast majority military personnel) in it, I constantly heard instructors stressing that this information should be taken back to attendees’ units, shared, and used to improve training back home, increasing the chances for this information to reach those responsible for responding to a chemical or biological attack. I heard numerous encouragements for officers to coordinate more closely with their units’ Chemical Corps folks or request food supply inspections from the Veterinary Corps when in doubt about food safety while deployed. It was reassuring to see instructors encouraging servicemembers to use this information proactively, particularly when so much of what our program focuses on is strong preparedness and prevention as deterrents for CBW attacks.

This course was an excellent opportunity for me to interact with professionals in fields entirely unlike my own while having fun and learning a ton. I enjoyed gaining more hands-on knowledge about CBW agents and military medicine while contemplating what this course represents in overall U.S. biodefense.

Book Review – Toxic: A History of Nerve Agents, from Nazi Germany to Putin’s Russia

By Chris Quillen, Biodefense PhD student

Nerve agents are very much in the news these days. Bashar al-Assad’s government in Syria repeatedly used Sarin against its own people during that country’s civil war. The Putin regime employed Novichoks in both Russia and the United Kingdom against citizens it deemed insufficiently loyal to Moscow. North Korea’s Kim Jong Un utilized VX in the assassination of his brother at an airport in Kuala Lumpur, Malaysia. Across the globe, the use of nerve agents is challenging the international nonproliferation regime in numerous ways.     

Against this backdrop, Dan Kaszeta’s Toxic: A History of Nerve Agents, from Nazi Germany to Putin’s Russia provides welcome background and context on these specific types of chemical weapons. A former Chemical Officer in the US Army with decades of chemical weapons experience including multiple stints at the White House, Kaszeta offers much-needed technical expertise on the invention, production, and investigation into nerve agents. The focus specifically on nerve agents is a welcome change from many other histories that tend to lump all chemical (and sometimes biological) weapons into one amorphous “poison gas” threat with little differentiation between them. While older chemical weapons such as sulfur mustard or phosgene are sometimes mentioned in comparison with nerve agents, the author never loses his focus on his primary subject. This focus also enables Kaszeta to bypass the introduction and extensive use of chemical weapons in World War I that tends to dominate many other similar histories. Instead, Toxic begins with the Nazi discovery of Tabun, Sarin, and Soman in the context of World War II and follows the history of the dissemination of this technology to the present day.

The in-depth discussion of Nazi nerve agents is one of the real strengths of this book.  Kaszeta conducted extensive archival research and revealed numerous interesting new details including insights into why nerve agents were not employed during the war, either on the battlefield or in the gas chambers. Similarly, his discussion of nerve agent development by the US, UK, and USSR during the Cold War is impressive even if it tends to focus heavily on weapon systems (likely reflecting Kaszeta’s military background). The sections on the Syrian Civil War and the Skripal poisoning in the UK are also notable for their impressive detail and valuable discussions into those investigations.

Kaszeta’s best analysis appears in recent events that he investigated as part of his work with the open-source research organization Bellingcat. He directly confronts the disinformation campaigns trying to deny Syria’s use of Sarin. The author correctly points out that much of the effort is not designed to disprove Syria’s actions, but simply muddy the waters enough to make investigators throw up their hands in defeat. Kaszeta similarly attacks Russian disinformation about the Skripal poisoning and uses a combination of technical knowledge and common-sense logic to demonstrate the weakness of Moscow’s denials. One would not expect to find much humor in a history of nerve agents, but Kaszeta’s devilish sense of humor makes several appearances, especially when disproving the lies of the Russian and Syrian governments about their nerve agent use.

That said, the book is inconsistent overall. The sections on the Aum Shinrikyo Sarin project and the VX assassination of Kim Jong Nam, in particular, lack the same level of attention as most of the others. The basics are all there, but the minimal amount of detail and the lack of insights are sometimes striking compared to other chapters. Relatedly, Kaszeta sometimes provides copious details on nerve agent production facilities and weapons systems and then fails to provide sufficient analysis of what it all means. This is nowhere more evident than in his too brief final chapter where he brings the entire history together. He, undoubtedly, has more insight to give and the book would likely be much improved if he shared more of it.

Kaszeta remains focused on nerve agents throughout his book, but he sometimes diverges from the broader historical narrative in distracting ways. The chapter on the psychological effects of nerve agents is a key example of this tendency. Kaszeta raises interesting questions about possible linkages between nerve agents and mental illness, but the topic seems out of place and his argument is underdeveloped. Perhaps lacking the appropriate medical knowledge to pursue on his own, the author simply wanted to raise the issue for others to investigate, but this story seemed a speculative diversion away from the main story.    

While most of Kaszeta’s conclusions are well-reasoned, one in particular stood out as questionable. He argues correctly that nerve agents were brought into being through the ingenuity and hard work of people working for the Nazi regime and every other related discovery builds upon that breakthrough. He then makes somewhat of a leap that without this important contribution, nerve agents never would have been invented at all. This conclusion seems debatable at best. Both sides in the Cold War would have continued their chemical weapons research even without discovering the Nazi nerve agents. The science of chemistry also would have continued to advance even without the military impetus. Investigations into the organophosphate compounds that form the basis of nerve agents would have continued regardless. After all, many nerve agent discoveries were originally based on research of pesticides. While the Nazi contribution cannot be denied, the idea that nerve agents would have remained undiscovered without it seems highly unlikely.      

The greatest contribution of Kaszeta’s Toxic is as a historical and technical reference on nerve agents, an important issue. The appendices, in particular, offer solid scientific descriptions of nerve agent issues and background information on several countries rarely discussed in the literature, such as the former nerve agent programs in France and Yugoslavia. Written in accessible language, the book uses Kaszeta’s scientific knowledge to shed light on important questions. For example, he argues that while Soman is more effective than either Tabun or Sarin, few countries have pursued Soman production because it involves the expensive precursor pinacolyl alcohol. He also uses this knowledge to debunk conspiracy theories. Specifically, some have argued that Sarin was only detected in Syria after a warehouse with the binary precursors of methylphosphonyl difluoride (DF) and isopropyl alcohol was bombed. As Kaszeta rightly argues, the bombing of such a building would create a massive fireball from the two flammable chemicals, which would not magically mix together to create a nerve agent. The author’s ability to apply his knowledge and experience to contemporary issues is invaluable. For anyone interested in the historical impact of chemistry or the role of chemical weapons in world affairs, this book is a worthy addition to their reading list.

Commentary – Assessing China’s New Biosafety Law

By Sally Huang, Biodefense PhD Student


The COVID-19 pandemic, which was first detected in the Chinese city of Wuhan in December 2019, has turned the world upside down. While the origins of the pandemic, either a natural spillover event from animals to humans or the result of an escaped virus from the Wuhan Institute of Virology, remain contested, there is no denying that the virus has served as a focusing event for political leaders. As a rare, sudden event that has inflicted large-scale harm upon the public, the pandemic has also functioned as a powerful catalyst for policymaking [i]. While China had been drafting new biosafety legislation since 2019, the pandemic accelerated its finalization after President Xi Jinping announced his intent to enhance biosafety measures in February 2020. The law’s approval also comes as China recently experienced one of its worst COVID flare-ups in 2021, challenging the country’s success in overcoming the virus.

On October 17, 2020, China’s Standing Committee of the 13th National People’s Congress approved the Biosafety Law of the People’s Republic of China [ii]. This law is the first of its kind, unifying numerous preexisting biosafety policies under a single framework [iii]. Yet, one may be wary of the law’s credibility in effectively addressing biosafety gaps in China’s infectious disease framework given the political drama surrounding China’s response to the pandemic. China is under heightened scrutiny as the international community questions the origin of the pandemic, China’s initial handling of the COVID-19 outbreaks in Wuhan, and whether Chinese institutions and facilities are prepared to counter future infectious disease threats. Thus, even though China proactively initiated the Biosafety Law to address biosafety concerns, its rapid completion could be seen as a reflexive action to ameliorate the international community’s skepticism. The Biosafety Law’s broad and sometimes vague approach to addressing pathogen management, biohazardous agent accountability, capacity-building, and preparedness also highlight that there is much work to be done beyond approval of the law.

China’s Biosafety Law is unlike a highly detailed US law. Rather, it is analogous to a US government-issued strategy, a high-level document setting forth broad principles for subsequent legislative actions and policies. Thus, Chinese ministries will have to subsequently provide additional details to build upon the Biosafety Law. While strategy documents retain a certain amount of ambiguity to set the stage for more prescriptive, future policies, China’s Biosafety Law exhibits a noticeable lack of clarity. An analysis of the Biosafety Law’s key elements will therefore help inform outside parties about how China plans to navigate the infectious disease and biotechnology landscape moving forward.

Prior to diving into China’s Biosafety Law, it is worth taking a few moments to describe the linguistic differences between how Western and Chinese scientific communities use the terms, biosafety and biosecurity. When using these terms, the Western scientific community references two separate, but interrelated disciplines. The Chinese scientific community commonly uses the term shengwu anquan (biosafety) while also presently developing familiarity with shengwu anbao (biosecurity). Due to the widely varying opinions on what biosecurity means depending on where one works, Chinese scientists characterize shengwu anbao (biosecurity)as a subcategory of shengwu anquan (biosafety) as opposed to an independent field of study. An unintended consequence of this is the Chinese scientific community’s tendency to use these terms interchangeably [iv]. This may be a result of China’s intent to grow their biosecurity sector under the aegis of their biosafety policies, which were made more comprehensive following the country’s 2003 SARS outbreak [v]. On the other hand, this may cause confusion to the unbeknownst reader. In an effort to best maintain the Biosafety Law’s context in this article, the evaluation below adopts China’s interpretation of biosafety and biosecurity. Therefore, readers should keep in mind that as biosecurity (as described below) encompasses the security of biotechnologies, it is applied in the context of biosafety.

China’s Biosafety Law: Why Now?

COVID-19 highlighted the absence of a central agency and legal framework in China to provide direction for policies related to the management of threats posed by infectious diseases and biotechnology. Even with nearly a hundred existing biosafety laws and regulations, China has struggled with communicating, coordinating, and enforcing biosafety regulations. This demonstrates that a variety of policies can foster inconsistencies and poor policy oversight [vi]. As a result, China’s regulations are problematically left open to interpretation by all levels of government [vii]. Left unattended, these issues could balloon into long-term complications that could disrupt or contradict efforts to combat infectious diseases. Thus, China’s new Biosafety Law is meant to unify preexisting biosafety policies under one single framework to promote national biosafety standards and regulations, and demonstrate to the world their commitment to improving biosafety practices and infectious disease preparedness.

What Does the Biosafety Law Aim to Do?

Comprised of 88 articles, China’s Biosafety Law aims to bolster prevention and response to the threat of biological agents, nurture responsible laboratory conduct, and promote stable development of biotechnology to ensure the well-being of the ecosystem and population. As a basic, all-encompassing law, it takes a broad approach to formulating supervisory parameters for various issues of concern beyond biosafety and biosecurity. It bestows the Chinese State Council—the executive body of state power in charge of carrying out policy—with the authority to enforce, oversee, and lead investigations for all activities addressed under the law [viii]. With the Biosafety Law serving as the chief blueprint, it will work towards integrating various areas to fortify national and economic security, and social stability as well as set a precedent for future policies. The main components of China’s Biosafety Law include biosafety, biosecurity, public health preparedness, ethics, and biodefense.

Biosafety Prevention and Standards

China defines biosafety as the effective prevention and response to threats of biological agents and related factors to peoples’ lives and the ecosystem, and the stable development of biotechnologies [ix]. Although the law lists various areas in which biosafety would apply, it does not clearly define laboratory safety procedures or implementation of containment principles in the event that accidental outbreaks were to take place. This is interesting as the Western definition of biosafety more clearly lists criterion and values for protecting lab personnel and the public from the threat of biological agents [x]. However, it is worth noting that biosafety is explicitly written as “an important part of national security” within the Law as numerous articles describe the boundaries of biosafety activities and appropriate behavior in China [xi]. Article 6, for example, emphasizes the need to strengthen international cooperation and fulfill biosafety obligations under international treaties. This is especially pertinent to China’s compliance to the Cartagena Protocol on Biosafety in order to improve governance over the movement of pathogens and modified organisms [xii].

Article 8 empowers individuals to report activities endangering biosafety with the goal of preventing government authorities from ignoring early warning signs and valuable information provided by experts. This is a significant provision that could provide protection for whistleblowers. During the earliest stage of the COVID-19 outbreak in Wuhan, for example, Dr. Li Wenliang, a doctor treating patients with the novel coronavirus was detained and reprimanded by Chinese authorities for raising alarms about the hazards of the virus via social media. After his death from contracting COVID-19, he was hailed as the “hero who told the truth” as the Chinese public became outraged over the initial cover-up and number of lives that could have been saved if authorities had heeded the warnings [xiii]. The inclusion of this provision should pose a sanguine outlook for whistleblower protections, but specific assurances are not described. Only time will tell how Chinese government officials will act in the future.

The biosafety-focused articles also promote joint agency collaboration to enhance biosafety capacity-building. Article 42 stipulates that China should formulate a unified biosafety standard for pathogenic microorganisms in laboratories. Article 45 establishes hierarchical management for biosafety laboratories (BSLs) to ensure that research on pathogens is carried out responsibly in appropriate BSLs as categorized by risk level. Expanding upon responsible operation of pathogens, Article 68 calls for construction of a national biosafety infrastructure to accommodate high-grade pathogens and bolster national preparedness and response. As of now, China has only two BSL-4 labs [xiv]. The Biosafety Law does not dictate which types of biocontainment labs will be built. However, China is reportedly planning on building thirty additional BSL-3 labs and at least one BSL-4 lab over the next five years [xv].

Most reflective of the COVID-19 environment is Article 70 which details the State Council’s role in ensuring “the production, supply and deployment of medical rescue equipment, treatment drugs, medical devices and other materials needed for emergency response to biosafety incidents” [xvi]. Like any other country combatting COVID-19, healthcare workers and first responders in China are on the frontlines and require proper protective gear and medical countermeasures to help those in need.

Public Health and One Health

With the pandemic sparking additional concerns about novel infectious disease outbreaks, multiple provisions of the law address public health concerns. Article 18 dictates China will establish a biosafety inventory system to catalogue important biological data, including animal and plant, and other invasive species. Article 15’s biosafety risk investigation and evaluation system, combined with Article 16’s unified national biosafety information sharing system, will then help identify animal and plant epidemic risks that endanger China’s biosafety. China is also poised to streamline communication between government departments to efficiently classify and manage potential outbreaks. Article 47 aims for more controlled management of experimental animal research in laboratories to better protect the public. These articles reflect China’s efforts to amend loopholes in its public health and biosafety systems after SARS escaped Beijing labs twice in 2004. Continued speculation of the origin of COVID-19 also places pressure upon China to straighten their public health systems.

Articles 22, 23, and 27 through 30 have a One Health focus—an interdisciplinary approach that recognizes the intersection between human, plant, and animal health [xvii]—and dedicate attention to the development of monitoring systems to trace and manage epidemics among plants and animals. Article 31 stresses the importance of strengthening capacity building measures for prevention and control of animal and plant agents at borders and ports. Article 32 expresses China’s aim to protect wildlife and prevent the spread of infectious diseases of animal origin. This will be vital for countering infectious diseases that are approximately 60-75% zoonotic [xviii]. To further champion animal and plant epidemic protections, Article 60 sets out to formulate lists of invasive alien species as guides for creating relevant management measures. By taking a One Health approach to recognizing and reducing infectious disease threats, these articles demonstrate China’s hope in preserving biodiversity, ecosystems, and the natural environment.

Security of Biotechnology Research and Applications

The Biosafety Law does not include a definition for biosecurity. Instead, biosecurity is considered a part of biotechnology dual-use research of concern (DURC). China’s singular attention to biosafety after the 2003 SARS outbreak meant that the Chinese scientific and legislative community did not become familiar with biosecurity until later on [xix]. According to Michael Barr, there are widely varying opinions on biosecurity in China and there is a “divergence of awareness” [xx] depending on where one works, but biosecurity is generally considered a subcategory of biosafety. This differs from the Western scientific community’s interpretation of biosecurity, in which biosafety and biosecurity are separate, but complementary, disciplines.

Recognizing the role of DURC in biotechnologies and how it influences pathogen management, Article 34 strengthens the safety management of biotechnology research while prohibiting research activities that endanger public health and damage ecosystems or biodiversity. Article 36 seeks to formulate biotechnology R&D standards and classifies biotechnology R&D activities as high-risk, medium-risk, and low-risk “according to the degree of risk of harm to public health, industrial agriculture, ecological environment, etc” [xxi]. Article 39 emphasizes the importance of regulating the purchase and introduction of biotechnologies and related biological factors in accordance with a control list and prohibits individuals from purchasing or possessing items on this list. The law does not provide any details on the contents of this control list.


The Biosafety Law also covers ethical issues such as how China should improve supervision of Human Genetic Resources (HGRs). The ethical handling of HGRs has become an important issue in China after Dr. He Jiankui used CRISPR technology to produce gene-edited babies in an attempt to reduce their susceptibility to HIV [xxii]. This controversial experiment raised a number of red flags for the international scientific community—not only was it a flagrant flouting of medical and research ethics, but it also evinced China’s ineffective regulations and scientists’ lack of compliance. Therefore, Article 53 calls for strengthened supervision of the collection, preservation, and utilization of HGRs and related biological resources. Article 54, which empowers the State Council to carry out necessary investigations, provides a means of verifying compliance with these new provisions. Details on how the State Council would conduct these investigations, however, are not provided. Nonetheless, the universally negative response to Dr. He’s experiment provided a strong incentive for China to redefine its HGR regulations and reshape its bioethics standards.

Promoting Biodefense

Through Article 61 of the Biosafety Law, China hopes to “take all necessary measures to prevent biological terrorism and the threat of biological weapons”[xxiii]—echoing the Biological Weapons Convention’s (BWC) objective of prohibiting the development, manufacture, acquisition, stockpiling, possession, and utilization of biological weapons [xxiv]. China has already passed legislation for domestic implementation of the BWC and reported its biosecurity policies and enforcement measures to the United Nations Security Council’s 1540 Committee. In 2019, however, the US State Department reported that China was engaged in “biological activities with potential dual-use applications, which raises concerns regarding its compliance with the BWC” [xxv].

Article 62 tasks the State Council with creating China’s own version of the US’s Select Agent and Toxins List which is used to regulate access to dangerous pathogens that could be used by terrorists. Though criteria for this list are not described, a biological agent control list would provide China with a more formal method for managing, monitoring, and investigating suspicious purchases or activities with biological agents at risk of being misused to cause harm. Meanwhile, Article 65 calls for investigations of remnants of biological weapons found within China and the construction of facilities for their storage and disposal. The discovery and disposal of abandoned biological weapons holds historical significance for China as the country was subjected to multiple biological attacks by Japan during the Sino-Japanese War, and Chinese prisoners of war and captured civilians were victims of Japanese BW experiments conducted by Unit 731 in Manchuria during this time [xxvi]. At the end of the war, Japanese abandoned the site and destroyed records. However, recent discoveries of new records and an incubator used for the production of Yersinia pestis (the causative agent for plague) at sites in China indicates that the destruction of Unit 731’s equipment and materials was not completely thorough [xxvii]. Thus, other experimental equipment and biological munitions have the potential to be unearthed. These efforts to clean up the legacy of Japan’s biological weapons program in China complements China’s long-standing effort to safely destroy abandoned Japanese chemical weapons [xxviii].

Penalties for Violating the Biosafety Law

The Biosafety Law concludes with a final chapter on penalties for individuals who violate the law through the abuse of power, neglect of duties, engagement in malpractice for personal gain, fabrication of false information, and/or criminal acts. Penalties for such violations are financial fines that range between thousands to millions of yuan depending on the scope of the violation committed. The law does not delineate any prison time or any other form of penalties distinct from financial fines. With these current penalties, China hopes to influence scientific institutions and personnel to comply with the Biosafety Law. Yet, these articles do not describe pertinent criminal laws that would apply nor does it address whether novel criminal laws will be created to enforce the Biosafety Law—leaving the parameters for legal responsibility and investigations ambiguous.


Even as the Biosafety Law reflects China’s strategic positioning to incorporate biosafety, biosecurity, and biotechnology into its national security system, this ambitious set of laws needs to be accompanied by verification and accountability measures to ensure its proper implementation. What’s more, it will be interesting to see how China’s new expansive benchmarks will hold up, especially as the wording of key articles may be too broad and vague to be interpreted clearly. Nevertheless, countering infectious disease threats will be a balancing act requiring steadfast commitment and investment. COVID-19 has served as a long-awaited wake-up call for China to re-center their policy efforts and develop purposeful strategies to reduce the threats posed by natural and man-made biological threats. As the world continues to face infectious disease threats, the Biosafety Law serves as a preliminary touchstone for Chinese scientists and institutions to elaborate upon. This new law is the beginning of a long process of heightening biosafety from a local concern to a national one and developing the policies, processes, and institutions necessary to implement the law. Only then can the Biosafety Law begin to be the comprehensive and effect

[i] Thomas A. Birkland, Lessons of Disaster: Policy Change after Catastrophic Events, American Governance and Public Policy Series (Georgetown University Press, 2006),

[ii] Biosafety Law of the People’s Republic of China, October 17, 2020,

[iii] Shihui Qiu and Ming Hu, “Legislative Moves on Biosecurity in China,” Biotechnology Law Report 40, no. 1 (January 21, 2021): 27–34,

[iv] Michael Barr, “Cures That Kill,” China Security 4, no. 4 (2008): 33–42.

[v] Gigi Kwik Gronvall, Matthew Shearer, and Hannah Collins, National Biosafety Systems: Case studies to analyze current biosafety approaches and regulations for Brazil, China, India, Israel, Pakistan, Kenya, Russia, Singapore, the United Kingdom, and the United States (Baltimore, MD: UPMC Center for Health Security, July 2016), 8.

[vi] Jia Li and Yunfeng Jing, “Biosecurity Law — A Landmark Law to Be Released Soon,” China Law Insight, October 20, 2020,

[vii] Barr, “Cures That Kill.”

[viii] “The State Council,” accessed February 6, 2021,

[ix] “Biosafety Law of the People’s Republic of China” (China National People’s Congress, October 17, 2020).

[x] Judi Sture, Simon Whitby, and Dana Perkins, “Biosafety, Biosecurity and Internationally Mandated Regulatory Regimes: Compliance Mechanisms for Education and Global Health Security,” Medicine, Conflict, and Survival 29, no. 4 (2013): 289–321,

[xi] “Biosafety Law of the People’s Republic of China.”

[xii] Biosafety Unit, “Parties to the Cartagena Protocol and Its Supplementary Protocol on Liability and Redress,” The Biosafety Clearing-House (BCH) (Secretariat of the Convention on Biological Diversity, March 5, 2018),

[xiii] Verna Yu, “‘Hero Who Told the Truth’: Chinese Rage over Coronavirus Death of Whistleblower Doctor,” The Guardian, February 7, 2020,

[xiv] World Health Organization, WHO Consultative Meeting on High/Maximum Containment (Biosafety Level 4) Laboratories Networking: Meeting Report (World Health Organization, 2018),

[xv] Frank Chen, “China Goes on Biosafety Lab Building Spree,” Asia Times, July 7, 2020,

[xvi] “Biosafety Law of the People’s Republic of China.”

[xvii] “One Health Basics,” Centers for Disease Control and Prevention, November 5, 2018,

[xviii] Stephanie J. Salyer et al., “Prioritizing Zoonoses for Global Health Capacity Building—Themes from One Health Zoonotic Disease Workshops in 7 Countries, 2014–2016,” Emerging Infectious Diseases 23, no. Suppl 1 (December 2017): S55–64,

[xix] Amy E Smithson, Monterey Institute of International Studies, and James Martin Center for Nonproliferation Studies, Beijing on Biohazards: Chinese Experts on Bioweapons Nonproliferation Issues (Monterey, Calif.: James Martin Center for Nonproliferation Studies (CNS). Monterey Institute of International Studies, 2007), 47,

[xx] Barr, “Cures That Kill.”

[xxi] “Biosafety Law of the People’s Republic of China.”

[xxii] David Cyranoski, “What CRISPR-Baby Prison Sentences Mean for Research,” Nature 577, no. 7789 (January 3, 2020): 154–55,

[xxiii] “Biosafety Law of the People’s Republic of China.”

[xxiv] “The Biological Weapons Convention (BWC) At A Glance | Arms Control Association,” Arms Control Association, accessed January 20, 2021,

[xxv] Richard Pilch, “Engaging China on Bioweapons and Beyond,” James Martin Center for Nonproliferation Studies, May 28, 2020,

[xxvi] Sheldon H. Harris, Factories of Death: Japanese Biological Warfare, 1932-45 and the American Cover-Up, 2nd edition (New York: Routledge, 2002).

[xxvii] “China Reveals New Evidence of Japan’s Germ War Atrocities,” Xinhua Net, August 18, 2017,

[xxviii] Wanglai Gao, “Unearthing Poison: Disposal of Abandoned Chemical Weapons in China,” Bulletin of the Atomic Scientists 73, no. 6 (November 2, 2017): 404–10,

Commentary – Systematizing the One Health Approach in Preparedness and Response Efforts for Infectious Disease Outbreaks

By Michelle Grundahl, Biodefense MS Student

We can use a One Health approach to improve our next pandemic response to actually strengthen global health security – and we can choose to systemize and globalize right now.  One Health is a collaborative, multisectoral, and transdisciplinary approach — working at the local, regional, national, and global levels — with the goal of achieving optimal health outcomes recognizing the interconnection between people, animals, plants, and their shared environment. The objective of this workshop – offered by The Forum on Microbial Threats of the National Academies of Sciences, Engineering, and Medicine – was to confront our emerging health threats through systematizing and integrating the One Health approach. Systematizing is defined as arranging an organized system; to make systematic. Living through the current pandemic required us to perform outbreak detection and response to SARS-CoV-2, but prevention and preparedness is actually what we should be doing prior to outbreaks. Topics in this workshop included integrating One Health into existing coordination mechanisms (into national action plans for health security) and integrating animal and human health surveillance systems.  Essentially, this new paradigm in biodefense will create a framework across sectors and bring order among disparate expertise. The adopters of One Health are ready for the challenge.

Should we create a National Pathogen Surveillance and Forecasting Center for biological threats? Pandemic prediction, prevention, and policies are our next step in responding to the current SARS-CoV-2 pandemic. Medical countermeasures are useful during outbreaks but perhaps it would be better to truly mitigate global health threats, and even prevent them. We can achieve global health security through relationship building and lateral leadership. Two themes were repeated during the workshop: (1) future public-private collaboration must happen and (2) strong health systems are needed (globally and locally).

Day one of the workshop focused on the practices of existing programs and how these could improve the current model for global public health responses. The Africa CDC provided their lessons from COVID-19 and they stressed the continued importance of using a holistic approach to health threats. Specifically, the creation of a new framework for the African continent – Framework for One Health Practice in National Public Health Institutes – recognizes that other countries are frequently hampered by siloed health systems. The African Framework explains that the World Health Organization (WHO), the Food and Agriculture Organization of the United Nations (FAO), the World Organisation for Animal Health (OIE), and Sustainable Development Goals (SDGs) call for a One Health approach in order to comply with the 2005 International Health Regulations (IHR).

Back in the United States, we learned about the activities at Harris County (Texas) Public Health office. They explained their operational approach using One Health practices. An example given was the removal of old tires (mosquito breeding grounds) to combat Zika. Another was their response to Hurricane Harvey when they sheltered people and their pets together. Most recently, Harris County did surveillance of SARS-CoV-2 in pets.

On day two, the sessions tackled the urgency of a One Health approach and how it can be applied immediately. The development of a One Health workforce is one path forward. Dr. Lonnie King suggests that we should value a “T-shaped worker who has a deep understanding and high proficiency in one area with the skills to work collaboratively and respectfully across disciplinary lines for synergistic problem-solving.” In fact, USAID has a workforce project to do just this. An example, Africa One Health University Network (the latest effort in this USAID project) is creating a competent future workforce by developing multi-skilled students, who can work outside of silos. Universities can integrate systems thinking and encourage collaboration across disciplines. Woutrina Smith reminded the audience that social context is important, too; we cannot forget to incorporate the social sciences into traditional science to effectively create solutions using the data that we generate. Transdisciplinary thinking is essential.

Day three looked at the future of One Health with the experience of SARS-CoV-2 in mind. Biosurveillance using shared international data would create the ability to better forecast outbreaks. This will require cooperation through public-private partnerships, along with policy changes. The workshop suggested the goal of building a “broad, threat-agnostic global health system.”  This includes learning from the past to determine future capabilities. Collaboration across disciplines, sectors, and communities can enhance the detection of threats. Surveillance is key here. Realistically, it is unfeasible to collect and monitor all global health data.  Local, national, and international epidemiological surveillance systems are still needed though. They should be designed (and refined) with One Health in mind. The session on “Precision Epidemiology, Human Behavior, and the Future of One Health” (led by Jonathan Quick) discussed machine learning, which can sort through the massive amounts of data that we may begin to collect. Intelligence and national security applications of this surveillance data were not obviously addressed in this three-day event. Future conversations to address this sort of data will need to include scientists and intelligence professionals. Regardless, most agree now that global health security is national security.

Many of the topics of this workshop focused on current and future actions; which were reminiscent of the challenges listed in 2016’s Pandemic Prediction and Forecasting Science and Technology Working Group of the National Science and Technology Council. The major theme for this workshop was that collaboration is a must if we want to improve resilience to global health threats. Other groups (outside of this workshop) are collaborating and systemizing at the state level. On March 1st, New Jersey passed a bill (A-1992/S-347) for the ‘New Jersey One Health Task Force’ to operationalize One Health in the state. Looking forward, will we excel in our reaction to the next pandemic? Will we also create multisectoral preparedness that allows us to forecast, or prevent, the next pandemic?

There were many heavy hitters speaking at this NASEM workshop, including: Peter Daszak from EcoHealth Alliance; Laura Kahn from Princeton University; Casey Barton Behravesh, Director of the One Health Office at the US Centers for Disease Control and Prevention; John Nkengasong from the Africa Centres for Disease Control and Prevention; Jonna Mazet, Professor of Epidemiology and Disease Ecology and Executive Director of the One Health Institute School of Veterinary Medicine at University of California, Davis; Tracey McNamara from Western University of Health Sciences; Peter Rabinowitz from University of Washington; Lonnie King, Dean Emeritus for the College of Veterinary Medicine at The Ohio State University; and Jonathan Quick, Managing Director of the Pandemic Response, Preparedness, and Prevention Health Initiative at The Rockefeller Foundation.

Conspiracies, Contagion, and Convergence: Troubling Trends and COVID-19

By Stevie Kiesel, Biodefense PhD Student

For hundreds (if not thousands) of years, disease outbreaks have been accompanied by exaggerated or downright false claims of origin, spread, and treatment. Some of these claims are misinformation—incorrect information spread without an intent to mislead. For example, shortly after COVID-19 was declared a pandemic, claims that garlic could cure COVID-19 spread across social media. The majority of posters did not appear to have malicious intent in sharing this content, making these claims misinformation. On the other hand, disinformation is deliberately misleading or biased information. Far-right Telegram users planned to weaponize disinformation when they urged followers to spread inaccurate information about COVID-19 safety precautions via flyers in certain neighborhoods. While misinformation and disinformation are both dangerous, disinformation is more insidious. Throughout history, both mis- and dis-information have spread prolifically during pandemics. This article provides a brief history of conspiracy theories during pandemics, discusses some popular COVID-19 conspiracies, and examines a potential convergence of various communities spreading similar conspiracy theories.

Fear of disease occupies a special place in the human psyche—an invisible threat that can cause physical deterioration and possibly death. Though science has come a long way in understanding pathogens and the human body, even today “much remains unknown in medicine, creating fertile ground for fear.” While this is certainly true of the novel coronavirus SARS-CoV-2, conspiracy theories have accompanied disease outbreaks for millennia. Susceptibility to conspiracism is present in every country and can gain traction at any time, though it is more common around unprecedented events. Disease outbreaks are certainly one example, but the attacks of September 11th and the 2010 Deepwater Horizon industrial accident show that conspiracies often accompany newsworthy events.

The influenza pandemic of 1918 saw its fair share of myths, often aimed at rival countries. For example, the United States and United Kingdom initially linked the outbreak to intentionally adulterated aspirin from Bayer, a German company. These accusations reflected a post-World War I mistrust of Germany. Similarly, a rumor circulated throughout Brazil that the 1918 influenza virus was intentionally spread around the world by German submarines in an act of biological warfare. Though Americans often call this pandemic the Spanish flu, many countries had other regional names for it based on their particular prejudices. Conspiracy theories commonly lay blame on specific groups in an attempt to turn public opinion, even going so far as to claim that an outbreak is the result of biological warfare. For instance, a pernicious rumor in 14th century France claimed that a Muslim prince enlisted help from France’s Jewish population to bribe lepers to contaminate public water sources and kill Christians. A few hundred years later, conspiracy theories around yellow fever eventually led to the genre American Gothic. The father of American Gothic, Charles Brockden Brown, caught the disease himself, and though he recovered, others in his life did not survive it. His writings often used disease as a “conventional vehicle of terror.” His style was also deeply paranoid, including “hidden voices, secret societies…[and] fears of the Illuminati.” These themes, as well as a fearful fascination with the Illuminati, reverberated in American popular culture and religious life as yellow fever continued to spread.

Conspiracies accompany nearly every significant outbreak of disease. Some believed that the SARS outbreak of 2002 was caused by a virus created in a Chinese weapons lab (sound familiar?). During the H1N1 (swine flu) outbreak of 2009, rumors circulated that the World Health Organization and pharmaceutical companies conspired to manufacture the outbreak so that they could profit from vaccine distribution (a theme that appears with many outbreaks). And the current outbreak of novel coronavirus is a case study in how the internet and political tensions can exacerbate conspiracism in the United States.

Because SARS-CoV-2 is a novel virus, misinformation and disinformation have provided many people with answers where science could not yet do so. The World Health Organization labeled this phenomenon an “infodemic,” where technology and social media are used on a massive scale. While technology provides new mechanisms for keeping people safe and informed, it can also result in an overabundance of information, as well as the proliferation of incorrect and potentially harmful narratives. The pandemic has spawned countless conspiracy theories, but the most widespread can be generally grouped into four buckets:

  • Virus origins and spread. There is a great deal of theories about how the virus came into existence and how it is spread. Members of the Trump administration, as well as the former POTUS himself, have claimed that the Wuhan Institute of Virology is responsible for bioengineering SARS-CoV-2. Some adherents of this theory claim the virus was then intentionally released, while others say it escaped the lab accidentally. Another popular theory is that 5G networks are acting as super-spreaders for the virus. This theory has been linked to several acts of vandalism against 5G towers and an increased propensity for violence.
  • Preventative measures. Claims that preventative measures like mask wearing and social distancing are ineffective got a lot of traction on social media and were amplified by the Trump administration’s words and actions. This is not a uniquely American phenomenon: for example, Moldova’s former President was routinely photographed violating social distancing and mask mandates in his country. And in the US as well as Germany, the United Kingdom, and other countries, these preventative measures were met with angry protests by those who believe the lockdowns were a pretense for increased government control. And unfortunately, recent studies have proven that belief in COVID-19 conspiracy theories reduces willingness to engage in these preventative measures and protect communities.
  • Vaccines. No other preventative measure has spurred quite as many conspiracy theories as the COVID-19 vaccine. The theories range from mundane (the vaccine actually gives you COVID-19) to bizarre (the vaccine will alter your DNA) to absolutely wild (the vaccine contains a microchip that will allow Bill Gates to track your every movement and implement a New World Order). Others are simply concerned about the safety and effectiveness of the vaccine because they perceive the approval process as rushed and/or they mistrust the government and pharmaceutical companies. As of December 2020, only 60% of Americans surveyed said they intended to get the vaccine, while 20% said they were fairly certain they would under no circumstances get the vaccine.
  • Treatments. At the start of the pandemic, home remedies for COVID-19 were extremely popular on social media. Other bad information about COVID-19 cures came and went throughout 2020. Some of the most popular “cures” include garlic, saline nasal wash, exposure to high temperatures or sunlight, antibiotics, and hydroxychloroquine. None of these are effective against COVID-19.

Bad actors often encourage and amplify the spread of these narratives, twisting them for their own purposes. Extremists have latched onto many of these conspiracy theories and used them to recruit and radicalize followers. Social distancing, lockdowns, and online school and work have moved many people indoors, online, and looking for answers. When scientists, doctors, and public officials cannot provide the answers people are looking for, they become incredibly susceptible to messengers that claim to have a simple answer.

Conspiracism ebbs and flows, and though it is not a uniquely American phenomenon, we are currently living through a peak in what Richard Hofstadter has called the “paranoid style in American politics.” Understanding all the factors that have led to this crescendo is beyond the scope of this article, but political turmoil, increasing inequality, and a global pandemic play a significant role, exacerbated by the rapid spread of information and a waning trust in institutions. While much of the focus is on the political right, particularly given the recent siege of the Capitol, there is evidence of a convergence of conspiratorial thinking among those on both ends of the political spectrum, as well as those with few political beliefs who find answers in these ways of thinking. COVID-19 misinformation has been rampant on the right as well as within wellness and spirituality communities that are traditionally uninterested in politics or lean left. Liberal and leftist activists have also spread similar misinformation rooted in suspicion of pharmaceutical companies, the “medical industrial complex,” and the government.

The QAnon conspiracy is another recent example of this convergence. Declared a domestic terrorism threat by the FBI in 2019, adherents of the theory have been linked to at least a dozen alleged crimes. This statistic does not take into account any crimes committed during the Capitol siege, but QAnon adherents had a sizeable presence there. While many Q followers approve of Donald Trump because they believe that he has been trying to dismantle the deep state cabal of pedophiles and Satanists that run the US government, QAnon has appealed to people across the political spectrum. Though at its core, the QAnon conspiracy is based on an old antisemitic trope of the Blood Libel, the core belief has been laundered through movements such as #SaveOurChildren (claiming to be fighting child sex trafficking) and by social media influencers that put a gentle exterior on an extreme ideology. Much like multi-level marketing schemes, this rebranding targets potential marks by constructing a façade to hide the ugly reality and consequences. The subreddit QAnonCasualties is full of stories from former Q adherents as well as their friends and family. These stories show how conspiracism can consume someone’s life, leading them down a path to extremism that often ends in ostracism and sometimes even violence against their loved ones. The subreddit also shows the many different communities that can lead to Q, from churches to the wellness community to other conspiracy communities to right-wing politics and in countries outside the US.

Conspiracy theories and extremism will remain a potent threat for years to come, and currently disparate communities may converge in ways predictable or surprising. Conspiratorial thinking is often black and white, an “us versus them” mentality that can erode a person’s aversion to violence. Terrorist groups can (and have) taken advantage of this shift in mindset and used conspiracy theories as an opening to eventually introduce more extreme ideas. The Capitol siege and subsequent crackdown on inflammatory rhetoric on the major social media platforms may be pushing people toward sources such as Gab, Telegram, and Bitchute where extreme ideas flourish. The Biden administration has suggested several actions to combat the threat of domestic extremism, including a threat assessment and capacity-building to disrupt extremist networks. These are positive steps that must include experts outside of government and from a variety of disciplines, including those experienced in successful cult deprogramming and deradicalization. While promoters of and participants in extremist violence should be held fully accountable under the law for their actions, we should not lose sight of the structural and systematic failures that have made these conspiracy theories so appealing today.

Commentary – Incorporating One Health into Global Security: Educating the Public and Governments

By Maddie Roty, Biodefense MS Student

The Global Health Security Agenda Annual Ministerial Meeting, held 18-20 November 2020, focused on addressing gaps in global health security by promoting international and multidisciplinary engagement, coordination, and funding. Leading up to this event, there were side meetings addressing various topics related to global health. On 27 October, the United States Department of Agriculture (USDA) hosted the side meeting “Incorporating One Health into Global Security: Educating the Public and Governments.” One Health is an important topic that promotes a multisectoral approach needed to address global health security issues from climate change to zoonotic spillover events, and to improve the human and planetary conditions. Dr. Jennifer Rowland, an AAAS Science and Technology Policy Fellow at USDA, moderated two panels, one made up of One Health educators and the other of government officials with a role in One Health. The panels addressed how to educate students about One Health and how to implement One Health initiatives in US government agencies.

The One Health education panel included: Dr. Laura Kahn from Princeton University and the Founder of One Health Initiative; Dr. Deborah Thomson, Founder of; and Dr. Olga Pena, Mitacs Canadian Science Policy Fellow. Dr. Rowland asked each panelist a series of questions regarding the value of teaching students about One Health, how it helps support the goals of international organizations, and the challenges we face.

The most sobering point during this panel was made by Dr. Pena, who said “One Health disrupts human-centric views.” Too often, we are blinded to the interconnectedness of the human, plant, animal, and environmental conditions. What humans do affect the health of the rest of the planet, and what happens in Mother Nature affects the health of humans. Maintaining human-centric views will not only be harmful to the planetary condition but to humanity as well.

Sustainability is a challenge for One Health. Historically, the health sector has been reactive to threats, not proactive. Once a threat subsides, so does interest and funding. Dr. Thomson emphasized the best way to sustain efforts is to talk to the people who are most curious, most interested, and most willing to learn: children. If we want to change policies in the future, we need to reach the future politicians. For efforts to be sustainable, One Health education must also be tailored to the local community, traditions, and beliefs. Partnerships at the local level must be developed, and community leaders must be taught and empowered so they can continue teaching.

Unfortunately, providing education about One Health is challenging without the appropriate funding and resources. The panelists stated frustrations with finding funding for something as interdisciplinary as One Health, and even less funding for education because “education is not a product.” Building synergistic relationships that exchange funding for expertise, such as government agencies partnering with organizations and universities, is one way around this challenge, but it is not common enough to be a sufficient solution.

The One Health government panel included: Dr. Casey Barton Behravesh from CDC; Dr. Jane Rooney from USDA; and Mr. John Haynes from NASA. They answered a series of questions about how One Health is incorporated into the agencies, how agencies can work together, and how agencies can empower One Health work.

The most important takeaway from this panel was that One Health relies on partnerships. Despite the name, One Health is a team sport and no one person or one agency can accomplish its objectives. Like the education panel, this panel was concerned about funding and resources in the government for One Health, showing that interest and investment must come from the highest levels of government. In December 2017, there was an interagency workshop with subject matter experts and high-level agency voting members to come up with priority zoonotic diseases and generate recommendations on how to move One Health forward. Coronaviruses were on the list, and the workshop included suggestions for how to prepare for coronaviruses. Unfortunately, the resources were not there to follow through with the recommendations. Two years later, the COVID-19 pandemic has obviated the consequences of this lack of commitment and resources.

Of all the panel members in this meeting, Mr. Haynes impressed me the most, perhaps because he was the most surprising participant. Prior to the meeting, I had no understanding of how NASA would be involved in One Health, let alone serve as one of the leading agencies promoting the concept. Apparently, I was not alone; Mr. Haynes elaborated on how NASA attends public health and other medical conferences to raise awareness about what NASA is doing and how it should be incorporated into the health sector. NASA has an air and health quality applications program, and it has been very active during the COVID-19 pandemic. One program, for example, is modeling how the Saharan dust plume impacts public health, and specifically if the plume is associated with greater morbidity and mortality from COVID-19. There is no public health school in the United States that includes environmental remote sensing observations like those that this program offers in its curriculum. Mr. Haynes believes, and I am convinced, that this is a problem as most public health students and professionals have no idea these data are there and how valuable they can be for disease issues.

The main lessons from both panels were that One Health is extremely interdisciplinary and requires increased commitment and funding from educators, government agencies and leaders, and the public to protect the human and planetary conditions. The COVID-19 pandemic – occurring at the same time as compounding disasters like wildfires, hurricanes, and famines – show just how interconnected all of these issues are, and, hopefully, will stimulate increased and sustained dedication to One Health principles. 

Now more than ever, it is important to be actively engaged in global health security. If you would like to watch any of the side meetings or the Ministerial Meeting, click here.