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It’s March 2026: Q4 2025 is done, end-year numbers have come in, and annual reports shared through summary earnings calls over recent weeks have set the tone for how biotech capital will move in 2026. We’re also a few months out from JPM 2026, where there was even more China-West biotech deal chatter than last year, if possible.

Now is therefore the perfect moment to zoom out and translate the noise into a clearer map: what is emerging across deals and financings, why they’re emerging now, what a ‘global-grade’ China-origin asset really means in practice.

I can think of no one with a better read on the landscape from an investment point of view, than Dr Leon Tang, one of the leading China biotech experts around, who sits closest to the investor and partnering circuits and always has his finger on the pulse.

Leon brings almost two decades of experience in biomedical research, BD and investment. He is a founding partner of InScienceWeTrust BioAdvisory, a biotech business development consulting firm that focuses on pharmaceutical licensing between the East and the West, which has advised over 30 clients ranging from Fortune 500 companies, world-leading investment funds, leading public and private biotech companies, and stealth biotech startups. He is the BD head of Mianus Accelerator – a new venture that aims to help Western biotech companies to access China’s world-class first-in-human clinical development capability. He is also the co-founder of the InScienceWeTrust Community, an Asian-biotech focused non-profit, and one of the most active Asian biotech communities I know, with over 4000 active members across global hubs, including in North America and Europe.

In addition, he is scientific advisor at BioSpark Group, with past lives in the venture capital and academic worlds. He holds a PhD in Biomedical sciences from the Icahn School of Medicine at Mount Sinai, a Master’s at Nankai University in Biochemistry, and a Bachelor’s from Tianjin University in biochemical engineering, and has published over 50 academic papers, including in Nature Reviews Drug Discovery and the Lancet Oncology.

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Read our Conversation:

(Audio transcript adjusted for clarity and flow)

1. Setting the scene

Ruby: Let’s get started by setting the frame. From your vantage point across networks and portfolios, including investors, BD teams and the wider biotech community, what feels most different right now, whether that’s compared with six months ago, a year ago or even further back?

Leon: if you ask me what’s the biggest difference compared to what I saw six months ago, obviously I’m a little bit biased, always looking at a lot of stuff from the lens of Asian biotech, particularly China biotech. I would say that the overall industry, especially the Western side when they look at China, the sentiment is much more positive compared to six months ago.

And if you go a little bit further back, even to one year ago, there was still debate whether embracing China was a good idea. There was an executive order rumoured from the Trump administration to ban the license deal from China to the US and so on. So that conversation and chatter is now much, much quieter today than before.

In the meantime, I would that say since JP Morgan in January, there’s a lot of high profile deals and collaboration. And the headlines announced really embrace the China biotech as an essential part of the global R &D ecosystem - through the deal making, through R &D collaboration, even through high profile big pharma executive visits.

So I think that would be the biggest difference: the sentiment and also the action with China biotech is much more positive compared to six months ago and much, much better compared to one year ago.

Ruby: And in terms of the recent end-year summaries from industry across biopharma, especially for those with China cash flows or China pipelines or cross-border ambitions, what have been the real questions for you underneath those very optimistic announcements, whether that’s real capital or real partnerships; opportunities and risks, things like that.

Leon: In terms of cash flow, think there are very few China originated drugs probably except for Zanubrutinib (Brukinsa) from BeiGene/Beone, and Carvykti (Cilta-cel) from Legend Biotech, who are making profit for Western companies. But most of others were only recently approved, and have not really reported revenue from the Western companies’ earning calls yet.

I’m probably more focused on the deal making front, licensing deal or R &D collaborations. For dealmakers, there are always two parts. One part is really for your balance sheet or for your CapEx/upfront payment, and then the milestones, everything biobucks (contingent, milestone-based payments in biotechnology licensing or acquisition deals between large pharma and smaller biotech firms), that’s a different category, which is really important for the Chinese biotechs to talk to their investors, but not necessarily have an immediate impact with the earning calls every quarter.

So focusing upfront payments, think if you look at all the deals since the beginning of 2026, the momentum suggests that this year can be bigger than 2025, which was already record breaking year in upfront payments. Biobucks has the same story. Last year, the global BD&L (business development and licensing), the licensed pharmaceutical space, China to West deals contributed to about 49% - about half the total deal value. As a comparison, in 2024, the United States were contributing about 50%, I think 47%. So from 2024 to 2025, the leader in licensing deals changed from United States to China. If you just look in the first two months of 2026 number already, China going to be dominant. It’s pretty clear. it continues.

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2. Deal trends: Part 1

Ruby: In the pharmaceutical licenses you just mentioned, the big headline grabbing China-West partnership announcements that we’ve seen over the previous years, and then the burst of attention around January in San Francisco at JPM. In terms of organising the landscape then, what have been key patterns you’ve noticed in assets? any surprises or revisions in terms of modality, whether that’s ADCs versus bi-specifics, or clinical versus pre-clinical stage or buyer type - large foreign MNCs versus funds or other biotechs or even in structures for co-development or M&A, what they’re telling you about demand and innovation progress or pace and talent, or perceptions versus reality?

Leon: This is probably gonna take two hours to answer to really give you a little bit of a reasonable description, so I have to force myself to three. The first one I would say is diversity. So the China-to-West deal right now is diversifying away from previously, which pretty much mainly focused on oncology licensing deals. Two years ago, that was pretty much the majority of them. But today is really different. Diversification in terms of disease area. Yes, oncology is likely still number one, probably not far ahead of immunology, if you look at recent deals in the first two months of 2026 . And also obesity is catching up real quick.

The format of deals are also diversifying quite a bit: if you go back three years ago, most of the deals would be straightforward license deals. Right now it has so many different flavours (except for straightforward large ticket M&A, which is still not happening very often). Everything else is very similar to what you would say. You have a typical license deal with a preclinical phase one, phase two, phase three assay.

Actually this week, Pfizer’s licensed a commercial-ready product from the China biotech Hangzhou Sciwind Biosciences,and I just saw the news that that asset was approved in China, shortly after the deal was closed. So right now Pfizer is a commercial obesity company. So they have a commercial product on the market as of today, because they licensed a late stage asset (Ecnoglutide, a GLP-1 drug) from China. But of course this asset was only approved for Chinese market. So that’s a new development: big Pharma licensed a late-stage asset only for China market! That’s one diversification.

Another is: there’s a deal which even with the US biotech companies, rarely happens. Eli Lilly had a deal with Innovent, which is arguably the number one biotech based in China now, by market cap, because BeOne, or what used to be called Beigene, has become a Swiss company. So Innovent has become number one. Innovent and Lilly’s deal: if you look at it, there’s no asset transaction, but upfront payments of $350 million with up to more than $8 billion biobucks - one of the largest deals in 2026.

And there were no asset transactions involved. What Eli Lilly really got from this $350 million down payment, is really to have the option to co-develop drugs from target nominations until phase two with Innovent, in oncology and immunology. So what Eli Lilly got is not a specific asset, but Innovent’s capability to develop drugs in immunology and oncology.

And a similar situation also happened in the largest deal on record as of today, between CSPC and AstraZeneca. That deal, the first half probably involves four assets in obesity, and the other half is the option to develop another four obesity assets they don’t even have yet. And that deal costs AstraZeneca over $1 billion upfront payment, up to $18.5 billion total value. It’s the largest deal out of China.

So those also showed the diversification, also the confidence and the trust of big pharma like Lilly, like AstraZeneca. In China, biotech has the capability to develop drug from early stage all the way until phase two. I think that’s the first one.

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3. Changing perceptions

Ruby: We’re talking about not just partnering on assets, but partnering on capability, or even the last example you said, the potential for capability - not even capability realised. So all of these stages really showcasing a huge amount of trust and hope in what Chinese skillset and talent and capability can bring to the table. That’s such a huge transition in the recent years. It’s incredible.

Leon: Right. But if we think about this happening exactly to some of Japanese and American biotech, I’ll give you two historic references. The deal Sanofi did with Regeneron, many, many years ago, Regeneron was a tiny biotech, it didn’t have the capability to do late stage clinical development, not even to mention commercial capability. That’s why they had this extensive collaboration with Sanofi. Sanofi’s best-selling drug on their pipeline right now, was originated from Regeneron, Dupixent/dupilumab. So you see the Chinese are following very similar footsteps as what Regeneron did, to become today as one of the largest biotech player in the world.

Another example is the US’s Alnylam, which had a lot of collaborations. One of the best cholesterol controlling drugs (Inclisiran/Leqvio) originated from Alnylam, went to The Medicines Company, then got acquired by Novartis. That’s probably the most innovative commercial stage cholesterol controlling drug on the market.

Ruby: Do you think it is because the momentum has built to a level where there is this trust that wasn’t there before?

Leon: There’s trust, there’s also recognition of each other’ capability. It’s not like China never changed and all of a sudden the Western companies discovered them. It’s an iteration process. Let’s just use AstraZeneca, for example. I think they have around 14,000 employees in China, and I assume majority of them are ethnic Chinese, and were trained in China. But of course there must be a lot of their global talents that were trained or worked in different countries, a different culture background. A lot of them must come from Europe. The people are very fluid: they change jobs, so over time, they’re going to build trust.

Hengrui - they have a senior executive who recently joined. She was a senior executive at AstraZeneca. And Hengrui’s BD head was a former executive from the BD team at J&J. Hengrui’s BD team, most of them had worked in a Western big pharma biotech investment firm before. So they know how they’re connecting the trust, naturally exchanging on a personal level or professional level.

Before any massive core development collaboration deal is announced, hundreds of billions worth of asset transactions will have already happened. So the R&D team from, let’s say, Lilly and Innovent knew each other really well - actually Innovent received investment from Lilly many, many years ago. So this deal is their seventh or tenth deal. They start with a straightforward and simple - I sell you buy an asset, give you rights - that kind of simple integration, until right now it has become a full, almost marriage type of collaboration. It’s a gradual build up. So I see all of this as a very natural integration of big pharma with late stage clinical development capability and commercial capability, and China based biotech company that really proves themselves, who are cost effective and deliver high quality early stage research in a lot of disease areas. So I think it makes sense for both companies, and for both sides.

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4. Deal Trends: Part 2

Ruby: You mentioned there were three main types of trends and you talked about diversification first.

Leon: Diversity application is one. The second one, I would say definitely the influx of Western investment fund. Obviously, there are a lot of geopolitical barriers. There were many Western investors in China, I would say five or 10 years ago, especially in biotech. And then a wave of them left China, and then there was like a “China Rehab” capital challenge. And now they’re coming back.

There’s an incoming conference in late March called CHIC, the China Healthcare Investment Conference in Shanghai. The majority of their speakers are Tier 1 Western investment funds, senior investors. The Western investment fund are coming back. There’s Deerfield, there’s RA capital, there’s OrbiMed, there’s TCG Crossover Capital, you name it. Most of them are Western investors, most of them come from the United States, despite the uncertain US-China relationship. Despite all the geopolitical issues and the regulation and the government roadblocks, investors, are very, very pragmatic and resourceful. They figure out some way, because China’s early stage R &D capability just has so much more advantage compared to the Western biotech infrastructure or ecosystem. The investors just cannot let it happen without their capital.

The third trend is really on the regulation front. China’s regulatory agency used to be called CFDA. That just tells you how much the Chinese regulators admired the (US) FDA! That’s the name, before they changed it into NMPA, right? People used to say that China is a copycat. But guess what, the Chinese NMPA and Chinese government regulators are now coming up with new mechanisms. Now, China can do first-in-human or clinical trials so much faster and with so much flexibility, that its actually giving the US FDA a lot of pressure. This topic was brought up so many times in 2026. Albert Bourla, Pfizer CEO, talked about it, and the former commissioner of FDA, Scott Gottlieb talked about it, publically criticising the FDA: “you are too slow, you are too bureaucratic, you are slowing down our biotech industry.”

China has this unique system called the investigator-initiated trial (IIT). If you want to do, let’s say, AAV-based (adenovirus-associated) gene therapy for some rare diseases in the US, good luck! It’s very difficult. The FDA is going to require you to have a CMC package (Chemistry, Manufacturing, and Controls), prove you already have enough supply, you have a clinical GMP (Good Manufacturing Practice) facility, you have enough safety data, and you have protocol which costs tens of millions of dollars – all of this takes a long time.

The investors and the biotechs are really miserable right now if they are in the gene therapy space in the United States. But in China, it’s very different story. China has this IIT (investigator-initiated trial) system really designed for cell and gene therapy, without having to have a full blown commercial GMP facility, without even needing approval from the NMPA regulators.

If you have really encouraging data pre-clinically, and if you can really prove that it’s likely going to be very safe, with tremendous clinical benefit, then the hospital IRB (institutional review board) will green-light you, and you can get the trial done in a local hospital quickly.

This has already happened: EsoBiotec, the Belgian company, were doing in vivo CAR-T for a lentiviral based candidate. They did their first in human trial in China, and after just a few patient data, it looked really fantastic. AstraZeneca put down up to $1 billion to acquire the company, and it became the first clinical stage in vivo CAR-T based on lentiviral vector in the world. As of today, big pharma has done five acquisitions of the in vivo CAR-T company. Based on public information and private information, I can tell you that the majority of them have already started or will start first-in-human clinical trials in China.

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5. Deal pricing

Ruby: You were dropping these very high value deal numbers, with a lot of money on the table. When you’re looking at this landscape, have you thought: this is underpriced, or they paid too much there? Is there a big difference between some of these deals in terms of how realistic they are?

Leon: As a deal maker, I always think that the price is fair in that specific situation. The big pharma challenge is real, there’s a hundred billion dollars of patent cliff. The induced revenue loss is real. We all knew that Sanofi’s CEO Paul Hudson was on the way out. Every analyst will tell you the problem is, despite the revenue in recent years looking pretty decent for Sanofi, their patent-cliff problem was not being solved. That’s probably one of the major reasons he was asked to pass the baton to someone else So that’s a structural challenge for big pharma. They have to buy stuff, in-license new stuff, to maintain their pipeline and maintain their future revenue.

With that being said, before, China biotechs were honestly not very savvy in terms of doing deals with Western big pharma or biotech. This why some people called it arbitrage opportunities, and pretty much we call it the “China discount”. But in 2026, all of a sudden, the China discount - at least look at those leading deals out of China - is totally gone. And instead of getting China discount, now you have to pay the “China premium”. It’s crazy! They actually compared the recent transactions, especially asset transactions of license deals with Chinese biotechs compared to other BD deals of the same period of 2026 with Western companies of the same stage, say phase one versus phase one, phase two versus phase two - then you pay more to get a Chinese asset.

That’s a very interesting phenomenon, but of course, it is a little bit of FOMO. We know that a lot of big pharma right now have full-time employees of their BD team in China. One of the largest European pharmas has a BD team of 10 people based in China, go through all those Chinese assets, even talking to boutique Chinese companies. So as a deal maker, I always think: how can you get a good price if I have multiple bidders? It doesn’t matter if it’s Chinese asset, European asset, Indian asset or Singaporean asset, as long as you have, let’s say two or three bidders, you can use them against each other. You say that Party A gave me 100 million dollars, you have to match as Party B if you want to win. Pay more, it’s very straightforward. So because you have so many buyers in China chasing after the same hot assets, of course the price is gonna go up.

Like I mentioned, the Chinese Healthcare Investment Conference, there are so many investors also chasing after early-stage Chinese assets, because typically big pharma don’t feel like taking such high risks. It’s going to be the investors doing that, but now, investors have to compete against each other for the same early stage assets, even if higher risk. So of course, early stage asset price is going to go up as well. It’s just competition in the marketplace. expected market dynamics.

Ruby: So moving from China discount to maybe China premium, as you said, in some cases. there is all of this hype and an urgency to get hold of the right assets. But then at the same time, all of that perhaps is still sector specific. And in the general broader audience landscape, at least in media narratives and non-biotech specialist spaces, we’re still trying to convince everyone that Chinese biotech is even good enough quality or viable. So this widening gap between reality and the sector versus the general audience, I guess, that will just change with time as we see pipelines mature and patients actually taking these China origin medications, having their lives changed for the better around the world, then general audiences will start to see the evidence. And also, then, we’ll start to see the risks and the challenges come up as the reality lands. Do you find yourself a lot of the time still jumping between these two widening worlds?

Leon: Honestly, the generalist is really not a serious player in biotech space. Even in the US, if you look at who is really driving the biotech industry, it’s really the specialists. The specialists have so much capital, they don’t necessarily need a generalist. Generalists are placed mainly in big pharma, if you ask those generalists in government fund, sovereign fund, or retirement fund, they manage a hundred billion dollars. They want to invest their minimal check size of $200 million. How many biotechs can take that? They can’t. So what general investors would do instead is to look to big pharma. That’s it. That’s what a generous investor, especially a public investor is really doing.

Biotech is really driven by specialists. Now it’s even more clear. So I don’t really worry about retail investor in today’s situation .The science of biotech already complicated enough, and now you’re throwing in in China and geopolitical issues in it too. Honestly, I don’t recommend any generalist sitting in the US who doesn’t know any Chinese, to invest this sector. It’s too difficult!

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6. Deal-making drivers: buy side and sell side

Ruby: If we talk a bit more about your role as a dealmaker and in supporting investors on both sides of the world, can you take us behind the scenes - on the drivers, whether that’s on the buyer side, biopharma, big MNCs and top tier biotechs, what is changing in terms of how they search or screen? you mentioned marriage, decades long partnerships, slow building. But now that everyone’s getting conviction on China origin, China linked assets, what is changing?

And on the investor side, you’ve just mentioned maybe not the general investors, in your opinion, but at least the specialist investors. the funds are deciding whether the China risk, China exposed assets, even if they’re high risk, whether that’s investable next five years, and what they’re under or overwriting in terms of the science, the execution, geopolitics, anything else.

Leon: First of all, the big pharma, we call them strategic, including profitable mid to large cap pharma and biotech in the world. So for them, they typically have a capability to do multi-billion acquisition either as a company, which I saw this morning, Servier, the second largest pharma company from France, acquired the US based company, Day One.

I put that into this category, where they are pretty adventurous, have been China for a long time, and fully embrace China from A to Z. They even talk to the universities. One of the big pharmas, their China trip organiser asked me to connect them to Westlake University, which is now one of the best universities in China. They wanted to talk to the professor. It was fascinating how deep they are in Chinese biotech universe – not even just Chinese biotech, but Chinese academia - they even know that Westlake is good at the biological basic research. Very surprising how the front-running pioneers, even big pharma, really know China.

But of course in another category, they are a little bit more conservative, they are still worried. The most they want to do is just a license deal. So we see that wide spectrum: there are early movers, there are late adopters.

For investors, it’s very similar. There are some investors, they were created 15, 20 years ago when there was a first wave in the belief that China biotech might be promising. The best example probably is Lilly Asia ventures, created with the big help of Eli Lilly. It was a semi-corporate venture to begin with, and later on became an independent private investment firm. They’re one of the most influential biotech investors in China.

So this is a China dominant one. There are also some US ones. Probably the number one most active investor from the US is Orbimed. They never left China even when other healthcare tier one investment firms did, due to geopolitical, COVID, whatever reasons, the others left. But Orbimed never left, so now they have a huge advantage when China biotech is picking up. They got in a lot of good companies early on in. And of course, there are other tier one funds, who never thought China was important. So now they are playing catch up. And a lot of funds are actually opening their incubators in Shanghai or Suzhou. Some of them are shutting down their incubators in the Bay Area or in Boston. It’s happening because again, no brainer. If you are a capitalist, you just look at ROI. With $10 million in Kendall Square in Boston, you will not even have cell line development (for your biologics). But in China, with $10 million, you can probably already dose first patients in IIT trials.

So as an investor, if I get some technology, say from Harvard, I can either do the &D development in Kendall Square, so the professor can visit, or I can do it in Shanghai or in Suzhou, where the professor can still visit virtually, via ZOOM call, not a big deal. This week, actually, we saw the reverse emerge, of Candid therapeutics with Rallybio. That’s how they’re to go public. The article that described this IPO through a reverse merger, it called Candid biotech a “San Diego- Shanghai biotech”. This definition is very interesting. So Candid is one of the superstar private companies, and they are falling into this big category called “buy and build” biotech. Many companies in this category in the US start with a pipeline, they license the pipeline from Big Pharma.

But in Candid therapeutics, their four pipeline assets were licensed from China. Yet different from most other US biotech, they’re not a classic NewCo story (a newly formed company built around a licensed or spun-out asset). Most NewCo in the US, once they license the assets, they start developing in the US or in Europe.

But Candid decided: no. Since China is so efficient with early stage clinical development, why not just develop those assets in China? So they built a team from scratch in Shanghai, and they have multiple trials running in China. The company went out of a stealth mode in late 2024. Now they are going to IPO. How fast is that? The valuation is crazy. They start with $370 million series A. And before they reverse merge IPO, they raised another more than $500 million. So they raised $900 million, almost $1 billion. Now you can do the math of what their valuation going to be. Very interesting. And if you look at their investors, these are all the best investors, most of the best investor from the US, from China, Europe. So it’s big party, the most popular party, all those investors want to pile in.

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7. From the perspective of Chinese biotechs

Ruby: So we’ve talked about the biotechs on the Western side and the investors, but then also thinking about the Chinese assets and the companies that are producing these. As they’re now becoming increasingly selective about who they partner with, what are you seeing from their point of view as they’re gaining experience, becoming choosy in who they think has a good reputation to let them land better outside of China?

Leon: It’s about option. You can pick and choose. Right now, especially if you are Innovent, if you are Hengrui, or if you are CSPC, all those hot deals have multiple suiters, multiple bidders. Don’t think that the Chinese don’t know how to do deals anymore. They really know how to do deal, because their deal makers are trained in the US or in Europe, They know how the trade secrets of doing deals can be easily transferred just by building a team. Just get the talent to come over, and they’re going to streamline everything, and you can have globally competitive deals. A lot of investment bank and the top transaction lawyers are helping those China biotech biopharma as well. The talent is so fluid, in the end it is really about whether your asset is globally competitive, and can really fit the big pharma pipeline. China biopharma now have zero knowledge gap.

But again, the caveats. People say that China right now has somewhere between 5,000 to 8,000 pharmaceutical focused companies, including big pharma and biotech. That’s a huge number. But if you look at the companies who really have done meaningful deals in the past three years, the numbers are less than 200. So the percentage of really good China pharmaceutical or biotech companies is really, really low. Let’s say you talk to 100 Chinese biotech companies, the majority of them will be not so good. If you are not very selective.

Ruby: That’s a big difference proportionally. For a Chinese biotech company to choose to partner with the right Western multinational, is it that perhaps that multinational has already got expertise and market access in that particular type of pipeline? Or is it because they’ve got a longstanding relationship built on trust? Or is it that the size of the deal is the best? Or a combination of those and more. Hard to say?

Leon: This combination - all of this and more. It’s really case by case. Not because the company just said, believe my asset is best, I can sell it. But if you plan really well, sometimes you can envision what the future is going to be. And then if all the stars line up, by the time you are ready to transact and your asset becomes really hot, then that’s where you can do pick and choose. Then the decision process criteria, who they’re going to work with, is really everything you mentioned and more.

So it’s really hard to say, but the bottom line is the company who made the right decision two or three years ago to start a project. Right now, let’s say they get into phase one, you’re one of the hottest of the field. They’re have a really strong upper hand. There definitely is a seller’s market in that case. That’s where those big deals really come from.

Ruby: And then in terms of your job, delivering these deals and making those connections, as we’re saying, there’s not only excitement and realisation, but also hype. Is your job becoming easier now that you’re doing less convincing and more practical doing? Or is it trying to sort through the greater amount of things on the table?

Leon: I have two mandates. I have a buy side mandate, which is Western biotech companies and investment funds. I have a sell-side, when I represent my sell-side mandate, which typically is a China biotech company, phase one ready or phase one, phase two stage asset, we try to find a Western partner, outlicense our China rights. In that case, the good news is that I don’t need to tell them anymore that Chinese biotech research and assets are good. That conversation is now totally skipped, I don’t need to that anymore, they already are China believers. I barely talk to China skeptics.

A typical BD conversation, you tell them why this is a good fit for your programme, why this is going to have tremendous value if we work together because we are small, or we cannot do early stage clinical development, we cannot do commercialisation, but you guys can do that. We create a value together, That’s the typical stuff. The difference between representing a US biotech or European biotech to out-license to big pharma, and doing this for China biotech, is really small now. So that’s the sales side.

On the buy side, I represent the small guys, to buy Chinese assets. So actually our job becomes harder and harder, because the big guys, the strategists, are flooding China with their big cheques. We’re always joking that in the building process, any time big pharma joins, we leave. We get priced out. We get gentrified by the big pharma. They do the terms sheet of upfront pay much bigger than ours. So that’s always a little bit challenging.

However, the market has also become stabilised. Big pharma have all the cheques, but their risk tolerance is much lower than us, than my clients. My client typically their job is taking risks. Our chequebook is smaller, but our stomach for risk is much bigger. So that’s where we play.

I think that before, people in general labeled all the China biotechs as having less negotiation power, but now that label pretty much is gone. Again, a lot of China biotechs, if you legally look at them, they are not really Chinese companies at all. They’re either Cayman Island registered companies; some of them are just straightforward Delaware companies with operations in China; or the IP resides in the US or Europe from the beginning. So legally speaking, actually a lot of so-called China biotechs are European or US biotechs with R &D operations where the “R” is in China.

Even if you really define big pharma based on where they do R &D, AstraZeneca has five R &D centres, one in Europe, two in US, and two in China. So how would you call AstraZeneca? Is this a Chinese company, an American company, or a British or Sweden company? What’s your definition? They’re listed (as a public company) both in London and also in New York.

Ruby: As everyone is doing cross-border and having multiple locations around the world, it seems that strategically you call yourself whatever region is optimal for the situation you’re in. Whether that’s geopolitics, capital, whatever.

Leon: R &D is intrinsically and by design global. And somehow the politicians, the government need to pigeonhole them into different country, which just does not reflect the nature of this business.

Ruby: Yes, that’s such a great point. Health, biotech, innovation has always been global. Institutions and geopolitics, segments it all in challenging ways.

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8. Europe vs US

Ruby: Just picking up on European versus American investors, regional differences in appetite or perception. Can you share a bit more about that from what you’ve seen?

Leon: I would say one or two years ago, there was a misconception, especially by some American investors, or even especially American politicians, who believe that the US is the dominant buyer of Chinese biotech asset innovation. They said, once we cut off the US-China license deal, China is about to die.

Everyone in our industry was laughing so hard, because we know the numbers. Actually, in 2024, the Europeans spent more money than Americans in licensing Chinese assets. 2025, some people argued that because of the potential US ban of Chinese assets going to the US company. there’s a front load of Chinese assets in case this happened. And you remember last year, the draft executive order from Trump administration to ban Chinese license deals, someone saw that, and they front loaded. So last year, I think the US probably spent slightly more money on Chinese assets than Europe.

The China biotechs, they have option, So a good example is the largest China outbound deal by value - it’s not with the American companies, it’s with AstraZeneca. AstraZeneca and CSPC signed the largest deal ever with China Biotech, $18.5 billion. And also remember, when did AstraZeneca sign the deal? when Minister Starmer visited China. So that was one of these diplomatic icings on the whole thing.

So we cannot say to Chinese biotechs, we demand you do this. They would just say, if you’re really so demanding, I won’t do business with you, I will do business with Europeans. That’s why people realise banning the US-China dealmaking would be such a bad idea for the US biotech and biopharma and US investors. The net is a huge downside for the US industry. So we should just figure out a way how to live with China. Take something they’re very good at, take something we are really good at, and let’s just work together, create value together for patients around the world. I think that’s where the mentality should be.

And you can also tell right now, instead of blaming China: “they steal, they cheat, they subsidise”, which is just a little bit true, most of it not true, right? Now there’s sharp contrast between how China does things and the US does things. The US gas realised our FDA is the problem. I mean, the Chinese have IIT, we have nothing like that in terms of equivalent pathways.

For a US biotech company, if they are invested by some well-informed investor, they will tell them to do the first in human trial outside of the United States, and to recruit patients as much as possible outside of the United States until trials must be done in the United States to satisfy regulations. It used to be Australia as a preferred choice, but now China gradually become the preferred choice because of patient population, because of cost, because of everything.

Ruby: From the China side, what do they see as an advantage of Europe versus America? Or are there not really, because as we just said, every company is actually global?

Leon: So I think in the US, our position makes it very clear that biotech is a bargaining chip. So whenever President Trump and President Xi need to negotiate, this is on the table. It’s just the risk. Biotech needs certainty. And we are in such a high-risk industry. Any regulatory geopolitical uncertainty can destroy a company, period, and that’s exactly what happened, domestically in the US. That’s why a lot of investors say they will never stop investing in cell and gene therapy in the US, just because of FDA, unless they’re weak.

So the same thing for some, not all China biotech biopharma. If they want to have five year, ten year collaborations with a partner, they want to make sure the partner is going to be located in a stable environment. In that case, Europe probably has more attractive potential than the US. There are a few straightforward European acquisitions of Chinese located or based biotech company in the past couple of years: Gracell was acquired by AstraZeneca, ProfoundBio by Genmab, Biotheus by BioNTech, and another was SanReno, acquired by Novartis. All those buyers came from Europe. That could be just an accident… you can form your own opinion!

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9. Execution

Ruby: And then moving on to the execution, after the deal and the partnership gets going, what signals can we use to predict the potential of realisation or the risks of these cross border partnerships, for Chinese biotech with enough capital, enough expertise, if they decide to utilise their own manufacturing and supply chains on the ground in the US market, rather than partner with a Western MNC to access patients and providers? Obviously, maybe it’s early on for some of the deals we’re seeing now, but the ones that have been going for a couple of years now. What are you seeing being indicators of them being successful or less so,

Leon: If you really want to become commercial stage company for the Western market, even if the innovation originates from China, you have to manufacture their stuff preferably in the US or Europe or in allied friendly countries. So that’s one of biggest barriers for the China biopharma biotech to climb the value chain, and to become a late stage or commercial stage for the Western market.

BeOne is now a Swiss company, it’s not a China company legally. So they totally uprooted themselves and put themselves in the Western ecosystem. So I don’t treat B1 as a China biotech at all, but a European or global, mid-sized biotech. so all the baggage other China biopharma have, they don’t. But for the others, like Hengrui, they do have the challenge. Their manufacturing, their R&D efficiency, cost advantages and so on, only exist if they do that in China. If they leave China, they leave their core competitive advantage, that’s why they have to partner with the Western biopharma.

So that’s why I don’t worry much about the late stage biotech or strategic big pharma, big biotech from the West. They will not have much pressure from the rise of China biotech, because actually, especially between US and China, the geopolitical issues create a pretty insurmountable barrier for China biotech to really climb the value chain. To use the jargon of NPV (net present value), the majority is going to stay with the US biopharma, with large biotech, just because they control their manufacturing, they control their commercialisation and late stage clinical development capability.

10. Looking ahead

Ruby: And finally, the forward view. We’re in March now and we’re looking ahead at the rest of 2026 and beyond. From today’s vantage point, what are you watching for, in terms of the momentum going forward?

Leon: The biggest one is really still the regulation and geopolitical risk factors. We are a global business, and anything that disrupts the global collaboration and money or capital flow or change of knowledge is going to be pretty substantial for our industry. So that’s definitely number one risk for China-to-West collaboration.

But of course, people get into biotech because there’s a lot of upsides in helping patients around the world. I would still closely watch the deal flows, either licensing deal or R&D collaborations like what Eli Lilly did with the Innovent. If those kinds of deal flows continue without any sign of slowing down, the truth is that the American corporate executives are so well informed, and they have a direct line to the White House, to all those Congress, policymakers, lawmakers, and they make informed risk taking. If that continues, probably their evaluation of risk exists - but it’s not that big, which is good.

I will also look at the exchange of talents from the West and China. whether they continue, whether collaborations also continue. If that’s the case, I think that misconceptions and misunderstandings will be less likely to happen, or less likely to mature to such a stage that some dramatic detrimental decision would be made from either side of government or policymakers. So those are three things that I’m most curious about.

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Watch or listen here on substack or Youtube, and/or subscribe on Spotify & Apple Podcasts. These newsletter posts provide all links, plus a full text transcript of each episode.

This week, UK–China relations are back in the spotlight. Keir Starmer is the first British Prime Minister to visit China in 8 years, and his trip is renewing attention on how the West is defining engagement, risk, and cooperation with a country that is now a global producer of frontier technology and innovation, including medical science, pharmaceutical innovation and artificial intelligence.

Today’s timely episode looks at the longer relationship between Europe and China that sits underneath moments like this, to understand what responsible engagement can and should look like today and in the future, focusing, of course on health.

My guest today is Professor Kerry Brown, an academic, sinologist/historian, former diplomat and prolific author who has spent decades interpreting China for Western audiences. He has published over 20 books on modern Chinese politics (see end of post for list), as well as written for every major international news outlet, and been interviewed by every major news channel. As one of the key voices on China in the West, he is adept at articulating the necessary yet sometimes uncomfortable truths about how such a complex nation can be understood by the rest of the world.

Kerry is the Director of the Lau China Institute at King’s College London, where he is also Professor of Chinese Studies, Associate of the Asia Pacific Programme at Chatham House, Adjunct at the Australia New Zealand School of Government in Melbourne, and Co-Editor of the Journal of Current Chinese Affairs. He was previously Professor of Chinese Politics and Director of the China Studies Centre at the University of Sydney, Australia, and directed the Europe China Research and Advice Network. Before that, he worked at the British Foreign and Commonwealth Office for almost a decade, as First Secretary at the British Embassy in Beijing, and then as Head of the Indonesia, Philippine and East Timor Section. He holds a Master of Arts from Gonville and Caius College at Cambridge University and a PhD in Chinese politics and language from Leeds University.

Our conversation connects historical context with present-day relevance to explore why medicine, health and science have become some of the most consequential - and least understood - contact zones between the UK and Europe with China, and how academic institutions are crucial influences on medical knowledge and healthcare delivery for patients everywhere.

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Read our Conversation:

(Audio transcript adjusted for clarity and flow)

1. The changing bilateral relationship

Ruby: This week, UK and China relations are dominating headlines, and you’ve been providing expert commentary on Keir Starmer’s visit to Beijing. But you’ve been writing about this relationship over a much longer arc. And in your book, The Great Reversal, you outlined a bilateral history of over four centuries. I know you’re currently working on a sequel, which looks at the wider relationship of the European continent with China. So if we step back from the headlines and look at the historical context, what have you found in terms of life sciences and medicine that stand out in the relationship with China, and what feels different about where we are today compared to before?

Professor Kerry Brown: What’s really changing is that, in the past, the British and the Europeans had a fairly superior view of their own abilities, compared to China’s technological and scientific and medical ability. We had historians like the great Joseph Needham, who reminded the West that in China’s distant past it was really an important player in terms of science and inventions.

But what we’re seeing today, and certainly on the visit by the Prime Minister of Britain to China, is a great rebalancing, where China has capacity, people, funding and is producing really important new things. And I that has happened very very quickly. 15 years ago, we wouldn’t really have been looking at the absolute speed of China’s ability and the way in which it’s become a research superpower. And that’s creating all sorts of challenges, but it’s also an amazing moment to see this completely new capacity joining the world community. That’s a very big change.

In the past it was often true that Britain was keen to promote itself as a country that was great in technology and great in research. Nowadays, we still have great capacity, but we’re learning to be a bit more humble and looking at ways in which we’re collaborating with the Chinese, where they really have major important innovations and abilities that we just don’t have.

As you’re well aware, universities in China are now really going up the global rankings. Fudan University, Tsinghua University, Beijing University, Beijing Medical University - all are rising almost every year, at a time when Western universities are on the whole either fighting to maintain their position or falling.

That’s just one area in which we see major structural changes, but it’s a story that is going to really accelerate, and every day we have to make sense of China doing something that we didn’t really think it was going to do before. This is exciting but a bit scary.

Ruby: It’s been such a rapid change. When I was in the Foreign Office at the British Embassy in Beijing during the pandemic, so only five to three years ago, when we were delivering on UK China health collaborations, it seemed to mostly be one directional, the UK sharing health expertise to China. But now it seems increasingly it’s mutual or even the other way around from China to the West. And so, talking about COVID as a stress test for the whole world.

2. Impact of COVID

Back in 2020, we wrote a journal article together on the politics and the science of the coronavirus. But we wrote it in April 2020 before we even knew much about routes of transmission, the scientific aspects. Even then, it was so clear how biases and politics tend to overshadow the science. When we look now back at the pandemic, what do you think it exposed about expertise and technical authority and trust in public health, when comparing how different nations and systems acted? And how does that impact how we look at China now, or China looks at us, in terms of trust and understanding, and therefore the potential for collaboration?

Kerry: The pandemic was really the great leveller, because to be honest, no one came out of it looking particularly good. We all had vulnerabilities exposed and that includes China. Towards the end when there was the more infectious Omicron variant, or the protests at end of 2022 against the very serious restrictions, even China was struggling, and people questioned the data about how many did die from the virus there.

Everyone should take the pandemic as a learning experience because we all really struggled and our health systems came close to collapse in many places. We learnt that there’s definitely an issue of trust. China was sometimes explaining things and wasn’t trusted, sometimes it was accused of hiding things - and the West seemed to instrumentalise this issue against China. Trump referred famously to the “China virus” and there was this really unpleasant period when suddenly anything to do with China was a problem, and the place itself was, this great toxic issue, and I hadn’t experienced that before.

It became very difficult for it to feel that this was not just about the politics, there was cultural and even racial issues. That was quite sobering for me, and I think still we’re really emerging from that. Although there are more pragmatic relations now, and Britain has certainly returned to a more balanced relationship with China, all of that left deep issues and caused strong voices in Britain to feel that, in many ways, because of the pandemic and other reasons, we should have nothing to do with China.

I’ve argued publicly that this is not rational. We’ve, as you said earlier, got a long history, Britain and China. We’ve had ups and downs. Xi Jinping yesterday, when he met the Prime Minister Sir Keir Starmer, said something about a turbulent relationship. I guess we know that’s always been part of how we get on with each other.

But despite that, the other thing that we learnt from the pandemic, which has been reinforced by other issues, is that we can’t deal with these issues as nation states. There has to be a broader international response and how we do that, in what way we do it. That’s not easy, but the underlying reality is that any pandemic is not going to respect national borders in the future. And one thing we should have learned from what happened in 2020-2021 is that a more coordinated and a more effective way of collaborating across borders is really important. When the pandemic first appeared, it was very chaotic and there was no real consistency. We can’t have that happen again because the toll not only on people’s health but their mental health was colossal.

Ruby: The pandemic, health and science previous to that were treated as the softer or safer spaces for engagement across borders - and maybe deprioritised because of that, to be something to do when other areas feel more contentious, or perhaps when smoothing of relationships is required and it can be a comfortable place to lean on. But as China’s biotech is shaping economic competitiveness and future disease threats are realised to be tied to security, that distinction has changed so much. And so now health is, as you said, right in the middle of much more hardline topics.

If we’re looking at universities and academic institutions and medical schools getting caught up between political signaling and trying to deliver operationally. Even though health behaves so differently from trade and security, it’s still fundamentally shaped by these wider factors. You work directly on academic collaborations through King’s College London and the Lau Institute, including on medical school partnerships, on nursing training, and you’ve written on this quite recently for Nature as well. How have you seen these academic collaborations across the UK and Europe with institutions in China?

Kerry: They are significant. China is our second largest research partner after the United States. So it’s bigger than Germany, it’s bigger than France. In terms of peer-reviewed we’re producing, I think, 16,000 peer-reviewed papers with Chinese colleagues every year - and a lot of that is in life sciences. Some of it is in business studies and other areas but life sciences and medicine are key areas.

King’s College London has two well-regarded teaching hospitals, St Thomas and Guy’s, and we’ve set up a degree where we teach medicine to Chinese students in Shenzhen in Southeast China, and we do a nursing project in Nanjing.

One of the issues is: what are our common values? And that’s not so simple because in the past certainly, there was an idea that a lot of the experimentation, a lot of the clinical trialling in China was less regulated. I know that GSK and other companies sometimes had issues about how drugs were trialled in China, and there were lots of regulatory and also ethical issues. The Nuffield Foundation had an ongoing project of thinking through what are the ethical parameters to work with Chinese colleagues. In the past that was critical. You remember when a doctor was accused of gene editing and DNA editing. This was something even the Chinese government at the time rejected - he lost his job. But it was a sign that this was an environment where anything goes. I remember an astonishing example, actually of an Italian doctor, I believe, who was trying in Heilongjiang in Harbin to do the world’s first head transplant. And I do remember, the head of our college at the time was a neurologist. I asked him as an expert could you ever think of doing a head transplant and he just looked at me rolled his eyes and said no no no that’s not possible. Now it is much better regulated, and that’s because of a lot of the work that, colleagues like you did when you were working in the embassy.

There is much better understanding of the need for common values to reassure patients. and now, in the Chinese healthcare system, as far as I have had experience of it, when it’s good, it’s world class. It’s really excellent and outstanding. It’s a vast country, so there are massive differences, but in Britain there are also massive differences, so that’s not unusual. I suppose though that we have a probably more embedded sense of dealing with common risks and common calculations of what would work and what wouldn’t work.

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3. Ethics and Rights

Kerry: I don’t think it was a waste of time to think about common ethical principles. One way to see this is that China is not into the idea of universal values. I mean, it doesn’t mind rules and regulations that sort of work for utility. It’s best that everyone drives on the right side of the road, or the left side of the road, rather than trying to mix them up. So you have global rules to make sure that there are common standards, and it just means that things are possible, and that you can stop inconvenience or even catastrophe.

But I don’t think that China buys into this idea that there’s a set of values, like freedom and all the rest of it, are universal and have to be transferred from one society to another. So I think the Chinese roots are a more communitarian approach rather than a universalist approach. the idea of Chinese society being very networked not really buying into the idea of an overarching set of values. China was always quite a hybrid society with Confucianism, Taoism, Buddhism and really more of a of battleground of belief systems. It never had a common belief system like Christianity operated in the West. So I think that lingers - not to say that classical Chinese thinking is not full of rich, profound thinking, and Confucianism is an ethical system - but it’s certainly different in the way that it judges values.

There are issues about why one should do things and what one’s aims are between Western institutions and Chinese ones today. For instance, on the issue of human rights, China would say that it believes their collective human rights are to deliver development for society, as a fundamental thing to make people’s lives better. And that’s true. China eradicated absolute poverty four or five years ago - that’s a huge achievement.

But in the West, we still believe in individual rights, and the power of the individual, know, the great enlightenment sort of view of the world, that the individual is the final arbiter of what is right and wrong for them. And so there’s a fundamental difference obviously on how we view and frame human rights. That is probably something we now are more able to accept: that we’re different, rather than trying to have a clash. In the past, Europeans had a reputation for really believing they could change China. I think today we realise that we just have to accept that we’re different.

But at KCL, we’re now looking more at risk management and not really trying to get dragged into big discussions about the fundamental principles. Just assuming that Chinese colleagues are motivated by the same things as us in the healthcare system, which is to look after people’s wellbeing. As we discussed in the past, for mental health it’s really, really interesting because clearly both our societies are having a massive struggle with mental health. The pandemic was pretty brutal in Shanghai, in lockdowns there. It had a big impact on people’s well-being. in a sense that has also given us a common ground. I don’t know whether the prime minister’s visit will be able to address those kinds of collaborations It’s more difficult, it’s more culturally embedded and bounded, but it’s likely that as China becomes more wealthy and more developed, it is experiencing critical issues where people struggle with their mental health, and so I think that’s an area that we definitely could construct more of a common framework in the future, as we’ve already done with more traditional areas of medicine and treatment.

4. When it works well vs not

Ruby: And in practice, when academic collaborations work well, what does that actually look like on the ground? What types of methods of collaboration align culturally or operationally across the two sides?

Kerry: In 2011 I remember the National Development Commission, a think tank in the National Development Reform Commission, produced a report with the World Bank called “China 2030”. And one of the issues in that was how to develop a modern healthcare system. I did some work at the time when I was based in Sydney with our medical faculty there about what that meant. And one of the issues was moving from, infectious diseases to chronic diseases - cancer and heart disease being the biggest killers.

The premier at that time, the late Li Keqiang, he made a speech about healthcare as a generator of GDP growth. He talked about the new spaces of growth in China that were needing development, because the growth rate was falling obviously as China became more developed. He talked about healthcare very much as a growth generator - so actually, strangely enough, the UK and China align because British universities are capital hungry; they like big paying projects. I’ve discovered that, in even the most benign looking healthcare cooperation, it’s often a very commercial undertaking.

And one thing about collaboration in China is that, within any business deal, people go in with very big ambitions. They think they’re going to be providing a service to 1.4 billion people, and will become wealthy. And then of course reality hits them and they realise it is a very very different market. I remember dealing with an Australian care home provider that was very successful in Australia, and it thought wow there’s an ageing population in China, we’ll be able to set up posts there. And then they realised that the whole system was completely different - the regulations, the funding.

So I’ve learned that it is often the commercial issues that are going to be more challenging and that being realistic about that at the beginning is going to probably frame what you can and can’t do because if you’re going to have a successful project you’ve got to realise it will probably be quite a lot of work, You’ve got to ramp your expectations down and just make it probably what you would try and achieve in Europe or your home territory rather than go into this idea of a massive market in China that just needs to be tapped for you to become super wealthy. I think that lack of realism has been a big impediment over the years

The other thing about China is that it varies a great deal across the country. You’re doing collaboration in one place, like in Shanghai, it’ll be international standards mostly, probably better than we would find in many British places. But if you go elsewhere, it’s obviously very, very different. China is a continental-sized country. It’s literally a world within a world, So I think that that complexity is often very hard for people to navigate and there’s not really the common standards across the country That’s true in other places, but I think in China, it’s very very varied. So it is not easy to make generalisations about working in China. You do really have to know your partner and know what you’re doing and why you’re doing it and that takes a lot of communication and trust-building.

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5. Pressures and operational challenges

Ruby: And then for Western academic institutions, or just institutions, in working with China, are there any pressures back home on how that is done?

Kerry: I think the pressures are public perception. You have to communicate what you’re doing and on the whole, the political environment in Britain towards China is better now. But you certainly do have people wanting to scrutinise what you’re doing, why you’re doing the part you’re doing, and then they’ll make all sorts of claims about there being a problem in China. It is hard to do due diligence in China, I think. It’s often very, very difficult to get access to the records you need. But at the end of the day, if you’re dealing with very prestigious universities like Beijing University or Tsinghua, they have a reputation I don’t think they want eroded, so they’ll usually be the right partners if you can have them.

The other issue in terms of academic cooperation, is whether there can be a clear sense of what you are going to get from it. We’re not into altruism - I think universities are very self-centred. And that’s fine, because it’s a very tough time we’re moving into. KCL has had a good experience with China in terms of students coming here, but that’s obviously changing now. Universities in China are really excellent, many of them, so Chinese students are tending to go to them more often than are coming abroad, and the numbers are coming down. But it’s important to see strategically what you can achieve from China that addresses some of your research or student recruitment needs. British universities on the whole haven’t probably put a great deal of thought into a long-term China strategy. It was always good having so many Chinese students with the international fees but now they’re having to think: how are we knowledge partners; how is that an equal relationship when China - as I said earlier - is so advanced in many areas; what do we think we’re getting from this relationship that works for us, rather than being overwhelmed?

So thinking strategically is really important. At the end of the day though - and it’s true in many areas - the people to people contact is good. It would be good if we had more people going, because I think that opens people’s eyes and creates these dialogue opportunities which is what we need. Of course, there are challenges sometimes with working with Chinese partners for cultural issues. Sometimes politics gets in the way too and administration. But actually despite all of that an enormous amount of very positive collaboration happens between individuals and I think that that’s probably always going to be the case.

6. Europe

Ruby: And is there a distinction between how UK institutions do this with China versus wider Europe or it’s quite similar?

Kerry: I think the difference is that the UK has a massive advantage in the number of Chinese students that have been here who are bridges. That’s been true for 25 years, even if many have gone back or many are in academic positions. I met two cancer specialists the other day, one originally from China who’d come here in the mid ‘80s, and the other who came via America at a similar time, but is now based in Britain. These are internationally respected experts, and they are here in the UK because they came here to study, and stayed. That has given Britain a big advantage, because it wasn’t so common in other European countries.

Also, the fact that we use English has been a big advantage, because most Chinese now do learn English rather than than French or German. And in addition, we still have a good reputation in medicine. I don’t think Britain can be complacent about this though. 25 years ago, as a diplomat, we would go and promote the National Health Service as being a really great model for China. That’s not really the case now. China has an interest in British academics and British expertise but probably less so in British health practices. I think that’s definitely changed.

Ruby: As you’re researching for your new book on Europe-China relations, are there any insights that you’ve gleaned relevant to what we’ve talked about today?

Kerry: Europe has been seen by Chinese as a knowledge superpower. and historically, the European Union members, Germany, France, Britain, when it was a member, there was a lot of technology transfer. And I think it is important to remember that now the situation is that China is producing the technology that we need rather than the other way around, that we do need a kind of framework for that to happen and that doesn’t exist at the moment. I Europe exists as a technocratic kind of entity really, at least the European Union does, and it is really in the business of creating frameworks for things to happen if it’s trade, investment, I think technology transfer is something that Europe’s going to need, It’s an alternative up to a point of America, but not too dramatically. So I think Europeans thinking getting access to Chinese technology is very important.

But the role of Europe as a cultural power in China, It’s still regarded with great respect. And in the new geopolitics that plays well because America is not an easy partner to deal with now and Europe has a potential to be just different to that and have a more pragmatic relationship with China, even though it’s unlikely that it would lead the side of the United States. that’s never going to happen in terms of security. but there’s other areas where they can work probably more deeply than they do at the moment.

Ruby: In bio-pharma, compared to the US with China. tariffs and security legislations meaning Europe becomes an alternative and less risky option at the same time, Europe’s built this reputation of being a regulator to the extreme, this applies more to digital actually, and data privacy and restrictions to the point where it’s been critiqued to actually hinder progress.

Kerry: I think the phrase was that America innovates, ⁓ Europe regulates and China imitates. well, Europeans probably believed that without regulation you couldn’t innovate and therefore it was just creating the infrastructure and the ecosystem that you could magically do things you couldn’t before those rules and regulations were in place.

Europe’s historically seen itself as diverse and therefore creating internal competition that would make people fight to have better ideas. it’s an old idea that why did the Industrial Revolution happen in Europe? Because there was real competition between city-states really and that people like Galileo could go from one place where he was being persecuted to another and be able to continue.

It’s puzzled Europeans for a long time why China didn’t take part in the Industrial Revolution and why it fell behind after an initial history of being a really important scientific power. today you would definitely criticise the European Union as being too much about regulation and that the Europeans are quite defensive. Their posture towards electronic vehicles, EVs, has mostly been driven by the German manufacturing industry that are obviously very uneasy with their export markets for their cars.

So I don’t think Europe was really prepared for a China that was innovating in ways in which it would be very competitive and then extremely able to export into the European markets. And they have complained about over capacity. They’ve complained about China and state subsidies. That’s become a big, political issue. I don’t think Europeans are going to stop regulating.

But they’re going to have to do things in a different way because the whole pattern of their relationship with China now, like with the UK and China, is changing because of this technology issue. And I don’t know whether collectively they’re going to be able to do a kind of deal that Britain would also want to do, a sort of technology transfer deal, because they have such huge capacity. But the last attempt they had to do a deal, the common agreement on investment in 2019 was negotiated for seven years. was relatively good deal, but it was stopped for political reasons. So politics definitely gets in the way.

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7. What China wants

Ruby: What have Chinese stakeholders shared about what they are still keen to learn from UK or Europe? Where do they think the West still genuinely adds value e.g. clinical research or medical education, any topics that you see that there is still interest, respect and eagerness?

Kerry: I think certainly medical education. King’s has set up a joint medical degree in China. There’s respect for that, but I think, it’s becoming more and more competitive. China is producing really important research. It’s got great capacity, its research and development budgets are massive. When you go to Chinese universities they’re well-resourced, they’re impressive and new. Zhejiang University has a massive new campus and last time I went to Chinese University Hong Kong in Shenzhen, also massive new campus. Shanghai Jiao Tong has a big medical faculty as well which is incredibly impressive, just massive.

I think that the story is likely to be what are we going to do to get access to Chinese in innovations and medical knowledge now. I mean I think it’s a a tipping point, my sense. I mean we definitely are going to have to become more competitive, and our mindsets have to change. Because it still lingers, you know, the idea that we are definitely superior in terms of how we do things and educate. Yet every day now, you see that being contested. So that mindset has definitely got to be revised pretty quickly.

6. Learning

Ruby: It’s tough to revise it, right? as a former diplomat and sinologist, you’ve been advocating for nuanced engagement across the East and West for decades and you’ve mentioned the response is improving in the West, but it’s all still relatively outdated, and not nuanced enough. So what does that mean? How do you communicate effectively?

Kerry: The speed of change in Britain is not great. And you can say the same thing 50 times and finally, someone might say, okay, I hear you. I mean, I’m happy that there’s now a more pragmatic relationship, because it makes sense, it’s rational.

I don’t like irrational actions. I’m a realist, you know, so while I understand there are cultural and other issues when you’re dealing with countries with a very different background and a very different history and, maybe a different understanding of their role in the world, which China clearly has compared to Britain. But I think that we just have to be reflective.

There is discontent in Britain. Obviously people don’t have a great experience with their healthcare here. The primary healthcare system is frustrating people, long waiting lists. I think we’ve got to really do what the Chinese do and look around and say, okay, if this doesn’t work, then what does work, and where else can we learn from? And when China was emerging from the Maoist period in the late 70s, it was impressive the fact that they had their delegations go abroad to look at everything - and they did it for a long time. They still do it to some extent.

I think that that’s very praiseworthy - these delegations to come and look at the UK’s devolution, looking at our National Health Service, looking at our educational system. China didn’t necessarily adopt many of the things, and sometimes people thought - well, why are they coming - but I think that there was a lot of reflection and study of what others were doing.

China took some things and ignored others, and I think Britain needs to duplicate that. We need to have a good hard look at other healthcare systems, and the funding of those systems. I worry about how Britain is going to navigate these issues when we can’t afford what we have at the moment: with an ageing population becoming a bigger and bigger problem. China has similar issues, it’s got an ageing population, and I’m fascinated by how they’re engaging with technology, the use of robots in China. I’m fascinated by how that works and what are they going to do about their significant demographic issues? This is all stuff that we should be going to learn from, because in many ways China is a massive social experiment. So why don’t we just look at this and see what we can learn here? There won’t likely be many things that we can learn in the political system because we are very different. But in healthcare or in education, maybe there are ways in which we can learn.

It has to become much more systemic. But you’re absolutely right, changing attitudes and mindsets is a cultural issue, and nothing is harder to change than those cultural issues, because people really cling to them, they’re part of their identity. It takes a real shock to make people reflect on, is this really the right way to do things? There’s obviously real challenges. I don’t know if anyone’s doing it right but I don’t think that we can say we’re a great model, Britain at least, and probably not America. So we are in this period of great levelling where we’re all grappling with similar problems and no one’s got an absolutely great solution. We’re going to have to really thicken our discussion and dialogue to learn from each other and have better routes to learning.

Universities in Britain don’t have obvious institutionalised ways of talking in a very open, frank way to Chinese colleagues about what are our common challenges, how do we deal with them. We do it in a really ad-hoc way, but I don’t think that we do it on scale. And I maybe we’ll start to do that, but that will take a lot of trust building and a lot of openness. To be honest, the fault is as much on Britain’s as was on China’s side. We are probably not happy trying to open our eyes to a very different place and a very different cultural outlook, maybe giving us ideas for how we could improve, but I think we’re going to have to start doing that.

7. Risks of not engaging

Ruby: I guess, as an academic, you’re advocating for a more academic method of learning and understanding! Maybe a strong communication method also is to think about the dangers of not engaging and the more heavy handed risk angle. Whether that’s, as you’ve mentioned, on shared global challenges like ageing populations, rising chronic disease or pandemic threats, or if we are viewing even medical and science collaborations with China as national security risks or competitive threats, then ensuing decoupling. What are the risks of that?

For example, this morning I was reading about how leaders in the Conservative Party have been criticising Starmer'’s trip and saying that if the Conservatives were in power, there would have been no visit by a British Prime Minister. And there was pride in the fact that there hadn’t been a leadership visit in eight years, which I thought was a pretty incredible perspective. But can you share from your experience, and your writing as a historian, what are the risks of not engaging with China on medicine and on health?

Kerry: They’re pretty considerable. Hypothetically, and it’s more likely now than it ever was in the past, some of these amazing start-up companies in the science parks in Beijing or Hangzhou or Shanghai, what if they come up with some really good effective treatment for cancer for instance, or any other sort of significant chronic disease? Everything points to that being more rather than less likely.

At that point, do you maintain this “we don’t want anything to do with them” even if they may have come up with a really great treatment for heart disease or something that really would be hugely important to us, but it doesn’t matter because our values are so important that we won’t even engage in this area? I think that makes no sense, that can’t be in your self-interest.

You’re right, the politicians in Britain are really good, when they’re out of power, of saying that they definitely wouldn’t do anything. And the moment they come into power, then it all becomes very, very different. I think it would be very weird if a conservative party with the current economic issues was still in power, that it wouldn’t look to have some sort of deeper dialogue with China, particularly because the geopolitics now with America becoming very unpredictable, means that you’ve got to basically look after your interests and diversify your relationships even with those that are not remotely or traditional allies.

So the risks of not engaging with China now are significantly more than they were 10 years ago to 20 years ago. It keeps on getting more and more obvious that you don’t really have many options. You can’t give yourself the illusion of choice. ⁓ We don’t have much choice except to work with China.

The anomaly at the moment is that actually, despite the differences on big issues, the things that really will matter to humanity do matter to humanity. China and Britain don’t really disagree on the environment. We both agree there’s a massive problem on AI. We are both concerned on public health issues. We both think there should be priority on nuclear proliferation for different reasons. We are both not keen on massive increases in nuclear weapons, particularly because China’s got four neighbours to the nuclear powers.

So actually on the big stuff, we don’t disagree - which is not the case with the USSR and in the Cold War where there were fundamental disagreements. It is therefore odd that we argue as much as we have in recent years because we actually have more reasons to agree and converge than we have to disagree. And politically I think that it’s not a priority for Britain to argue with the power that we agree with a great deal. It is a priority to be clear about where we have issues and know why we have those and how we can protect those. But that’s a strategic issue, it’s not a of absolutely massive existential issue where you just won’t deal with the power no matter what. That doesn’t make any sense.

Ruby: Starmer has said today that like it or not, China matters for the UK. what do you think responsible, productive engagement looks like when we’re talking about health and medicine and science?

Kerry: I think it’ll be cautious. But it would also be pragmatic in the recognition that Britain’s needs are real. There are a huge number of pressures on Britain, economic, geopolitical and otherwise. A pragmatic relationship where Britain is clear-eyed and has sense of strategic priorities is really important. I think the Stammer visit, well, it’s high-level dialogue, it’s not going to make an immediate impact tomorrow, but at least we’ve got a more open-minded environment in which we are just trying to relate China and what it has to our current needs. I think we hope that will lead to some practical outcomes. A difficult relationship - we’re very different - but at least this relationship is going to be less hackling and hectoring than it was in the past.

Professor Kerry Brown has written over twenty books on all aspects of contemporary China. These give an overview of the modern development of China’s politics, society, economics, and history. They have been translated into over 10 languages.

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Watch or listen here on substack, and/or subscribe on Spotify & Apple Podcasts. These newsletter posts provide all links, plus a full text transcript of each episode.

Happy 2026!

To welcome in the new year, the CHP Podcast is delighted to be joined by Josh Smiley, President and Chief Operating Officer at Zai Lab 再鼎医药 - one of China’s most globally recognised innovative biotechs. As a seasoned senior executive in the global biopharma landscape, Josh sits directly within the intersection of science, regulation and capital markets - he brings a rare insider’s view into China’s biotech rise.

Zai Lab was founded in Shanghai in 2014 and now operates with offices and dual-listing across China and the US (NASDAQ & HKEX). It is well known for bringing cutting-edge medicines into China, partnering with argenx, Bristol-Myers-Squibb, GSK etc. in immunology, oncology and neuroscience, while increasingly advancing its own pipelines toward international markets.

Since joining Zai Lab in 2022 as President and COO, Josh oversees all aspects of the company’s commercial operations, manufacturing, business development, finance, human resources, information technology, corporate affairs and overall strategy.

Prior to Zai Lab, he served as Chief Financial Officer for Eli Lilly, one of the world's largest biopharma multi-national companies. He spent more than 25 years at Lilly, in positions of increasing responsibility, including as senior vice president of finance, corporate controller and treasurer, and in leading US sales and marketing, business development, and mergers and acquisitions. Earlier in his career, he worked in investment banking and consulting, and he holds a BA in History from Harvard University.

In our conversation, Josh speaks candidly about the realities of operating inside China’s biotech ecosystem, where ambition meets constraint, and how global innovation is scaled and adapted across borders. It is a wide-ranging and substantive discussion that offers genuinely distinctive insights from someone who is shaping the sector from the inside.

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(Audio transcript adjusted for clarity and flow)

1. Introduction and the Evolution of China’s Biotech

Ruby: Josh, it’s so great to have you here. Through my strategy work with you at Zai Lab, I’ve had a front-road seat to how you think about the global biotech landscape and China’s position within it. Many people have strong views about this space, but few have a true insider’s perspective like you do.

Josh: We’ve been around for 11 years now at Zai Lab and our founder and CEO, Samantha Du, was one of the pioneers in China biotech going back to a company called HutchMed back in the early 2000s. She’s from China, but trained in the US at Pfizer and went back to start a biotech company.

Back in about 2015, and you know this well, you’ve written a lot about this: as the China internal market was growing and becoming much more open to global innovation, Samantha saw the opportunity to start a new company really that would focus on first serving as a partner for global biotechs who otherwise didn’t have capabilities or insights on the ground in China to take advantage of the fact that there was IP harmonisation, regulatory harmonisation with the rest of the world, and now health insurance or access for patients for innovative drugs.

So those forces coming together about 10 years ago led to a really good opportunity, and it allows me now in my role to work across the globe on innovation. We get to see the best biotech products that are working their way through the global pipelines. And for many of those companies who otherwise don’t have a presence in China, we serve as their partner to get drugs in oncology, immunology and neuroscience approved and marketed into patients in China. At the same time, we’re working on our own pipeline and taking advantage of the really exciting and accelerating innovation ecosystem across China.

I sort of sit between - I have an office in Cambridge, Massachusetts and an office in Shanghai. I get to sit in two of the capitals of biotech in the world and work across borders. Its’s a great time to be in a role like that - it is a great vantage point to get to see how innovation is working on a global scale.

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Ruby: You joined Zai Lab about three years ago. before general Western or English language discourse had realized the opportunity and what is coming out of China - the quality of innovation, the cost, the scale, the pace of it. What made you want to join the industry from the China angle? What was compelling about Zai in particular?

Josh: I worked at Eli Lilly for a long time, and in my various roles, I always had an eye on China. Lilly was one of the earlier multinational companies to really look at China as a potential source of innovation, ans not just as a big market. We were the first of the corporate pharmas to establish a venture capital presence in China - we started a group called Lilly Asia Ventures that I was part of, and I got to see opportunities to invest in innovative biotech companies emerging from China. This goes back almost 15-20 years, so I had a front row seat even in my old job to look at biotech in China. Lilly also began an R &D centre in Shanghai that focused on discovery. And again, that was one of the earlier attempts by a Western pharma to really tap into innovation, not just market access.

So by 2022 when I joined Zai, I was already seeing that the second and third generation of biotech companies in China were moving from fast follower, me-too innovation, into things that truly have an opportunity to play on a global stage. About a year later, that’s when recognition of what I was seeing from the inside out, started to emerge, and we began to see the huge influx of Western capital and Western attention on really good opportunities for global medicines, with impact not just in China, but for the globe.

I think Zai was uniquely positioned to do that because we were already in both the global piece and China. We work closely with global biotechs and pharmas so we know what good innovation looks like, and we know what regulators are looking for in terms of unmet needs and data and otherwise, for areas that we’re in. We’re really well positioned to take advantage of the fact that there are really good medicines now coming out of China, both from our own labs, but also from other partners across the ecosystem in China.

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2. Navigating Perceptions and Building Credibility

Ruby: That dual engine capability of bringing assets into China, but also bringing assets out to the rest of the world. It’s really interesting niche. With China-origin biotechs, some of them begin with China’s domestic market and when they succeed with good assets, they might then start looking at the rest of the world. And others like Zai Lab are globally oriented from the outset. But regardless of the initial strategy versus how it pans out later, it’s still not easy to build trust globally, or sustain the right types of attention. In the past few months, and past year, scientific quality has been conflated with geopolitical risk or perceptions. What do you think are the biggest enablers or tests for demonstrating credibility internationally?

Josh: We’re at an interesting point for China innovation and China biotech for the globe. What we’re seeing today is that, in some particular focused areas like oncology and ADCs or T-cell engagers or bi-specifics, there are modalities that benefit from iterative innovation, when you’re combining different molecules and thinking about how those combinations work best. There is a benefit from fast cycle time and otherwise. And that’s where we’re seeing really, really good assets emerge from China. We’re seeing enough early phase data in many cases in China patients or in China research sites only that get global innovators like Lilly or GlaxoSmithKline or AstraZeneca, interested in that technology. But to move from interesting early data in Chinese patients to global data that can register drugs around the world, that remains difficult.

The first hurdle is just capital. One of the benefits we’re seeing in China is biotech companies can move really fast. They can generate early phase data quickly and frankly cheaper than companies based in Cambridge or London can. And that can be measured in the tens of millions of dollars of investment, to take a good idea from a target phase to maybe some early clinical data in patients. But to move from that phase to registration is typically in the hundreds of millions of dollars from there. And while there’s a lot of really good focus in China and Hong Kong on these companies and stock market interest there’s not the deep, deep pools of capital that you see in the West that can put the next tranche of funding in to take an interesting early phase asset all the way to the finish line. So the first thing that I think the China biotechs are lacking is capital and big pharma or big biotechs on the global basis have that.

But I think even more importantly for the longer term, is the expertise and the benefits that we see in China from fast cycle times: identifying a target, figuring out the ways to go after that target, and then iterating until you find the best molecule. That skill set, that’s scientific expertise, it’s hard work. To build a molecule that you tested in preclinical setting - is it safe enough to try in humans? Once you have tried in humans, do you see enough response that makes it worthy of a bigger program and a bigger investment? Those are pretty objective.

But when you move into later phase development, it’s a lot more nuanced and a lot more subjective and experience-based. To understand what kind of development programme, what kind of clinical trials to run for patients and physicians who are based in the US or based in the UK - that’s a different skill set and it requires experience, nuance and judgment. Many of the Chinese biotechs definition just by don’t have that yet. They don’t have a team that’s been through the regulatory process in the US or in Europe or whatever it may be. So they really need a partner to help on that side. that’s where I think Zai Lab is in a unique position because we, have been part of 5-10 global phase III programs for the last 10 years at any given time, understanding those nuances with our partners, building expertise and running global trials.

Our leadership team is a good combination of people with deep Chinese expertise on the ground, with good research sites and thought-leading physicians and researchers - people who have done the drill on a global basis. So I think the next five years are going to be really interesting in China to see which biotechs are doing really well with some of these early phase opportunities, which ones take the next step and say “we want to hold on to this innovation. And act as the registration leader for this drug in the US or in Europe”, versus now, where because of the capital and expertise, the default (for most Chinese biotechs) is to generate some interesting data and out-license or partner that program with a global partner.

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Ruby: You spend a lot of time with Western audiences, including investors and partners and stakeholders. When you’re speaking with those who understand the system less and might be swayed by perceptions they’ve gained from other sources, what are the narratives you find yourself pushing back on most often? That you’re always trying to inform on?

Josh: I think the starting point is that medicine and innovation is not a zero sum game, particularly from a political perspective. There is this dynamic that anything that happens between countries – particularly countries like US and China, that there’s gonna be a winner and a loser. But it’s not zero sum in health. We all want to get better, we want to live longer. if people anywhere get cancer. They want to have the most opportunities and options available.

So the first thing our team starts with when we’re talking to stakeholders -including politicians, policymakers, general public and investors – is that any rise in innovation anywhere, and in this case in China, is good for everybody. It’s not at the expense of the US losing out in biotech. If there’s a great drug that we discover in our labs in Shanghai, there should not be any issue with that drug making its way to patients in London or the US or wherever it may be.

There are various, distracting legislative and policy moves, there’s a US law, the Bio Secure Act (just passed), that’s meant to protect US interests from China, military and policy and otherwise. I spend a lot of time with investors to explain how those kinds of bills and legislations may be important in some senses, but that don’t impact the kind of work that we do at Zai. They’re not meant to impact getting great drugs to patients around the world.

Maybe that global zero-sum competition makes sense in some settings - chips or defense, things like that - but in healthcare, it’s not zero-sum. Anything that anybody does anywhere, that can improve the outcomes for patients to benefit everyone, it’s not at the expense of a company or of a policy or safety in the US.

The second, is still this view that China innovation isn’t good. There’s this term: “China’s really good at going from one to a hundred, but not from zero to one”. So there’s still this misunderstanding that we’re only seeing Me-Too opportunities come out of China. That they may be more souped up now or perhaps better than they were before, but that they’re still not truly innovative. This is not true. So making sure global stakeholders, global investors and others understand that the work happening in China really is innovative, and that it’s not just a me-too opportunity.

Now, I do think there are areas that the West that are probably still doing better in terms of not truly novel biology, for example the brand new targets and things like that. There’s still a little bit more of that happening in the West, but I think that’s going to change as well, soon. I just look at the level of scientific expertise, the number of PhDs that are coming out of world-class institutions in China, the ability now to move directly from a university setting to a high quality lab in China. That (domestic talent and capability) is very different today than it was 10 years ago, where you probably had to go to the US or to Europe and train at a Pfizer or AstraZeneca and then come back and work, now you can go directly to really high quality, scientific shops in China. Innovation is now real in China, it’s sustainable, and it’s going get even better than it is today.

The third, which is related to the second, is that there is still some skepticism when really good data comes from China, and in trusting the quality of that data. There are now super high quality research sites in China, Zai Lab works at the investigators in some of the big sites in China, in Shanghai, Beijing, Guangzhou – of the highest quality, comparing really well with the sites across Europe, South America and the US. For high quality, research early phase data, you could trust those results, but I think this is where maybe even in a couple of years, we may face some additional questions.

For all early phase datasets and research and development, (clinical trials) tend to highly curate patients. You find patients who are going respond, who are naive to other treatments or are perfect candidates. And that happens no matter where you look. So if a lot of phase one data is coming out of China, as that research approach expands to broader populations, you’re gonna see some differences. That’s not because the quality of the data, wasn’t good in that phase one study, it’s just the nature of expanding populations, getting more diversity in the patient pool. You always see from phase to phase some reversion to the mean or median in data.

So even though there have been so many good programmes coming out of China, and so many global deals. If we fast forward, many of those programmes are likely going to show less than stellar results in their next set of studies. That’s just the nature of global development. I hope that doesn’t cast questions about the data in China or the quality of it (in the future). I therefore spent a lot of time sort of talking to investors to say that this is really good data that is indicative of a really good molecule technology, but for them to keep in mind that it’s early phase data and that it has to be replicated in broader populations.

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3. Building Trust in Chinese Clinical Data

Ruby: the third point about skepticism towards data quality - do you think it’s just a matter of time for resolution? That the more evidence there is in the next few years, once this concept of “Chinese biotech innovation being good quality” isn’t so new or shocking anymore, the idea will be accepted? If enough good quality trials, later stage trials and trials conducted in the US or other countries outside of China, you just have to be patient and wait for the trust to build?

Josh: I think that is the main strategy. There will be many good drugs that get approved on a global basis that you can look at and trace the progress. We’re probably a couple years from those global readouts that, on a broad scale and not just as a one-off, can begin to validate the fact that taking good early phase data from China makes sense. You can then broaden it out for the world.

At Zai Lab, we understand this dynamic, and we are really thinking about global development from day One. Because we don’t have a huge R &D approach ourselves, we tend to find targets or opportunities that we think are really good and already somewhat validated. (When in-licensing), we help our partners take advantage of China’s broad number of patients, and the ability to enroll quickly and develop cheaply for early phase data sets. There may be cases where it makes sense todo that in China to establish some proof of principle before then move to the globe to balance that with patients from the US or Europe or otherwise. At Zai Lab, we try to start right away with a global set of data. That’s allowed us to move really quickly with those programmes that we think are worth investing in.

By the end of 2025, more than a third of the global in-licensing will have been sourced out of China, which is just an incredible number relative to where we were five years ago. But in many cases, it’s a China data set where the global innovator will have to do a phase one study. In the next couple of years, this will shake out a little bit. We’ll start to see programmes coming out of China which are very high quality and can play on the global stage. There are still going to be failures - there’s no doubt about that because that’s just the nature of development. It’s still only one in ten programs in phase one make it all the way to approval, and most of the deals that are being done or the programs coming out of China are in that phase one setting. So we’re gonna see a bunch of failures, but that’s not a failure of the system or a failure of the quality of the research. That’s just the nature of the business.

Ruby: Yes, the “beauty of biotech”! It’s not easy to explain for non-biotech investors (who just want returns). And increasingly, you’re facing general investors, because biotech just such a hot topic. It must be interesting communicating with them the characteristics of this game.

Josh: That’s right. One of the big changes in the last couple of years since I joined Zai, is that previously, we did not have many general investors. The portfolio managers for the big Western investment houses such as Fidelity and Legal and general always have healthcare specialists, and they’re pretty nuanced in terms of how they think, but there were many generalists who didn’t want to invest in China - and China healthcare was even more of a total black box (to them).

Yet over the last twelve plus months, general investors have much more willingness, and maybe are now even forward-leaning into China related opportunities and certainly into China healthcare as well, as they see the number of deals being done and the prominence of innovation coming out of China. So now I do spend a lot more time when I’m talking to investors, not just talking to very technical healthcare funds and specialists, but broader general PMs. I think that’s great. As I say, health is not zero sum, so the more money that comes into biotech opportunities, the more good drugs we’re going to eventually get. Having that pool of general capital coming in is a really positive thing.

4. Opportunities and Challenges

Ruby: Yes, what you’re delivering on really depends on how you’re communicating it as well. You’re often interacting with other Chinese biotech leader peers and sharing your experiences with each other. What interesting developments in the three years since you’ve joined Zai Lab, or in the recent times since media attention has been pouncing on the sector, have you and others noticed, and how does that impact your work? Obviously it brings in capital, but it also brings perceptions and different types of pressures – there must be opportunities and challenges at the same time.

Josh: There are a few pioneer China-oriented companies that really have made that shift to operating on a global stage. I think Zai Lab is one of them, but there are companies like BeOne, Legend, and Hutchmed who all have drugs that have succeeded at crossing over to be seen as a global innovator. I certainly spend a lot of time following them, talking to their leaders. For the majority of really good innovative Chinese-oriented companies - they could be based out of Hong Kong or China or out of Shanghai or wherever - I’d say the majority really still do focus on generating a little bit of data to out-license that programme.

It’s interesting when I talk to investors in different parts of the world. When I’m doing a set of investor meetings in New York and talking about our global programmes, they talk about how the drug will compete with XYZ standard of care? Or when the next data milestone might be. Or how we are thinking about the commercial team that’ll support this drug.

But when I go to Hong Kong, the incentives for the investors there are, when are you going to out license this drug? When is the next deal going be done? So when you think about global capital and investor perceptions, there’s still a heavy (investor-driven) incentive for the more China-oriented companies to do a lot of early phase work, have a lot of programmes going, and then to just serially out-license them.

It’s interesting to me how many of those companies are now still are incentivised to sign a short-term deal and have a nice announcement around a billion dollar – in potential. They’re never a billion dollars upfront, right? It’s a small amount of money and then potential milestones. I wonder, will those companies might instead start to shift to saying “no, I want to hold on to this drug, to hold on to this asset and take it further, all the way to commercialisation in the US or at least, further than what I am doing now.”

Among my biotech peers, some of them think like we do at Zai Lab, which is that, if I have a great drug, the best way to maximise the return to my shareholders for that drug is to hold on to it, develop it and position it on a global scale. A lot of other really good innovative companies in China, the executives who have my job, or the CFOs or others, they are focused on how quickly can they partner this and move on to the next target, that continue to be an early stage research shop that then gets picked over by Pfizer and Merck and others.

5. Real Factors Driving Speed and Cost Efficiency

Ruby: And in terms of speed and scale and cost efficiency - the characteristics that Chinese biotech is known for. I think a lot of people don’t know why things are faster and cheaper, and they may make associations with low quality just because they don’t have another logical explanation. Could you walk us through the practical reasons - whether that’s talent or staff actually working more efficiently or working harder?

Josh: There’s no doubt, the data is clear that China biotechs can probably do things in half the time and half the cost. It’s going to be different for every programme, but it;s certainly borne out by what we do, and I think there are a bunch of reasons. The biggest one is the access to patients and investigators in China.

To establish proof of concept in a drug, there are just more patients and more high quality big investigator sites in China than there are in the US or otherwise. So it’s about how quickly you can get a protocol or an IND approved in China. That’s real - once you have something you want to study, you can get it done quicker in China because there just are more patients and sites that can enrol patients quickly. That’s just a function of a huge country and very big hospitals that not only treat patients every day, but also serve as research sites and everything else. That’s the number one thing.

But there’s a related piece that amplifies that. There have been significant policy and regulatory efforts in China over a number of years and continuing to accelerate, to make that early phase research to early development process faster. So the time it takes to review a protocol at a research site and get approved can be measured in weeks to a month or so. Whereas in the US, there are many layers of reviews and IRB boards etc. that make it a lot harder to get a study approved overall from a regulatory body, and then at the individual institutions, all of which takes a lot more time. So it’s patience and policy.

But then there’s no doubt that there’s a work piece to this, too. There are a certain amount of hours that go into iteration, to screen molecules and test them in non-clinical settings, combining different elements in bi-specifics and otherwise. You need capable, high quality scientists, but if it’s just a matter of how quickly can you do 300 hours of work? In China, there is a work culture in the labs where you give somebody a project and a deadline, and they’ll get it done even if it means working late into the night and early in the morning and on weekends. There’s a real piece of that.

And it doesn’t lead to lower quality. Frankly, speed of work has been demonstrated in lots of different settings. The less downtime and other things you have, actually the higher the quality of the work is. What it does mean though is that, when you need more subjective insights and otherwise, maybe you miss that sometimes. What we’re seeing now is that for drug technologies where you can clearly define a starting point and an end point, which require work to get to that in the meantime, this works really well today for precedented targets, known technologies, and interesting combinations or iterations because the work and the work culture is different. that is a real thing. If you get some unexpected result and have to totally rethink, that may not be as conducive to timelines and milestones and everything else.

The other piece is that, as this ecosystem in China has emerged, some of it comes back to incentives. When you take a known target and build a better drug against that target, and get to a certain point and then out-license it, that’s a very defined, scope. It lends itself well to “how fast can I do it? And I know the lab across the street is doing the same thing.” So there’s a huge competitive dynamic here.

I use the US as the contrast, but this plays out in Europe and everywhere else. Many of the biotech companies in the US are built around some really high science concept, right? And their goal is not to generate a result quickly, but to take what was somebody’s life’s work and an initial 10 million dollar investment and turn it into a billion dollar thing. So their incentive is not necessarily “how fast can I generate some interesting data”, but “how long does my capital runway allow me to build the perfect drug” that’s going to get acquired for billions of dollars as opposed to 15 million. So you do see different incentives in the biotechs in the US, and that is a function of where capital comes from, amd why people are doing what they’re doing.

That is one of the things that is good from a competitive perspective in China. I think everybody on the outside is frustrated at times with US biotech, and the management teams don’t want to do the what would you call the “killer experiment” that either says this drug is great or it’s not that great. Instead, they want to build as pretty a data package as possible, for as long as possible, with the hope of the exit being a big acquisition. But if instead your incentive as a biotech in China is just to do ten programmes and quickly send them out the door to other companies to then take that next level of investment, that enables speed and focus in a way that the US doesn’t. I think what we are going to see in the US, is some response to that to say, we can’t afford to spend five years on a lead-to-candidate programme to totally perfect it, because there is Chinese competition that’s moving faster. So again, I think that’s good for everybody.

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6. Differences between Chinese and Global Biotech

Ruby: You’re describing a more pragmatic approach on the China side, which is more adaptable and flexible, compared to delivering innovation in the US or maybe in Europe. Are there other distinctions across the landscapes? What have been really interesting characteristics you’ve noticed in your work and that you’ve adapted to as well?

Josh: At any biotech company now, if you look at the R&D organisation, anyone that’s based in the US, for example, a very high percentage of the workers are Chinese - maybe they were born in China or at least of Chinese ethnicity. But I think there is a piece that is interesting - not just cultural, biotech science and work - a general piece. There is more of a focus on deliverables and milestones. So, as a boss, if you say “here’s what we need to do for this project, we need to have these three things done and it needs to be done in 60 days”, that’s going to get done - it’s not questioned.

In the US, for the same thing, I would spend, as a leader, more time trying to convince people why that’s a reasonable timeline, why we need to do this and so on. So in US scientific culture, you have to convince people to get on board and convince them that a milestone makes sense, Whereas in China, it’s more like: “okay, that’s the goal, you’re the boss, you said that we’re gonna do it.” There’s a little less questioning, and in many cases that’s wonderful, right? But other cases though, the thing sometimes you miss is somebody saying: “wait, hold on, that doesn’t make any sense” or “here’s a confounding result” that should cause us to change the milestone or change the project. Knowing that if I say or if our leadership team says “here’s a goal”, I sometimes have to remind myself that people will take that a hundred percent seriously, whereas in the US they would be debating you on it later. So I think there is a real difference there.

Another thing is that, in many cases, people are pretty direct in the work culture in China in a certain way. I’m in Indiana today - we’re nice Midwestern people! Even if we disagree, like when I was at Lilly, you’d be friendly about it. But in China, people will just say: “that’s dumb”, “you’re dumb”, “that’s a terrible result”, “you screwed this up”. And I don’t think people’s feelings get as hurt.

When I first joined Zai Lab, when we were arguing about something, and afterwards, I felt really bad. I called my team and said “I’m sorry if I said it this way, that I didn’t defend you.” And they said “no, no, that’s just the way it goes! We argue and we don’t take it personally.” So I think that is a difference that I have to get accustomed to. And of course at Zai Lab, it’s interesting because half of our management team is Western, half is Chinese. We’ve all worked in various settings so we get a good balance of it, but I think there is a real difference.

Ruby: Yes, that’s what British culture is like as well. You never say what you mean and you’re always polite and nice to someone’s face, whereas in China, it’s a lot more direct. Translating across two very different cultures, but trying to deliver effectively, it’s always interesting navigating that. You’re essentially a bridge between, East and West, trying to connect and bring different types of perceptions and cultures together. I wanted to ask about the partnerships piece because this is one of Zai’s key strategies, Outlicensing, inlicensing, and also identifying what is actually a good opportunity. Zai has partnered with big global players like ArgenX, GSK and Bristol-Meyers Squibb, and why did they choose Zai Lab, and for you, what makes you choose to partner with someone in turn?

Josh: When global companies are looking for a partner for China, those in business tend to think that they’re looking for somebody who’s going to pay the most or give them the best economic terms And it really isn’t that. We have the privilege of working with great global biotechs. And in many cases, we’re working with their crown jewel, right? With ArgenX, we’re working on their drug Vyvgart, which is the whole foundation of their company. So these companies look for somebody they trust and that they know is going to communicate with them, clearly and transparently, who will have the best interests of the opportunity in mind.

ArgenX and Karuna, the companies we tend to partner with, big biotech companies who in many cases then get acquired by the Bristol Myers Squibb and others. For all of those companies, their biggest piece is the reputation that they have with regulators and physicians and the data that they generate for their products. They want a partner who they know is going put the same level of care and quality and thoughtfulness around their product in China than they are doing in the rest of the world. So they start with - do they know the people they’re working with? Do they trust them? Do they have the kind of experience, not just within China, but to understand what global regulators care about quality practices? Samantha, our founder, has done a really good job both on a personal level building that credibility and trust over many years with many partners, and then hiring people who also can do that.

And of course you have to be able to do the work in China as well, right? You have to understand the local dynamics, know how to read the tea leaves in terms of policy changes and otherwise. There aren’t that many companies that can do those things. You can find really good local companies in China who started out in the generic business and are now, very big and successful companies that market many drugs across China. They havelocal expertise for sure, but they don’t have the global experience or the level of understanding of the complexity of global development, interactions, regulatory and things like that. So maybe trite as it sounds, it’s really around trust and transparency and expertise. Getting all three of those, think is not easy. And there aren’t that many companies that can do it.

We’re in our 11th year. And in those first ten years, we’ve gotten eight drugs approved in China. We’ve done really well with those drugs once they are approved. Our longest standing, biggest drug today is a drug called Zejula, which is for ovarian cancer, with out partner GSK. But if you look at the ovarian cancer market for PARP inhibitors (the mechanism of this drug), it’s super competitive on a global basis. There’s another drug called Lynparza from AstraZeneca. And I think in every major market around the world, Lynparza has been the market leader in terms of sales and patients. But China, Zejula is number one (through us). you have to deliver results, and we’ve been able to do that.

Now, as we think about the next decade and think about partners, I think we’ve established ourselves as somebody that these global innovators will call when they need a partner. I don’t have to spend a lot of time going out to introduce Zai Lab to biotechs in Cambridge or San Francisco or London. They know of us now. But there are a set of things that we need to look at as well when we’re thinking about the next partner for a China opportunity. And a lot of that comes down to understanding what access looks like in China today, what the concentration of prescribing and best practices and other things are.

There are many cool innovations that we see happening for companies who need a partner in China, but we’re not going to be able to make that work as well as we would like to. We know areas like oncology and immunology that work well for our model, but for other areas, maybe not so much, even though we’re seeing really good drugs and development like cardio and metabolic. We’re seeing so many interesting innovations and developments there, but for uus, we haven’t found the right drug that can check all the boxes to make us a good partner for that company and to make the opportunity viable for China.

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7. Effective Partnerships

Ruby: On the drug Zejula, it’s pretty incredible that Zai Lab has delivered so well (as an in-licensing partner), for China to now be the only market in the world to surpass the AstraZeneca competitor. We’ve already talked about some of the reasons that Zai Lab is distinctive, but are there any particular reasons why this happened?

Josh: We do hire really good people and understand well. There’s a piece of that. But AstraZeneca, as you know, is a really good competitor in China. They’re very strong multinationals. But I think that one of the things that we would point to - and we would point to this in future partnerships as well - is the understanding of the local dynamics. We did separate trials in China to look at dosing and safety which provided a really good and differential experience for thought-leading physicians and thought leaders. Then of course, practicing physicians in China where there’s a more China-centric or China-specific dosing regimen that allow patients to get the benefit in a more robust way without some of the safety challenges that come with any kind of oncology drug.

So it was about understanding what the opportunity was in China in doing differential development, generating a data set that is most relevant for Chinese patients as opposed to taking the global stuff and force fitting it into China. And we try to do that in all of our programmes. Of course we want to leverage the broad deep global data set that companies are developing, but finding those unique places where it may be a little bit different in China, or where we can add different information, given the complexities or the differences in China treatment patterns - those kinds of things are particularly important.

8. China’s Policy Paradox - Health Equity vs Biotech Boom

Ruby: The China localisation piece, it’s essential to being able to operate successfully. And we’ve talked a lot before about the policy and the governance, the long term planning versus the refreshers and reforms and the private healthcare sector versus the reimbursement list - which is the pain point of all biopharma industry to access the public health system, and Zai Lab having that internal capability, helping partners to deliver on that. It’s interesting to think about the next few years as China’s health system continues to transform. How have you found operating in that landscape on the ground quite extensively?

Josh: There are two things. First, there are many challenges commercially in China, and it’s related to the same kind of challenges every country faces. There is not enough money to cover all the innovative drugs that have been approved. The reimbursement process the last few years has been challenging - how do you establish a price, get a drug listed on national reimbursement and then how do you maintain that listing over time? Pricing has been challenging for sure.

But I think the competing piece, or the positive piece, is that the underlying longer term trend is good. China’s introduction of a commercial insurance list - that is a really positive development. I’m not sure it’s going have a huge immediate impact, but I think the direction of travel is really good, from systemic changes to things like transparency around reimbursement processes. It’s still very hard to get a drug listed at a good price initially, but once listed, then it’s a lot easier to maintain the price. We’re seeing fewer big price cuts over time, and that makes it easier at least to plan and to be thoughtful around what you do.

And I think there are some recognitions - just like there have been in other public programmes in Europe and the US - that many patients still pay out of pocket, even though there’s national coverage. Depending on the drug and where you live, you could still be paying out of pocket, 20 to 30 % of the drug cost - that can be a pretty considerable expense for patients. There are lots of discussions from a policy perspective around finding ways to make that more moderate, to put a cap on out-of-pocket spending. Again, these are things that have come up in the US with Medicare and otherwise.

So there are longer term trends that will be great for the in market opportunities in China, but day to day, it’s tough, the competition’s fierce. Five years ago, if there was a great global innovation, you could be comfortable in bringing that into China and having some really good runway if you could get it approved and everything else. But now, what we find is that, if there’s an emerging opportunity in a new class or a new target or something, you don’t have a lot of freedom to bring that drug into China and have no competitors. the cycle times, even on the commercial side, are faster and more intense than they were a few years ago.

But I think that the one underlying positive to all this innovation percolating in China and otherwise, one of the policy learnings, and you know this better than I do, it would be if you want to have a great and robust industry of global biotech players in China, you need to reward innovation in your home market, right? I mean, we’ve seen in other countries that when you don’t do this, while the company may still be based domestically, the vast majority of their profits and operations and other things will then tend to migrate outside of the country.

If China wants the next ArgenX to come from Shanghai, then they should be rewarding rare drug innovation in reimbursement processes. That’s moving incrementally positively, but there’s still a lot of room to improve access and pricing for some of these oncology and immunology drugs that are, just by nature, more expensive on a per unit basis than, for example, a cholesterol daily pill.

Ruby: Yes, there’s this paradox within China’s health reforms – the state wants to deliver affordable, accessible health care, like universal health coverage, but in contrast, there is also this booming biotech sector that’s increasingly not supported enough, or rewarded financially enough, to target the domestic market – so biotechs are now looking to the rest of the world and the US in particular (which funds the world’s world’s pharma innovation with up to ten times the drug prices of other countries). I’ve been thinking about whether we will see policy adjustments in the next year, especially in March when it’s the 15th five-year plan, whether there will be support or realignment from China’s government.

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9. Translating Across Borders

Ruby: I wanted to also go back to local versus global mindsets. I’d love to hear a bit more about your experiences on the ground operating and leading across teams and across regions. What has that felt like when you were translating outwards versus in?

Josh: There are unique challenges in China. When we look at a drug like Vyvgart, which is an amazing drug for patients with myasthenia gravis, we see the success that it has had in the US and in other markets now, but in China there remain unique barriers and hurdles just in the way patients access care, or if they travel long distances to hospitals to seek care. They have to pay something out-of-pocket even though they’ve got national reimbursement. So the learnings from some of the markets around the world on what works well with physicians and otherwise, doesn’t always translate exactly to China, and that can be frustrating.

We’re off to a really good start with Vyvgart but when we compare it to what’s going on in the US, it’s still a small fraction. So you have that piece of: there should be more patients in China having access and benefiting from the drug, and here are some things that we can do, But with every market, there are different local regulations and ways that you can share data. That’s probably, in many cases, more frustrating than rewarding. You have to work through it.

I’ve worked in China, but most of my sales and marketing experience is in the US. Here, you start with; “OK, if you have a great drug with this kind of data, that’s going translate into good opportunities for patients and physicians.” But there are probably more intermediate hurdles in China, So I have to check myself.

Right now, we’re in the middle of setting our goals and targets for next year. And I have to find that right balance of wanting to say: “hey, this is a drug that we’re not doing our job if a thousand patients don’t get this next month, and here’s why they should”, with the realities of the things that can slow that down or get in the way in China. So the frustrating, or the leadership piece for me, is that I have to be more open and temper my ambition with the realities on the ground, and listen to our team of experts who are dealing with this drug, and with the patients and physicians every day.

But the rewarding piece – and this is less business and more just personally, just having the opportunity to be so immersed in a different environment, in a different culture. I’ve always had a chance to work in and around China, but I’m in China now every month, and just the opportunities beyond the work piece to understand the culture, to eat different food, to go to different cities, learning more about the people I work with and learning more about their backgrounds and things like that. It’s also interesting, just given how important China from a global politics and economics perspective, to see how things getting better or getting worse?

Though, again, the most exciting professional piece of this is just to be at the epicentre of what I think is a real and seismic change, in terms of innovation and medicines for the world. As I said at the beginning, everything I’ve been involved in for many years in biotech is around getting better drugs to patients. Having a whole environment now of of PhDs and scientists and others who are working on cutting-edge medicines - that’s just so exciting and rewarding. Zai Lab is just a tiny bit of that, but the more we can be part of that and the more we can help to bring some of these great scientific innovations out to the rest of the world in an efficient way, that’s really fun and exciting and rewarding.

10. Looking Ahead

Ruby: To wrap up, you mentioned reflections on 2025, and looking forward to 2026. What are you excited about building next?

Josh: We have a couple of really exciting things in front of us. First in China, we’re gonna launch a drug called Cobenfy, which is for schizophrenia. It’s the first new mechanism in Schizophrenia in 70 years. It launched in the US about a year ago, and we did some specific work in China with Chinese patients to demonstrate that it has the same efficacy and safety that it did in Western patients - and it does. There are 8 million patients with schizophrenia in China – a huge patient burden. Today, the standard of care is what’s called an atypical antipsychotic, but Cobenfy is a different mechanism that provides pretty profound safety benefits versus the existing class of medicines.

The two things you’re trying to do with medicines and schizophrenia: one is to knock down the delusions and hallucinations, and Cobenfy works as well as the existing class in that regard, but then secondly, on things like cognitive benefits and negative symptoms, not feeling withdrawn and getting back to interacting with their families and working and things like that, this drug has some real benefits versus the other class there. So we’re really excited to launch it in China this year. it’s going to be a really exciting opportunity for patients and certainly for Zai Lab.

The second thing then is our global pipeline, which we’ve spent a lot of time talking about today - we have a leading programme that has just entered a Phase III study on a global basis, for second line or late line small cell lung cancer. We’re enrolling that trial now, and will start to generate data by the end of the year that we can use for a submission. So an opportunity to have a drug launched outside China by as early as 2028. We’ll start a bunch of other studies with that drug this year, and we’ll move it into a first line setting. We’ll look at other tumours that this mechanism particularly targets. I think 2026 will be the year that we really are seen as a global innovator, not just a great China specialist.

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Watch the video podcast here on substack, or subscribe and listen to the audio podcast on Spotify (CHP/PH) & Apple (CHP/PH). This post provides all links, plus a full text transcript.

Today, we are thrilled to welcome Professor Joan Kaufman, one of the world’s leading experts on HIV and China. Joan has spent her career at the intersection of public health, policy and social justice, working across the United Nations, philanthropy and academia. Her work has profoundly shaped how the world understands health, rights, and China’s role in both.

Joan first moved to China in 1980, working with the United Nations in Beijing during a pivotal moment when China’s health system was just beginning to reopen to the world. In the 1990s in the Ford Foundation’s Beijing office, she pioneered work on women’s rights, reproductive health and HIV prevention. From 2002 to 2012, she led China programmes for the International AIDS Vaccine Initiative, building bridges between Chinese scientists and global vaccine efforts.

In academia, Joan has held senior roles at Harvard, Columbia, Brandeis and Tsinghua University. She founded Harvard’s AIDS Public Policy Project, directed Columbia’s Global Center in Beijing, and taught global health and social medicine at Harvard for may years. Today, she serves as Senior Director for Academic Programmes at Schwarzman Scholars, where she mentors emerging global leaders to think critically about China, global health and the world.

In today’s special episode, Joan joins us to reflect on the arc of China’s HIV response over the decades, and her life’s work at its heart.

Watch the podcast above on Substack, on Youtube, or subscribe and listen on Spotify (CHP, PH) & Apple (CHP, PH).

Read our Conversation:

(Audio transcript adjusted for clarity and flow)

Liu: Joan, first question to get us started, what’s up with the poster behind you? (see video)

Joan: Well, first of all, thank you both so much for inviting me to do this podcast. I’m really honoured and two of my favourite alums out of our, what, 1,200 alums so far, all, in my opinion, future global leaders in one way or another, including by your podcast series and your efforts to really help digest China and the world, at this particular pivotal moment in history.

So let me start by saying a little bit about this poster. I began my career in China in 1980 to 84, as Ruby mentioned, working for the UN Population Fund (UNFPA), and one of our big projects - and a big reason that Deng Xiaoping invited the UNFPA into China in 1979/80 - was to do a scientific census in the years following the Cultural Revolution, to really get a proper count of the Chinese population. Because one of the goals in the early 80s at the beginning of the reform and opening up period was to quadruple the GDP by the year 2000, but.

In order to do that, you really needed to know the denominator, which was the total population size, to help China in the early days, train demographers and get organised. At that point the one child policy hadn’t launched, it was really more about manufacturing modern contraceptives, counting the population, training demographers and a variety of other programmes.

1980 to 84 was a really interesting time to be in China, right after the end of the Cultural Revolution, and the very beginning of the reform and opening up period. I really divided that first year into two periods: pre-trial of the “Gang of Four” and post-trial of the “Gang of Four”. It was a very traumatised time in China for many people, with huge distrust of foreigners - especially Americans. There were two Americans working in the UN system (in total), which was tiny. I don’t think we were more than 20 people (overall), for all the UN agencies in China. We worked closely with the Chinese government, but Americans were particularly suspect, I would say. It was a pretty isolating time in those early days.

Post-trial of the “Gang of Four”, there was sort of a collective “opening up” - both emotionally, and in terms of more people coming in, more activities happening, and people being more relaxed, I wasn’t working on HIV AIDS then (yet). And in fact, there was very little discussion or even acknowledgement. Those were still very, very early years of the HIV epidemic globally. And China just said - “we don’t have any HIV/AIDS” for the longest period of time, until the epidemic really started exploding in the late 80s and early 90s in Southwest China, in the Golden Triangle area in Yunnan and bordering Laos and Myanmar, among injecting drug users.

I had lot of intervening experience after leaving UNFPA in 1984 to do my doctorate at the Harvard School of Public Health. I became very involved in the global HIV/AIDS response, managing a project on sex workers and HIV Prevention in Thailand, Mexico and Ethiopia with the AIDS and Reproductive Health Network at the Harvard School of Public Health. That was a collection of epidemiologists and social scientists from around the world. I was also consulting to the WHO Global AIDS programme in Africa.

And then by the time I went back to China for the Ford Foundation in 1996, I was really aware of the exploding AIDS epidemic in China and the need to really get organised quickly in order for it not to really get out of control, even though China was in full denial. I started working with the donor community there, with UNAIDS, and with several of the other donors like DFID that were meeting together as a donor group, to try to mobilise the Chinese on what was going on with AIDS and put in place some effective prevention programmes.

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Ruby: As one of the few on the ground in the 80s and 90s, Could you share with us what was it like? What kinds of partnerships and conversations were possible? What particular challenges?

Joan: Well, the 1980s was really early days for the reform and opening up period. The donor community was pretty small, it was mainly the diplomatic community, There were very few, UN agencies represented in China. So we had a very special relationship, I would say, one that the UN maintains today. And our relationship with the Department of Foreign Economic Relations and Trade, our counterpart agency there, and with our colleagues who were assigned to us from there to the UN Office as our national program officers.

I traveled a lot for UNFPA in the early 80s. We had about twenty projects. It was myself, the UNFPA coordinator and the international programme officer and the two national programme officers. We had a project with UNESCO on sex education in middle schools. I traveled to 10 middle schools in really rural counties around China: Hunan and Shandong and Hubei - many, many places. And often, (I was) the first foreigner anybody had seen in a very long time. I had a very interesting experience.

We did a lot of really good work, and I made many, many good friends at the ministry level, with people who went on in their own careers into more senior roles - and many of whom I reconnected with when I came back for the Ford Foundation in 1996, which allowed me to really, start with trusted relationships. For example, with the Ministry of Health, the Ministry of the State Family Planning Commission and other places, Ministry of Education - on some of the Ford Foundation projects that really helped move China forward in many ways.

It was a different period of time, and China was very, very receptive at that point to development assistance. (Maybe) not true for the Ford Foundation today, but certainly at that time we were warmly welcomed. I made many grants, small grants, $20,000 or less, that were highly impactful in China. A small amount of money went a long way, and I had a very large budget - probably two, three million dollars a year, you know, and able to bid on more. It was a rich time for the Ford Foundation as well.

Ruby: When you say the China side was receptive, can you describe what that was like? How did they speak with you? What kinds of partnerships were you building?

Joan: I came in as the second programme officer for my portfolio at the Ford Foundation. The reproductive health programme was gaining steam globally. There was a big New York part of it and 14 field offices, many of which had reproductive health programmes. It was in the years leading up to the International Conference on Population and Development in Cairo (ICPD) in 1994, which was a very significant every-ten-year global population and development conference.

The (Ford’s) China Office opened in 1988, The reproductive health portfolio began in the early 1990’s because of the one child policy and the need to really look at reproductive health and rights within the population policy. That was a lot of what my portfolio was about. But I also began the work on HIV AIDS.

Ruby: So after working for the UN agencies, you then left China and you came back to work for the Ford Foundation, an American philanthropy organisation. What were the differences between those two organisations, and how did China counterparts receive you differently as a result of who you represented?

Joan: At Ford Foundation in those years, we had lot of independence. Nobody really questioned the judgment of the programme officers who were selected for their expertise in different areas where they had their portfolios. It was a great job, actually. We had a lot of independence to decide how to move our issues based on our own programme strategy: who to fund, and those were only really rejected for legal issues or other issues.

Of course, you needed your Representative’s approval - the office approval - but we were a very independent set of program officers with a lot of discretion to move the issues however we felt the grants programme could do so. But that’s not true anymore. It has changed a lot over the subsequent years, I was probably in the golden period of the Ford Foundation in China in that way, as opposed to now, where it’s much more centralised and organised, with different approval process. But the UN was nothing like that - the UN is a big bureaucracy and works directly with government a government counterpart for every project - it’s all consensus-driven with government directly.

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Liu: As I hear this, I can’t help but hear echoes from history. There is a long tradition of Americans doing health related work in China from 19th century Peter Parker building the eye hospital in Guangzhou, and Yale in China doing the Yali/Xiangya medical school and hospital, and obviously the Rockefeller family founding the Peking Union Medical College. So, jumping into the 80s and the 90s with the HIV/AIDS epidemic, how do you see yourself in this historical lineage? did you think of that much? Did you know much about it when you first in?

Joan: I did know a lot about it, because I’m really a “China wonk” first and foremost, before (being a) global health person. I did my two degrees in Chinese studies and then I did a doctorate in public health. But the Chinese health system and medical history - I’ve written quite a bit about that, including the Rockefeller Foundation, who incidentally funded my PhD research. So I felt like I was evolving in a tradition.

But Ford was really the first foundation to establish a field office in China in the late 80s - pre-Gates Foundation by a long time, probably by 12 years or more. Gates opened around 2000. And so I think we played a really interesting role in that evolution of health assistance, because Ford was really focused on community-based approaches, including the development of civil society and an NGO community. And my programme and the other portfolios in the office were deeply involved.

And (it was) a very open period. The 1990s allowed the development of civil society in China in a really unique and important way. We were explicitly building - and with government support - a set of real, genuine civil society actors on women’s rights. There were many women’s NGOs that were established with the support and assistance of the Ford Foundation, in preparation for the Beijing Women’s Conference in 1995. That became some of the leading women’s rights organisations in China. And similarly in the HIV AIDS field, my portfolio played a very important role in building groups like the China Association of People Living with HIV/AIDS, the Positive People’s Network, that were patients: HIV infected people that were playing a role according to UN/AIDS GIPA Principle, the “greater involvement of people living with AIDS”, so that they were at the table for discussion - the affected communities. And then connecting that group in China with the global network of people living with HIV/AIDS.

So a lot of the forward work over the years was connecting up the transnational civil society networks, sending Chinese organisations to the regional AIDS or women’s conferences, preparation for the larger conferences, and then connecting up those global civil society actors with the new organisations in China for strategy, for networking - that still exists even while many of those organisations, are no longer in China post-NGO law which began in 2016.

We were also working with the academic researchers to fund important research on behavioural research on HIV/AIDS: what was happening with the more public emergence of a gay men’s community, and the risk there for HIV/AIDS with sex worker risk. We’re funded a lot of the behavioural research at Renmin University, the Institute for Research on Gender and Sexuality, Pan Sui Ming’s group (China’s leading sociologist and sexologist), the fabulous set of studies that came out of that which were very influential in shaping the HIV response in China. And then working directly with government - with the Ministry of Health, we worked in partnership with UNAIDS and other organisations on the Global Fund for HIV/AIDS and TB.

We’d sit at a table: the donor community with the National Center for and Control, China’s CDC and draft the Global Fund proposals. It was a joint effort - a collaborative effort - to get more money into China, to address the AIDS epidemic in the early 2000s.

And of course the policy changed in 2003 after SARS, and that was, largely a result of the donors working with the National Center for AIDS Prevention and Control at the China CDC, to take advantage of the post-SARS environment, so that China need not be in denial about the AIDS epidemic and urgently put in place a prevention and treatment programme after 2003.

When the (AIDS) epidemic moved from Southwest China into Central China, Henan and the surrounding provinces in the 1990s through this paid blood donation scheme, a lot of rural villagers in Central China were infected with AIDS and passed it on to their kids. It left a lot of AIDS orphans. It was a time of denial when (all) people were getting infected with HIV AIDS, not (only) stigmatised drug users or gay men. So it exploded into the open, and became a catalyst for the policy change in 2003.

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Ruby: Joan, you mentioned HIV as a catalyst. Could you share a bit more about that? Because HIV/AIDS has been framed as a kind of “pivot point” for China’s health system reform, forcing it to confront civil society and transparency and rights in new ways. Whether the stigma or the disease itself, what has made AIDS different from other health crises in China?

Joan: I think it forced the government not to just treat it as a medical issue. And that was the story of AIDS globally - you had UNAIDS come into being and coordinating all the other UN development agencies around the social determinants of health, and creating an enabling environment for the AIDS response.

So many people were dying in Africa. There were debates about access to essential medicine that were resolved around the late 90s by the global actors and the pharmaceutical companies, about allowing antiretroviral life-saving drugs to the people who are actually dying of AIDS in Africa. It was a huge set of global debates, echoing with the COVID vaccines, I would say, in terms of access to essential medicine - how do you get those drugs to the people who need them?

The whole enabling environment issue - the way in which stigma affects people self-identifying and coming forward for testing and treatment - many, many aspects of that got on the global screen for the first time. And then you had this very active agency, UNAIDS, that really did put AIDS on the map and keep it on the map. Along with UN General Assembly meetings and the creation of the Global Fund for HIV, AIDS, TB - many things that happened in the early 90s. And I think it shaped the way people think about responding to health crises.

We saw echoes that, of course, in the pandemic, right? There should have been some more lessons learned from the AIDS epidemic that we didn’t take forward, but many other things shifted the discussion of “you can’t just treat this as a medical or a tech fix”, you’ve got to really look at how to create an enabling environment.

And so, back to the civil society piece of that. For example, sex workers, gay men, drug users - you need these peer groups. You need people who are representatives of those groups to be able to actually reach their constituency. You need community-based organisations made up of like people to reach and access those communities with HIV prevention, messaging and technologies, getting people to get into testing and treating.

HIV is a chronic disease these days, especially now that there’s once-a-month or once-a-year injectables. We’re moving so quickly towards making it a manageable chronic disease, but the first step there is getting people to test and treat, to get stigmatised and marginalised communities to reach out through peer messaging and peer approaches.

So that’s why civil society was so important in the AIDS response and remains so. I mean, we see that the new wave in China is young gay men, who are not being reached with HIV prevention messaging. Which is tragic, because treatment is free and available. How do you get the International Labour Organization to work to protect labour rights for people with HIV and hepatitis? Those efforts through other sectors didn’t really happen until the AIDS epidemic. Why do people not self-identify? It’s because they don’t want to lose their job.

I left China in 2001, and I really felt my “unfinished business” was to work on getting all those international best practices in place in China. So the AIDS Public Policy Training Project (back in the US) was very much that. I had a team of ten faculty at Harvard, working with a counterpart faculty in China, where we were doing training at the municipal and provincial level for government officials and multi-sectoral groups, about these policies and practices for the HIV response.

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Leo: The longstanding suspicion against foreign NGOs and foreign actors - they’re certainly often not looked upon as likely friends with the bureaucracy likely partners. It’s astonishing looking back and realising how much of it worked, right? How many NGOs operated in China, for however long the government welcomed and allowed foreign NGOs in China. Eventually the Global Fund did exit from China, specifically on the point about civil society. The Chinese government’s Foreign NGO Law around 2016 was probably the end to this period of opening which lasted for two decades. So, Joan, if we’re trying to get into the minds of your Chinese counterparts, especially those in government, why did they come to allow this whole field of uncontrolled foreign actors working with activists and civic-minded Chinese who are not necessarily the most obedient to the state? What’s the logic there? How come this whole field got to take off for as long as they did?

Joan: Well, during that early period of 2000 to 2010 - and speaking specifically about HIV/AIDS - there was a recognition by the government of two things.

One, that they needed the peer groups and the NGOs, to reach the affected groups. Once the AIDS program was put in place starting in 2003, they couldn’t do it without access to the communities that were at the most at risk for HIV AIDS. AThat required engaging with these civil society groups, no matter how much they didn’t like them, to reach those folks, right? It was a pragmatic recognition, that the only way they were really going to get on the right side of the AIDS epidemic in China, was to engage with a set of civil society actors that could reach the affected people that needed to be reached. So that was the pragmatic side of it - and that’s the story of the AIDS epidemic everywhere, not just in China.

And the other part of it, which is I think more important, was to get the money from the donors and the development assistance. They had to do it. The Global Fund had a requirement for civil society representation, coordinating the country, coordinating mechanisms. And so, even if they had to fake it, they had to do it in order to get the money.

But I think it was a genuine understanding - by certainly the bodies that were developed during that period of time, the State Council AIDS Working Group, the SCAWCO - it was a very progressive organisation made up of people who really knew what the global experience was, and knew what they needed to do, in order to really get on the right side of the AIDS epidemic. The only USAID money in China was for AIDS in Southwest China and three provinces. And it required civil society representation, which was a huge amount of money.

I can’t remember how many rounds of Global Fund money came into China, but it all had an explicit requirement for civil society. And the China Society for AIDS Prevention and Control - or whatever the para-statal NGO was - acted as the umbrella agency to receive the money, and then distributed it to the smaller, “real” NGOs. It worked to some degree.

There were also other organisations I worked very closely with, including a group called Friends Exchange started by a a doctor in Shandong province in Qingdao. It was a magazine for gay men that was handed around, mimeographed and distributed before the AIDS epidemic. It was the only kind of organising body for gay men in China, and it had a lot of HIV prevention information in it.

An outside organisation that funded a lot of work on HIV for men who had sex with men, called the Barry and Martin’s Trust, also came into China and started supporting the Friends Exchange Network. Then Ford Foundation took it up and it became an official publication, and became an enormously important way to reach the gay community for prevention work. And it was embraced in a way by the government, because it became an important access point for an important community that needed to be reached.

I would say that it was a golden period there, before the NGO law came. And I would say that what happened since with the current government and political leadership started evolving around 2012 or so. There was much more of a reflective process of the role and risk of civil society and funding the colour revolutions in Eastern Europe.

I think the current leadership in China really reasserted the distrust factor At Ford Foundation in those years for civil society and its potential for for peaceful evolution, and came out with a set of “don’ts”, which included civil society and rule of law and many other buzzwords that closed down the space for the kinds of rich activity that happened with the HIV/AIDS organisations during the late 90s and the early 2000s.

Ruby: I wanted to build on that - this changing global health/international development landscape. In my last podcast episode, I spoke with Sid Chatterjee, who’s the UNRCO for China. He talked about how the UN engages with China today, which is very different from when you started with UNFPA, or later with the Ford Foundation. How do you reflect on your past and think about this current engagement?

Joan: I do think that the China of 1980s that I arrived in - working for the UNFPA is a completely different country than the China of, 2025, right? Certainly it’s no longer the case that you could do any of the stuff that we did It’s very much a changed political environment. Many of those organisations still exist, but they don’t have the foreign partners. and they certainly don’t have foreign funding. Many of the donors exited China - felt that Africa or other places needed donor assistance more than China did.

China’s really come up. It is middle income for sure, with lots of cash reserves and a development donor itself, right? China has adequate resources to fund its own health and development programmes. But it doesn’t mean China doesn’t need technical assistance to improve what it’s doing, and how that money is delivered.

I regretted what I saw happen starting in the early 2000s, where all the donors either reframed their programmes as “China for the world” - the UN agencies, the Gates Foundation, the Ford Foundation, all reframed their own portfolios so that it wasn’t about “China for China”, but what could China do for the world - or how could China help engage with the world. Yet there are a lot of unfinished agendas in China to say the least. Many, many, including in the HIV/AIDS world.

China is an active global donor through the Belt and Road, especially during the the COVID pandemic, making its vaccines available to many countries in the world. It has a lot of really educated public health professionals who’ve been educated abroad, educated in China - Tsinghua, Beida, Fudan - who’ve worked at global agencies like the WHO and come back. So China’s got a lot of its own health expertise, and and is extending its own power out there in the world, especially to Africa.

But I do think there are continuing challenges, and the NGO law has made it very, very difficult. Plus the weakening of the UN system in this current geopolitical moment that we’re in. The UN is very engaged with China, but the global system have changed so much in these last ten years. It’s harder to collaborate on global issues.

To some degree, the UN and the multilateral system are engaged with China, but the US certainly isn’t, and Europe less so as well, as the world aligns around the big powers and the new conflicts. It’s harder to get the collaboration we need globally for pandemics or anything else.

You know, I worry deeply about a resurgent HIV age epidemic, with the demise of USAID and all the money that many of the foundations and big donors have stepped up to try to fill some of the gaps on the most important issues like immunisation and parts of the PEPFAR program and things like that.

USAID was the biggest donor. It provided $12 billion of global development assistance for health. And the next biggest donor was the Gates Foundation with $1.2 billion - it’s an order of ten at least, right? The absence of that money in the global space is hugely impactful.

I worry about what this means in sub-Saharan Africa, where many of the organisations have been dismantled, that are the front line of providing HIV/AIDS care, prevention of mother-to-child transmission and antiretroviral treatment, working with young women who are really at risk of AIDS because of the social determinants of health and the lack of an enabling environment that supports them refusing risky sex. So I just worry about the world right now.

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Leo: You mentioned about the dismantling of the American aid system in the current administration. Trump complains that it hasn’t been very good for American soft power - and so we might as well just dismantle aid because it’s not bringing in political perks. And so as China looks at this, I can see them thinking: given all that’s happened, maybe it’s not a good idea to do humanitarian aid, but just to focus on the soft power piece. The US is stepping away, but is China going to step in and take the same role as was once filled by Western development aid and development professionals? What’s your view on this? If China is this rising power, what would a China-led global development landscape look like?

Joan: So in the global space, I don’t think China is going to fill the void. It’s transactional to some degree. The term “soft power”, you know, has many meanings. I think people look at the PEPFAR program, in particular, as an extension of American soft power because it was providing a huge amount of money for AIDS relief for sub-Saharan Africa - that you could say was in the US’s interest to prevent the explosion of AIDS in Africa in terms of global stability. But that was kind of a secondary issue - it was still much more of a humanitarian effort.

I think global health assistance is maybe unlike other soft power like Hollywood or the transmission of ideas and values through the media. Global health assistance is humanitarian aid first and foremost, and I come to it in my career very much as a health social justice person, working on humanitarian aid with health as a global public good, providing health assistance to poor people who need it primarily as a human right. So I come at it as a real do-gooder, you know, and I’m not an international relations realist person who’s looking at “what do you get for giving global aid? What do you get in return from the geopolitical point of view?”

But I do think that (all of this) does shape the way governments approach, to some degree. Certainly, Trump doesn’t see any value in it. That’s the end of USAID, right?But that’s wrong, because I do think China is playing a role on the humanitarian side, but also to build up its own credibility and importance in the global space - especially as the US recedes, providing money to especially the UN agencies like the WHO. Not making up for the US shortfall, but making a significant contribution, and also trying to play a role in bilateral development assistance on key issues like Africa CDC or malaria always with the interest of China in the first place.

We’re in a complicated world, right? there’s a lot of pressure on governments to take up more of their own health budgets. A lot of development assistance money has gone into defense because of the potential for war in Europe. So many of the big donors: the British government, France, other places, all shifting funding from health education, charity programmes or humanitarian programmes into defense budgets.

USAID has gone away, and the UN system is taxed in terms of its donations, so there’s just a lot less money available for development assistance. The golden age of global health is over. There’s no question about it.

I watched not enough money going into global health for much of my career. And then the HIV/AIDS epidemic shifted the donor space in a massive way so that much more attention was paid to global health and it spilled over into things like immunisation programmes and maternal and child health.

Those days are over, and that money is going to have to come from somewhere else. The foundations are stepping up to some degree to fund GAVI - the Global Alliance for Vaccines and Immunisations - and putting money into some of the other key assistance programmes and things like that. But the money that we saw over the last decades is never going to be the same, in my opinion. And governments are being pressured to fund more of that out of their own domestic health budgets. So it’s a changed world.

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Ruby: You mentioned that you’re worrying deeply about the resurgence of a new HIV epidemic. Can you share a bit more about HIV in China today? Because it’s not solved. What parts of the issues are enduring, whether that’s stigma, financing, data? and what parts of the response and the solutions have also endured successfully? And then because diseases have no borders, for the rest of the world too?

Joan: The HIV/AIDS response in China is a success story in many ways, because once the policy changed in 2003 in the post-SARS period, you had these advocates waiting in the wing to make the case for the need for transparency and direct action - and it happened. The government put in place a free treatment testing treatment programme and included a certain amount of poverty alleviation and care for orphans that has endured.

The treatment is not optimal. It’s not the most advanced medication, or the easiest to tolerate, but it is life-saving. China can do that. They can negotiate with the drug companies and get better medicines and medications.

But where’s the new wave of the epidemic coming from? It’s the young gay men. Everywhere in the world, there’s a certain complacency among young gay men about HIV/AIDS, because they’ve grown up in a world where there is treatment, and they can say they don’t think they’re going to die of AIDS. But you don’t want people getting infected with AIDS (in the first place).

There are things that China should be doing: rolling out full scale to prevent people getting infected, but this isn’t really happening effectively. There’s been a loss of attention away from HIV. China has the resources and the capacity and is providing the drugs, but they need more people need to get into tested and into treatment.

Globally, we’re looking at the possibility of a resurgence, especially in Africa, because of the weakening of the organisations there with the loss of development aid. And the probably the reluctance of African countries to put the resources into it that they should be doing themselves through their own national health budgets.

Ruby: You’ve worked in the field in China in multiple periods, and then you’ve also gone back home to the US, teaching as well as running programmes. How did people back in the US view your work in China? Was it different perspectives, different biases? What was that like?

Joan: I think the moment for me was post-COVID, when I was planning to go back (to China) after three years of Zoom life with my Chinese colleagues at Tsinghua in April 2023. The geopolitics of the relationship with China and the US. had changed so much that people said (to me): “aren’t you scared to go back? Aren’t you worried?”

I have had a whole career since 1980 where I’ve lived in China for probably fifteen-plus years and gone back probably two, three, four, five times a year - every year, pretty much since 1980, right? It’s like my second home in a way. Beijing is so familiar to me.

I wasn’t the least bit scared! I was really looking forward to it. And it was so normal when I got there, right? But I think that whole environment has changed. Whereas (before) it was kind of cool that I was working on China for so long, now it’s weird, because there’s so much anti-China sentiment in the United States. The view of China has changed so dramatically, now much more suspicion and distrust.

Ruby: Yes, suspicion, even on global health technical collaborations.

Joan: I think colleagues are more reluctant to engage with China, because they feel the risks that it brings to their institutions in the United States - or potentially to their professional career in terms of being able to work with the U.S. government, for example, right? That’s less so, I would say, since Trump came to office than it was during the Biden administration a couple of years ago. And I think things are softening a little bit now, but there is (still) a certain amount of reluctance to engage with China in any area of science and technology, because the security overlay is so intense and they feel that the risk to future funding might result from that.

Leo: As we look at China today, it looks a lot like America. Even though the one party state is there, it is a market based system. China’s CDC is modelled after the American CDC. China’s National Medical Product Administration is modeled after the FDA. The lawyers are trained in the American legal tradition. Tsinghua was founded by Americans, and obviously the stock market comes from the New York Stock Exchange. And so this process of transformation that turns China from a Soviet model to American model has really happened throughout your career, essentially one step at a time, one grant at a time, one project at a time. For a long time, China did play that willing role in terms of “we’re trying to learn from the West”, trying to reform. Now the Chinese government is trying to redefine the term “reform”, which is very telling of where we’re heading. So living inside that whole period of transformation, Joan, I really wonder about your view on how much of China today is really the product of American effort? It’s still very much Chinese and the roles that your Chinese colleagues, partners, grantees counterparts - the role that they played in shaping the system as we know today. And how do we also divide the blame - to be fair to both sides?

Joan: I have to say that the US, especially in the health area - the CDC, the NIH - trained up the Chinese health science side of things to an enormous degree. A lot of collaborative research grants, a lot of CDC-supported programmes, the US CDC GAP (Global AIDS programme) was there for many many years, working in concert with the China CDC. We trained up the China CDC and the EIS programme (Epidemic Intelligence Service). The Chinese system looks a lot like the American health agencies in important and good ways, and the US has been at the apex of health and medical research for decades - and China has really benefited from that.

We partnered with China to make China’s global health system better, and they’re probably going to just leave us in the dust because of all the science and technology funding that China provides now, and which we’re not providing at the moment. We’re giving up our lead position, if the lack of funding continues.

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Leo: Earlier you mentioned that there is an “unfinished agenda” that many of the global health professionals feel out of China over the past ten to fifteen years. What do you think is the unfinished agenda - the parts where China is still not getting, and it would actually be in their own interest to get that part?

Joan: I think it’s the civil society piece. I really feel that the contributions of the community groups and voice in the governance process it’s not optional. It’s a requirement for doing better, more targeted work, and for getting support by the communities that you need to reach. So that part of it is gonna play out. We saw it already with the COVID response: the protests, the pushback from the Shanghai lockdowns and things like that. That piece needs to be part and parcel of the way we approach global health, and I think a real acknowledgement of the enabling environment issues, which comes from more multi-sectoral engagement. Those are instrumental for effective health interventions that are lasting. The important role of NGOs in civil society, I truly have seen it in my work, especially in the HIV/AIDS space. And I think the other part of it is just the global collaboration agenda, especially between the US and China.

You can have a certain amount of global collaboration without the US, but the two biggest actors in the world, with the biggest influence and reach at this point, need to be working together on the next pandemic, for example, or really dealing with other types of risks that are going to spill over into the health area.

We need to find a way to get back to the table on these key humanitarian issues for which the whole world is potentially at risk. COVID was the prime example of why we need to be working together on emerging infectious diseases. We need to be working together with China, with the leading virologists in the world, on the One Health agenda. We have to find a way to get past the geopolitical tension. So my hope for the future is that we can move to.a more collaboration on global health risks between the US, China and the rest of the world.

Ruby: One final question for the 1st of December 2025. The first ever World AIDS Day was in 1987 - 38 years ago. Joan, you’ve worked through many World AIDS Day’s! Can you share any memories of how you celebrated this day with your HIV colleagues or in your research, wherever you’ve been? Whether in China, the US, or somewhere else in the world.

Joan: It’s always been a big deal. In my professional career, I’ve participated in many programmes on World AIDS Day, with lots of different people at different tables. in China, in the heyday of donor collaborations on AIDS in probably the early 2000s, everybody would convene. We would have a huge public event Zhongshan Park or someplace like that, with posters and activities, which everybody participated in. And I feel that these days it has way less visibility and prominence than it used to.

It’s become more routine, it’s become more just like any other disease. That “exceptionalism” of AIDS - it’s good that it’s not exceptional anymore, and more mainstreamed. But I feel that within the public consciousness, even if it’s not global calamity or global disaster, we (still) have to pay attention to it and be aware of it.

Ruby: The paradox of public health, when you’re healthy and well, it’s silent. But when you’re ill and there’s noise, so that is the difficulty with prevention in health care.

Joan: In my earliest days working with the UNAIDS office in China in the late 1990s, I was very close with the two people who were fabulous conveners of the donor community in China: Emile Fox and Sun Gang. We would regularly go off for beers and unpack the AIDS response in China - all the different actors, missteps and things that weren’t happening before the AIDS response really took off in 2003. I think my most memorable recollections are of the sitting around a table with those beers, really just trying to spitball what needed to happen. And to the credit of them and to others, many of those things mobilised over the next 10 years to put in place an effective AIDS response in China.

I would like to finish by saying that what I’m doing now - which is educating the next generation - that, for me is just as important, or more important than anything I’ve done in my life, because I feel that I’m going to exit the scene, but it’s people like you, Ruby and Liu, you’re going to take forward this important work in global health and U.S.-China relations in China and the world, including through our programme, the Schwarzman Scholars Programme. And we need to build up the next generation of activists who understand history and can engage, on your own social justice paths.

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🎧This is a special collaboration between at ChinaHealthPulse and at , to mark World AIDS Day, on 1st December 2025.

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Watch or listen here on substack, and/or subscribe on Spotify & Apple Podcasts. These newsletter posts provide all links, plus a full text transcript of each episode.

The second episode of the CHP Podcast welcomes a truly distinguished guest: someone who has spent decades at the frontlines of public health diplomacy, from refugee camps and conflict zones, to multilateral negotiations in Beijing.

I am delighted to share this conversation with my long-time mentor, Siddharth Chatterjee, the United Nations Resident Coordinator in China. As the senior-most representative of the UN Secretary-General in China, Sid leads and coordinates the work of over 26 UN agencies to work with the Chinese government in advancing the Sustainable Development Goals, from health and innovation to development and partnerships.

Before taking up this role in 2021, he led as the UN Resident Coordinator in Kenya and earlier as the UNFPA Representative there, spearheading national efforts to reduce maternal mortality and end harmful practices such as child marriage and female genital mutilation. Prior to that, he worked in many regions affected by conflict and crisis across Africa, Asia, Europe and the Middle East, including for UN peacekeeping, UNICEF, UNOPS and the International Federation of the Red Cross.

A Princeton graduate and decorated former Special Forces officer in the Indian Army, Sid is a widely published commentator who speaks and writes regularly on global development and humanitarian issues, as well as on health and wellbeing through his meditation and breath-work practice.

Today, he joins us to talk about what it really takes to build trust, drive impact and keep multilateralism relevant in today’s changing global health landscape.

Watch/listen above on Substack, on Youtube, or subscribe to the audio podcast on Spotify and Apple Podcasts.

Read our Conversation:

(Audio transcript adjusted for clarity and flow)

1. Multilateralism & China today - “The inside view”

Ruby: Sid, you’ve been leading the UN country team in China since 2021, through one of the most complex periods in global health and geopolitics, both during and after the pandemic. We first met over four years ago in China when I was leading the health team at the British Embassy in Beijing during the pandemic years, and I had the privilege of joining your UN office in China as a Health Advisor, where I was very proud to deliver a joint UK-UN health event for International Women’s Day. I saw firsthand just how unique, fascinating, and incredibly fast-paced your work is! Could you share with our listeners what that role looks like day to day, and how it has evolved over the years?

Sid: Let me take this back to January 2021. Coming to China was very consequential. Between Nairobi and Beijing, I had to pause for three weeks in Guangzhou for quarantine in a hotel room with no contact with the outside world. It was an important and gratifying inflection point in my life.

It was the first time I had the opportunity to just stop - my entire career in the UN has been fast-paced. I could think about the journey ahead for me, what I would be doing in China over the next five years. And therefore, I wrote the draft of an article, which was subsequently published in Forbes, about the UN-China relationship and the vision that I had.

I can say that during those three weeks and what I wrote there have actually come to fruition - and for three reasons. This is a government which is forward looking, with astute amounts of political will, and with perhaps amongst the best public policies in the last 30 years that I’ve seen - and China is the 13th country I’m working in.

It’s weaved together a range of partnerships from the state-owned enterprises to the private sector, to the United Nations family. I see as progress in this country is quite remarkable. Let’s look at a few statistics: from 1979, China’s per capita GDP was a mere $180. Most countries in Asia and Africa had higher per capita GDPs than China. 90% of China lived in abject poverty.

From then to now, they’ve brought their per capita GDP to $12,500, they’ve lifted over 800 million people out of poverty, they feed one fifth of the world’s population with 9 % of the world’s arable land, and they’ve managed to ensure they’ve achieved more or less the first five goals of “unfinished business”: ending poverty, ending hunger, universal health coverage (they’ve done really well there), quality education (that you can see from the human capital in this country), and lastly, gender, with the largest number of women in the labor force, close to 65%. So on all counts, it’s pretty remarkable (what China has achieved), at a time when global geopolitics has shifted dramatically.

And today, things have actually become even more complicated, the world is becoming multi-polar. We came out of the pandemic, and that microscopic virus exposed the fragility and the vulnerability of human health and health systems across the world. In the flash of that lightning, we saw the contours of inequality emerge. Inequality within homes, inequality within communities, inequality within countries and between countries.

The statistics were jarring: an economic impact that rivals the Great Depression. It really set back global economy, set back the sustainable development goals. Today, we are just at mere 17 % of implementation, though the SDG timelines are ending by 2030. We are seeing a triple planetary crisis: of climate change, biodiversity loss and of air pollution. We have 80 ongoing conflicts across the world, rising levels of hunger and food insecurity.

Now, in this complicated time, and here in China, we - the United Nations system - have built a relationship of trust, mutual respect and confidence with our host government. This is what was expected of me by the Secretary General as his representative of the ground, that through the period of the pandemic and post pandemic. We worked in lockstep with our Chinese partners, with the broader people of China in order to keep focus, despite the challenges of the COVID, on our work and not lose sight of what was our intention, which is to deliver on the UN Cooperation Framework 2021-2025 and as well as supporting China’s South-South relations.

We were able to build relationships with many member states, we co-convened and co-hosted events, including the one you mentioned with the British Embassy on health, with the embassy of Mexico and Germany on education, with Kenya on climate. We’ve done a range of these sorts of partnerships with member states to look at key critical issues of labour - including one with Brazil in preparation for COP30, where we were joined by the CEO of the COP30 over here in Beijing. So a lot of work has been happening on multiple fronts, multiple partnerships have been forged.

So I feel that when we look at, for example, the Global Development Initiative that China announced in late 2021, they immediately relied on the UN to provide them the best piece of technical guidance and to make sure that we could help them to align the GDI with the global norms and standards, which they did. In 2023, with the Chinese government, the permanent mission of China to the UN, my office and the China International Development Cooperation Agency, we were able to co-convene and co-host an event at the UN headquarters in New York to bring attention to the importance of the Global Development Initiative.

And while it keeps getting caught up in the geopolitical space, I always maintain that any country that helps to give velocity and momentum to the sustainable development goals is most welcome. So I think we made great progress there. In a country like China, one has to, as a UN Resident Coordinator, have conviction and courage. These are two essential attributes. Otherwise, it’s very easy to get blown away by the vagaries of geopolitics.

My job involves a lot of managing the geopolitics, working with the Chinese government on development ambition. That was the 14th Five-Year Plan. The UN just finished the Cooperation Framework 2026-2030 which aligns to China’s 15 Five-Year Plan, from 2026 to 2030, working with the member states, sharing China’s knowledge, sharing China’s experiences, and managing 28 UN agencies coordinating their work here in Beijing.

I’m very privileged to have come here as the UN Resident Coordinator, and privileged to work with a remarkable set of leaders of agencies, funds and programmes here in China.

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Ruby: Where do you see multilateral cooperation working most effectively within China right now, especially in health? What makes partnerships genuine and successful, particularly when styles and priorities can be so diverse?

Sid: We certainly need collaboration. You know, during the height of the Cold War, Russia and the US collaborated on the smallpox vaccine, which led to the ending of smallpox. So I feel that, regardless of the geopolitics, human health must be at the centre of our focus.

As in the words of Hierophilus, the famous Greek philosopher, he said that “when health is absent, art cannot manifest, strength cannot fight, wisdom, intelligence becomes useless and strength cannot be applied”. We have to make sure that health is taken at the very centre-piece.

In fact, when I look at the Sustainable Development Goals now, I emphasise that health is virtually the anchor for the success of the rest of the SDG. If you don’t have health, you have nothing. The economy slows down, everything stalls, and I think COVID exposed that to us.

So I just hope that the world comes together and converges in a multilateral spirit around health - and not just keep saying that “the WHO needs to be strengthened”. The World Health Organization needs to be given the power and the tools to effectively make sure that both non-communicable diseases and communicable diseases are easily managed, because we are not out of the woods here.

Here in China, a lot of progress is being made in the space of non-communicable and communicable diseases. Obesity has been recognised as a major issue in China’s recent Two Sessions (March 2025). We have major rise in diabetes, hypertension and cardiovascular diseases, increasing levels of cancer, so we have to look at this whole thing from an interdisciplinary approach. It is not a one size fits all. We have to really strengthen preventative sites, the primary healthcare systems and at an individual level for people to take responsibility for their own health.

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Ruby: I love what you said about health being at the centre. “Good health and well-being”, SDG 3, is at the heart of all of the other SDGs too. You mentioned that one reason China is able to push forward health reforms is because of this massive amount of political will. You work closely - not just with China’s health ministries - but also at the highest political levels. you meet with the State Councilor Wang Yi, you support the UN Secretary General António Guterres when he comes to Beijing to have conversations with President Xi. How do those high level relationships shape what’s possible for the UN’s work on the ground in China?

Sid: I’m doing this interview from an office which was established back in 1979, which was gifted by the Chinese government to the United Nations. That’s when we set up. At that time, the UN was a net aid provider to China. It used to bring in money, it used to bring in food, it used to bring in ideas, it used to give them papers on poverty eradication.

Now, it’s a very different China, and we are not a United Nations of the 1980s and the 90s. Otherwise we would have been redundant here. So we’ve adapted and made ourselves fit for purpose to the current context, to support China’s current realities and its future aspirations.

So yes, I joined the UN Secretary General - and I’ve been joining him since 2022 when he came here first time for the Beijing Winter Olympics, subsequently in 2023, 2024, and more recently in 2025 - in the meetings with President Xi Jinping. One thing I’ve observed: all the meetings run over time, simply because of the dynamic and the chemistry that President Xi and António Guterres have.

Really, it’s a dynamic of friendship, but it is also a demonstration of China’s belief in the multi-lateral system. They believe in it with genuineness. In fact, the amount of support I’ve got here in China, I can’t compare that to anywhere else in the world. And those relationships are built. You have to nurture them.

China is an old civilization. You cannot just come here and put an idea out there and think it’s going to work. You have to develop a relationship of trust. Once that is built up, you can then have avenues for open dialogue on multiple areas. China has its share of challenges, chronic diseases, rapidly aging population, the low fertility rates. There are a whole set of challenges, but at the same time, China is a centre for innovation, technology and big data.

In terms of the green transition, look at Beijing! 15, 20 years ago, this was a “gas chamber”. Today, this very city has got one of the cleanest air, better than many of the European countries. Why? Because of a convergence of political will, the right public policy, the right partnerships. They were able to demonstrate that a large city of this sort, you can actually have clean air. It’s quite remarkable.

I have been able to see these engagements and the commitment. China recently launched its National Determined Commitments at COP30. Here is a country which can actually be a good model for many other countries grappling with poverty, grappling with climate issues, grappling with health, grappling with so many of the issues that concern us and which are holding us back in achieving our full human potential.

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2. Trust, sovereignty and shared goals - “The global system”

Ruby: In Beijing, you bring together a community of more than 180 ambassadors and international heads of mission. It’s an extraordinary mix of priorities and perspectives. How do you turn that diversity into cohesion around shared agendas like health and development, to keep dialogue constructive and deliver diplomacy in practice?

Sid: I engage very regularly with the ambassadors in Beijing. More recently for the cooperation framework for 2026, 2030, but more particularly for the country programme documents of UNICEF, UNDP, UNFK, WFP. We met the executive board members, and there was a lot of reluctance and hesitation. Many of the member states felt that the UN should not be here in China. I had to explain why the UN continues to need to be in China to support support them.

And by and large, you know, despite a lot of opposition and several démarches (a formal diplomatic communication, e.g. protest, suggestion, or request for support, made by one government to another) as well, we were able to convince them how important the country programme documents were. In the end, they all passed seamlessly in New York during the time of the executive board. So I’m very pleased with this relationship that we built with the member states, the confidence that we have with them here. Not just with China, but the broader membership - it has been very, very productive.

Ruby: The UN’s role is evolving throughout the decades; multilateralism itself is changing. And as you speak about trust and shared purpose to build up essential corporations on these areas of climate and health and needs across different countries in the media - especially in English language media, there’s a narrative that as traditional donors like USAID and UK’s DIFID have stepped back, and as China and other partners are becoming more active through new initiatives, whether public, private or both working from Beijing. How do you see this transformation happening from your point of view?

Sid: I think that a mother in Beijing, a mother in New York, a mother in Mali - all have the same aspiration for their child: a better future, more promise. Everyone has that same ambition. This is where our shared purpose and our shared humanity is. This is why the UN is there and this is why the sustainable development goals are there.

The multilateral system is itself in a crisis. The biggest threat is the very existence of the UN right now, as we speak, is the utter fracturing of the multilateral system. Which is why the Secretary General has launched the boldest reforms to resurrect and rewire, to reimagine the new UN, make it fit for purpose - not based on the maps of 1945, but what it should be in the 21st century. The UN has a stark choice, either be dynamic or become dinosaurs. So I think China has taken an important role here in helping that.

President Xi recently announced the “Global Governance Initiative” (on 27th Oct 2025). I see that as an important input towards the reconvergence and reconvening of multilateralism. I was there at the Shanghai Cooperation Organization Summit, which the Secretary General attended, and I saw the commitment and the camaraderie between all the leaders that were present there. Multi-polarity is here, regardless of what the Western media or any other media says, it’s here to stay.

And we are seeing China’s leadership. the leadership of the ASEAN countries. the interaction which is taking place in Asia. I think this is an opportunity for the West, China, all the countries of the P5 (five permanent members of the UN Security Council - China, France, Russia, the United Kingdom, and the United States) to really collaborate. Today we have a UN Security Council which is stuck. We are seeing an acceleration of conflicts, issues remaining unresolved. So we need that shared sense of purpose to come together. Our leaders need to come together, to connect, to catalyse relationships for the global goods, for our humanity, for human development.

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Ruby: Why do you think the narrative is so defensive or anxious about the future? Why is it instinctively when change happens, it’s not optimism?

Sid: There’s the good old saying, you know, when you have a volcano. After the volcano has passed, you actually get fertile soil. This is the inevitable part of life. Crises cause anxiety. Now in that state of crisis, like those Chinese characters, You have the character for a crisis and you have a character opportunity and they blend into each other. It is in the world’s best interest for countries to collaborate, to cooperate for the global good. Geopolitics will be there. Differences will be there. That is why the UN exists. It is a table for everybody, small to big, mighty to weak.

Ruby: As these changes are happening in the international development landscape and China is expanding its role, including in global health, when you’re interacting with China’s counterparts and ministries and leaders in Beijing, what do you think they care about the most?

Sid: I believe that China is doing this out of conviction, just like any other country did - just like the UK has been doing, just like the US has been doing. I don’t see any hidden agenda. This is what global collaboration is all about.

I grew up as a child in India, where the vaccine program was supported by DFID, and my school bag and all that came from grants that came from USAID. These programmes were very, very important at that particular time. So when other countries are withdrawing, with defense budgets of Europe going up and less money going towards the development agenda, you will need countries to come up. And I’m really pleased that China, India, all of them are stepping up in order to want to support other countries.

China has invested in three things. And I think this is a global formula for developing countries, and particularly countries that are wanting to get out of the trap of poverty. Number one is to invest in human capital, that is why this surge of engineers and STEM, why these bridges and those roads get built in record time. Two, China invested in infrastructure, really connecting the country physically and digitally. This is exactly what we need. If Africa wants to achieve a continental free trade area, it will need to be connected. It needs a free movement of goods, services and people. That is how prosperity will come.

And number three, to invest in business. China had a budget surplus year on year. That liquidity that has allowed it to come in support of South-South cooperation in the global development fund. It should not be charity - and this is where having served half my life in Africa, I’ve seen what grants and charitable money does. It makes people dependent.

I mean, look at South Sudan. I started the UNICEF office there in the year 2000. When I look at it 25 years down the line, it’s like watching the movie “Groundhog Day”. Same situation, same planes going up and dropping food and humanitarian aid. What have you done in 25 years? Their population has got completely dependent. We have to invest in development. As the Secretary General has said, “there is no development without peace and no peace without development”. They have to go hand in hand. It’s not one or the other.

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3. China-Africa: South-South lessons

Ruby: Your work in Africa started in South Sudan in 2000, and you’ve worked for a long time in Kenya, in particular as the UNRC there and then UNFPA representative as well. This gives you a particularly rare and authentic perspective on the China Africa relationship with regards to health and development. What do you think outsiders tend to misunderstand about that China Africa relationship?

Sid: I came to Kenya in 2014. I was asked by the executive director of UNFPA, the late Dr. Babatunde Osotimehin. He said, “look, you need to deal with the very, very high maternal deaths in Kenya”. Kenya was amongst the 10 most dangerous places for a woman to give birth, three major causes: postpartum hemorrhage, HIV and hypertension, were the causes of death.

I got there and I was wondering, how do I get started? Because so much has been tried by UNICEF and UNFPA over decades. So I took my team to the University of Nairobi and we stayed there for about three days to look at the data county by county. And three days later, I was able to send some of these results to my professor at Princeton University. And they came back and I had this 3 a.m. call to say, “listen, of the 47 counties, 19 counties contribute to 98% of the maternal deaths, and of that 19, 6 contributed to 50% of the deaths.”

Now, suddenly, we had real data. Then we said, let’s focus on these 6 and see how we can change that. And when you’ve got your mind made up, events start to unfold. I get a phone call from the head of Huawei - the Chinese communications company - in Kenya, to discuss setting up a maternal health centre. And immediately after that, from Merck, and then Philips, and then GlaxoSmithKline, and then SafariCom. A constellation of companies came together. And there was a lot of reluctance within the UN - that pharmaceutical companies and UN should not be working together.

I said, “but we need to try something different”. Leadership came from the government of Kenya, and we were able to galvanise these six companies. We went into these six very, difficult counties on the Somali border, and in a matter of two and a half years, we were able to reduce the maternal deaths by an investment of about $15 million from a trust fund by one third - which under normal circumstances would have taken 10 to 15 years. This was the power of partnerships. And one of the things that enabled the movement of these people, was the infrastructure that existed, thanks to the Belt and Road Initiative.

So I’ve seen real development that can happen, real change that can happen - firsthand. In 2017, we got invited to the World Economic Forum in Davos to speak about this. It really gave the (local) government the confidence that they could actually push towards universal health coverage. Today, that same programme which we started then has become a $150 million telemedicine enterprise in Kenya.

We are limited by our imagination of what is possible. Regardless of the geopolitics, companies can collaborate. They need to sustain. So it is not an act of charity - we need sustainability. This is where public-private partnerships can have huge effect. Blended financing can have a huge effect. We need to reimagine the architecture of development financing, bring in more of the private sector, look at it as an investment opportunity. I see immense possibilities there.

China, Africa and hopefully others would join in. Africa needs a Marshall Plan 2.0. If you invest in infrastructure, human capital and businesses. Africa, whose population will be 2.5 billion by 2050, with about 800 million young people, will become the future of consumption and production given the young profile it has. But you have to make those investments now. And with the rapid aging of societies in Asia, in Europe, in the US. This is a great opportunity to make those investments. As the UN, we can bring member states together to advance the development agenda. More development, less discord, more camaraderie and dialogue.

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Ruby: When I was working from your office in Beijing, I had a chance to be in these rooms where you regularly convene African ambassadors, coordinate their objectives and coordinate with senior Chinese counterparts to have forward-looking conversations on cooperation. And to me, it was very clear how much trust and respect you would earn from all sides, within the UN system, with China, with the African partners, because of this track record you have of working for this many years in Africa. So from your perspective, especially for the global health sector, What do you think defines the next years in the China Africa relationship and where can it go further in the years ahead?

Sid: It’s immense. the sky is no longer the limit of what can happen, the possibilities that emerge. The African ambassadors here are amongst the brightest and the smartest I’ve seen anywhere in the world. The progress that the Forum for China-Africa Cooperation (FOCAC) has been making, I can see that the African ambassadors are very united with a shared purpose, shared commitment, and with a vision for the 2030 agenda, for what happens by 2063.

Everybody is really consolidated, and for me, it’s been a privilege to be working with both sides. We have become a trusted partner. The FOCAC process is very much a bilateral process, but the Chinese government and the Africa group have seen the value proposition that the UN can bring. We don’t bring money to the table, but we bring intellectual capital. We bring ideas and we try and see how best to give them the momentum and our UN country teams in the African countries working with their governments in how to implement the best of the forecast.

But today we can’t be the UN of the past, working on 20 schools and building 20 borewells. No, that is done by many others. We need to be looking at what kind of scale we can achieve. Millions of people to be covered, working with the governments from a regional perspective through a cross border perspective and to really make sure that in our united purpose as the UN, we are able to help our member states align with the best practices that are available there, help them to achieve the scale that is necessary.

Ruby: When you’re engaging with the African ambassadors, what do they tell you that they want to work with China on? What, from their perspective, is important?

Sid: The FOCAC has clearly outlined, from agriculture to health to education to infrastructure to the green transition. The possibilities are endless (for working with China). I’ve gone with a few ambassadors to visit the Kubuchi Desert, which is the seventh largest desert in China. You need to visit that desert to understand what China has done. An entire desert, which looks like the Sahara Desert has been tamed. It’s a sea of photovoltaic cells and wind energy. they have produced 3.2 gigawatts of electricity, it powers up three million homes. And under that, they’ve been able to grow some of the best luscious vegetables. The per capita GDP there is higher than the national average. It’s very interesting to see the possibilities of the green transition and what it can do. This convergence of big data technology and innovation. I’m hopeful that there is more collaboration in this space.

4. Close

Ruby: You’ve worked in such high stakes environments for most of your career all around the world. what continues to give you hope and where’s next for you too in your career?

Sid: Perhaps to dial this back to my childhood. I came from a refugee family, lived next to Chinatown in Calcutta. Circumstances were quite tough, and the only thing that I had was not academic competency or sporting prowess. All I had was hope. And that hope has carried me into different areas. I never thought one day I’d be a UN staff member.

I joined in 1997, standing as a security officer in a gate in Bosnia and Herzegovina, in Sarajevo. And here I am today as the head of the United Nations of China. The unseen hand of destiny has certainly played its role - and so did luck. But perhaps it was a passion for change that propelled me forward. It was a passion to make a difference that propelled me forward.

And so when I look forward, I would say that China has very much been a highlight of my career in every way, professionally, personally. My son has been growing up here for the last five years, very attached to this country. My wife has just moved here to work for UNICEF. It has been most gratifying on all comes. What next? Well, God and the Secretary General know.

But, you know, the most important thing is that I feel the sense of deep satisfaction that over the last five years, I’ve been able to work in a fabulous country with phenomenal government partners, phenomenal civil society partners, phenomenal colleagues, who keep this office with the energy and enterprise and great leaders of the UN country team. Wherever I go, I know that I have been working in a country which has been fundamentally very transformational to me, both personally and professionally.

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Watch or listen here on substack, and/or subscribe on Spotify & Apple Podcasts. These newsletter posts provide all links, plus a full text transcript of each episode.

To kick things off, I’m delighted to welcome a very special guest indeed: Professor Tien-Yin Wong is an internationally recognised physician-scientist and practicing ophthalmologist, being among the top 1 % highly cited researchers in the world, leading clinical and translational research, innovation, enterprise and industry collaboration.

Prof. Wong has trained and worked across East and West: he studied medicine at the National University of Singapore and received his PhD from Johns Hopkins University. Later, he was Chair of Ophthalmology at the University of Melbourne, Medical Director of the Singapore National Eye Center, as well as Vice Dean of Duke-NUS Medical School. He now serves as the Founding Dean and Chair Professor of Tsinghua Medicine, a new academic health system based at China’s top university, where he is leading one of the boldest experiments in health innovation: the creation of China’s first AI hospital.

In our conversation, Prof. Wong reflects on his journey across countries and systems, bringing lessons learned from the US, Australia and Singapore. He shares fascinating insights about the similarities and differences between China’s healthcare system and digital ecosystem compared to the West, how to align across siloed Chinese ministries (the perennial challenge for anyone working in China!), and how he is patiently, yet ambitiously, working to achieve these pioneering feats.

This episode sets the tone perfectly for what The CHP Podcast aims to achieve: conversations with experts who have truly seen China’s health system from the inside, and whose stories can help us understand where it’s heading next.

Watch/listen above, on Youtube, or subscribe to Spotify and Apple Podcasts here:

Read our Conversation:

(Audio transcript adjusted for clarity and flow)

Career

Ruby: Welcome, Prof. Wong! We met at Tsinghua University, where I also studied quite a few years ago for the Schwarzman Scholars Programme. I’m excited to chat to you today in depth about your fascinating career journey. You have had such a wide-ranging path: from ophthalmology, to AI innovation, to now leading in medical education. And you’re the highest ranking foreigner in a university in China! Let’s start there: what brought you here to where you are today?

Prof. Wong: It could be serendipity. You build your career by looking for opportunities, usually at different stages of your career, where you look to do something that can make an impact. So as a physician, it is for our patients and for the wider scientific community. These opportunities come generally in one’s career, every 5 to 10 years - and when that comes, you evaluate whether or not it is a growth opportunity, a developmental opportunity, a challenging opportunity.

Once you have become too comfortable, that’s when the opportunities present new areas in which you are able to stretch and challenge yourself. That’s roughly how I ended up here after many countries which I’ve studied and worked in. Now I’m in Beijing, in China, at Tsinghua University.

China’s health challenges

Ruby: You’ve worked across East and West, and you’ve seen how different countries around the world are straining under shared healthcare challenges, whether that’s ageing populations, rising chronic diseases, and the challenge of how to integrate tech into the system. Now that you’re leading in China, what do you think are China’s major health challenges, how are those similar or different to other countries, and how did that inspire you to address them with potential solutions?

Prof. Wong: China is a very fascinating story by itself and healthcare challenges are both very similar to Western countries in the US and UK, certainly in Singapore and Australia, but also has some distinct differences. The usual similar challenges would be that, as a country develops social economically the rise of chronic diseases such as diabetes, hypertension, obesity, as well as the improving social economic conditions and environment. Then you also have increasing lifespan and therefore ageing population. These two are the most significant demographic and healthcare changes that affect every country. But there are a few differences that China presents and adds on to what are already significant problems that the West are dealing with.

First, the rapidity of the changes in disease spectrum happened over a very relatively shorter period of time (in China) - possibly two to three decades. China’s grown into an economic powerhouse now, but it started from a very low base, So the rapidity of the country’s development that led to a rapidity of the ageing population and chronic disease. In a blink of an eye, China has moved from a young population whereby obesity was not an issue - in fact, nutrition and maybe even providing basic healthcare was the main issue - to now being a very different healthcare spectrum. The rapidity means that the healthcare system is not able to react and adapt quickly enough. That’s the first challenge.

The second is that China is really not a very homogenous country. In Beijing and Shanghai, the life expectancy is probably 83, 84 years of age, which is no different from the most developed countries in the West. But if you move into the Western inner regions, the life expectancy would be dropping, and it could be 60 or 70 years. Even in some regions, it could be 50 to 60 years. China is really not a single country in a single region. And therefore, its healthcare system needs to manage patients that are very old in some of the major economically developed cities, and yet still deal with some of the more, acute conditions that affects the young people in some of the less developed regions.

The third thing that’s very different from Western societies, is the lack in the healthcare policies and the financial models that has supported and that has been developed in the Western societies, including UK, Australia, and of course Singapore, where policies and financing mechanisms has adapted to some of these new diseases. In China, the individual patient and the family has to bear a higher proportion of the healthcare costs, because the healthcare coverage, the healthcare financing or insurance coverage has not yet caught up with some of the changing disease spectrum.

So there need to be changes in the system overall, in how China manages different regions - from very advanced cities such as Beijing, Shanghai and Shenzhen, to what are still predominantly rural regions, where basic healthcare needs updating of healthcare policies including financial models to support this changing disease spectrum. These are very unique challenges for a very large country that is undergoing a very rapid transformation. It’s not easy and I don’t presume that there’s a simple solution to this.

Ruby: Yes, it’s certainly a vast country, a vast population, with very distinctive challenges. It’s very difficult to address them and you have to approach it from all angles.

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Transforming Medical Education in China

Ruby: In your work now, you’re really looking at it from two particular angles. One is the skillset of the health professionals and training, and the other is the angle of technology. We’ll look at medical education first.

At Tsinghua University, you were invited to design a new kind of model of medical education. You’ve described this task as the three S’s: structure, strategy and pace. How has this process been, what kind of future clinician are you trying to train, and how should medical education in China evolve to meet the real needs of the health system?

Prof. Wong: Let’s break it down a little bit. There are overlapping, but different pieces, to bringing an overall vision to what is now known as Tsinghua medicine. So these three S’s. The first S is a structure. I was keen to push a new structure in China, which in the West is called an Academic Health Science Center or System: AHS or AHSC. Essentially, this structure involves joining at the hips two very distinct enterprises, creating synergies important for the training as well as the development of physicians to be able able to handle the future.

One is within the university system, which is, traditionally, the schools of of basic and clinical medicine. Where a student is trained typically as a medical student. Tsinghua University is one, in the UK, Cambridge, or in Singapore, the National University of Singapore, for example.

Then the second very important structure, which needs to be joined at the hip, is the healthcare system, or the hospital system. In Tsinghua, this is the affiliated teaching hospitals, of which the most prominent one would be the Beijing Tsinghua Changgen Hospital. This provides clinical care, but also the training and teaching of the careers of medical students after they graduate. In other systems his will be, for example, Addenbrookes Hospital in Cambridge, or the National University Hospital in Singapore.

It means that a single structure is responsible for the training and teaching of medical students when they are young, all the way to the post university or the post school of medicine training into the hospital system where there are young doctors specialist and then consultant. This is quite a long process, and a typical student entering at 18, 19 years of age at the university takes anywhere between 12, maybe even 15 years to become a safe practicing doctor. This cannot be done by a single entity, but it needs to be done under AHS.

So when I went to Tsinghua, I realised that such system really does not exist in China, because the schools and the university typically fall under the Ministry of Education, but the hospitals and the healthcare system falls under the Ministry of Health - and there are somewhat different missions of the university and the hospital system.

So while joining it at hip is important for training and development, it’s certainly not an easy marriage of sorts, because they are under different structures and different governance. Nevertheless, over the last three years or so, we created the first overarching structure that is ready for the future. And that’s what we call Tsinghua Medicine - not Tsinghua School of Medicine, and also not Tsinghua University Hospital.

And that leads us to the second S, which is strategy. This involves bringing together teams, looking at the problems that we’re trying to solve, and then creating a roadmap for that future shared vision. We are now moving along and trying to create that path for our medical students Then, the third S is bring all this together: space. An integrated academic health system should typically be where the University and the hospitals are seamlessly linked, generally on the same site, so that medical students can move from their classrooms to the hospital beds and the operating room, within the single day. This creates the atmosphere for a seamless learning opportunity. The three S’s sound simple, but obviously it takes a lot of work.

Working with Chinese Ministries

Ruby: you mentioned the silos between the ministries and how you were able to coordinate and integrate. If you have any lessons to share, I think that would be fascinating. This is one of the core struggles of China’s health system at large.

Prof. Wong: The two principal beneficiaries of the silos are distinct and yet are very important. The usual Ministry of Education and universities their focus is on students: “we want you to train them as best as you can”. Whether that is in medicine, engineering, law or the arts and social science, that’s the primary mission of a university and the schools. The other aspect would be the healthcare system under the Ministry of Health. Their focus is on maintaining a patient’s health and the population health.

You can see that the stakeholders in the schools and the hospitals are not completely aligned, so you need to align them. We looked at what is needed, and in the medical school, the most important is still ultimately the patient. We are keeping the person healthy, preventing disease, curing disease when we can. Then the medical education is a very critical but basically supporting mechanism, for us to train the manpower and the talents that is able to meet this patient objective.

So rather than having two different objectives, we have aligned them, where the student’s education is to meet the patient’s needs and the goal (at the same time). Then I think it makes sense for the siloed structure to come together to meet this sequential but very important goal of training students who will be doctors, who will look after patients, that will be for the benefit of the population and society. So you streamline the vision. Of course, it’s easy to say it. You know, there are always cultural differences and you do need time to for everyone to accept that there are different roles, but ultimately a single vision and therefore a single mission.

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Global-Local

Ruby: How did your global experience in teaching, and in practicing, help you along this journey, to apply it all to the China context? This was a key reason why you were selected for this role, the global expertise and worldview that you bring to the table.

Prof Wong: I think there are three phases of that learning process. The first would be that, in the US where it is quite established, in the academic health systems in some of the major universities, there was a very seamless integration of the school and the hospital under a very similar mission and orientation.

I was a student at Johns Hopkins, where it didn’t really matter whether you’re medical student or a PhD student, if you’re a scientist or a professor or you’re doctor. You belong to the same overall entity. You feel an affinity, and you feel the energy and the vibrancy of this in the US. When I moved to newer systems such as in Australia and Singapore, they also had this culture and this ecosystem. And that allowed me to really understand how do you do it when you don’t have that system.

(In China), we had to create this by again, having that shared vision, bringing people together, trying to find the right common goals, doing the easy task first, always keeping the communications open, bringing teachers and doctors together on very even platforms without attributing success to one or another. All of these are very important cultural changes that need to be done, and you cannot hasten this process, but if you know where we are going and the structure is going, then you can really apply some of the levers and drivers that allows this to work.

So when I had the US (and subsequently the Australia and the Singapore) experience, I already knew what was the final goal. Of course, China has a very different culture and challenges, but nevertheless, it allowed me to at least understood some of the problems that we were going to encounter, what are the workable levers and what sometimes really doesn’t work anywhere in the world.

Future Clinicians

Prof. Wong: We can also really go into a little bit more detail what we want our future doctors to be and how do we train them. The broad aspect is that we now know that a person’s health is not just dependent the cells and the genes that control our biology and diseases, but the entire environment. means we need to know where they live, how do they work, what they eat, what air does a person breathe. These are very important social, economic or cultural determinants of health. And therefore, a broad education of what affects health and what maintains health is very important, because that affects patients and how they either get diseases or recover.

Second would be technology. We are now, of course, in the age whereby technology is both a driver for transformation and innovation, as well as has many other risks involved. And the typical (example of technology) would be AI. we need to expose our medical students and our doctors to how they learn and practice AI, in a new healthcare setting that will be driven by a digital healthcare system as well as a data-driven ecosystem. That’s also a very important part of the mission of Tsinghua Medicine.

Ruby: Yes, it’s very important to think about the role of a doctor today versus future clinicians you want to try to train, especially as tech becomes more embedded in care, and especially as the world changes around us. I started practicing about 10 years ago now, and even at that time, things were so analogue, and the idea of technology, bringing it into the clinical pathway, the patient pathway, seemed very difficult. If you think about the start of your own clinical career, what technology and health looked like then compared to today, it must also be so interesting to see how much things have changed.

Building China’s First AI Hospital

Ruby: Now you’re doing something hugely exciting: you’re building what’s being called “China’s first truly AI hospital” - and at Tsinghua, which is the top academic institution in the country. What does that vision look like for you? And how will it look in practice when it’s completed?

Prof. Wong: It is still a concept that’s evolving and in planning. First, we need to define: what is an AI hospital? Is it just a piece of software in the clinic, or is it a fully integrated system where there are no doctors around?

The second is where we would want to start first, and which areas do we want to address first. One of the major (challenges) which I did not mention (earlier) would be at the primary care level. As China started its evolution of the healthcare system, they focused on training specialists. So there are fantastic and really excellent surgeons, are excellent cardiologists, very good transplant doctors, many different specialists in China. This has allowed many patients with very difficult, even rare diseases to be treated.

But what has been relatively lacking and underdeveloped, is the primary healthcare system. This means that many patients with very simple problems, the cough and colds, fevers, the little injuries - they will have to go to the large tertiary-type hospitals in China. Therefore, with that clinical and public health need, we feel that the first point of entry for the AI hospital would be at the primary care level. That’s the model that we’re developing.

Now, how do we develop it? Well, we use the latest AI technology, generally based on large language models, to curate algorithms that allow patients’ diseases to be picked up, to be diagnosed, to be precisely given advice, and therefore to be channeled appropriately at the primary care level.

We’ve also involved what we call “agents” - a newer concept, but a very important concept in AI in healthcare. The agent is really someone who orchestrates and coordinates care to make sure that the patient is appropriately managed or referred to specialists when they need to be referred.

And then, how does it look? How much hardware does the AI hospital have? We are now thinking about it from the engineering and the construction of this hospital perspective. We feel that it is unlikely to be like traditional hospitals where for a certain size of populations or patients, you need a certain amount of beds, operating theatres and clinics. We would like to map out the pathway for the clinical care first, where the AI agent interacts and therefore some of it will be reduced in terms of the hardware and the size of the hospital. So it will not be such a large physical hospital, providing the same amount of care as a large traditional hospital.

And then, we call it the “2Ds” of the AI hospital. (The first) is the data centre, data storage. Or data management. And the second D is the digital spine, or the digital ecosystem of the hospital. And for that we do need very specialised teams that know how to manage healthcare data in the most safe, secure way in which data can be used for the training of the AI models, and yet protect patient privacy and does not breach the data security issues of concern to many hospitals whenever they start looking at AI. Of course the digital ecosystem does require specialised software that will interface with the patient, likely on their phones or apps, as well as to the physicians, likely on computer screens, on the laptops, or the iPad systems that we are building. So I think the 2Ds, the data and digital ecosystem, is equally important in terms of the AI hospital.

Finally, I want to go to why are we doing it all, without there being a clear roadmap. The first is that there isn’t such a thing as a clear roadmap. If you ask many groups, there is an interest to incorporate AI into existing healthcare frameworks, existing hospitals. We find that that’s generally challenging, and not easy to do. We have taken the approach to build it from ground zero. In other words, without any substrate to begin with. Many healthcare system hospitals want to integrate or incorporate AI technology into existing structural foundations of a traditional hospital. That’s not that easy to do.

If I were to give an analogy, it is really like a renovating an old house with new digital wires and ecosystem, versus building the house from scratch, essentially. And we’re doing the latter approach. Building the house from scratch is what Tsinghua is trying to do for its AI hospital. It’s still very much in development, and I hope that the lessons that we’ve learned in building it will be useful for different countries and systems trying to build their own AI healthcare infrastructure.

Ruby: Staying flexible and adaptable for your forward-looking roadmap, that’s really important in health because some challenges you can predict, but the system brings up new ones or when things overlap that you need to navigate around. Also, China’s ecosystem changes so quickly that you cannot stay rigid - you have to adapt as you go along the way.

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China’s Distinctive Digital Ecosystem

Ruby: You’re able to build something so ambitious in China, because its digital health ecosystem is maturing at a much faster pace than many other countries around the world. Part of that is because society and daily life is much more digitised, whether that’s payments, travel, e-commerce. But part of that is because China is so much more open to other challenges that other countries might struggle with, such as privacy or governance.

Can you relate what you’re building to China’s internet hospital ecosystem that’s already expanding? We’ve seen with the rise of DeepSeek and other AI chatbots in China, they are doing pilots at regional level at very small scale, but not yet integrating AI into a offline-to-online (healthcare) pathway. Building AI into the entire hospital framework is so ambitious, Can you share a bit more about that?

Prof. Wong: I think all these are very good questions. I don’t suggest that we have all the answers. We have set out almost a moonshot project, with an aim and a declaration for a common goal, which everyone needs to work towards early on. Rather than building small little pilot pieces and clobbering them all together, we have set up the major goal first. So we think that that is a very different approach from many hospitals, trying to integrate various types of apps and software algorithms.

Some unique characteristics of China make it a suitable country (for us) to do this. As we have already mentioned, the rapidity of China’s digital ecosystem that started being embedded and integrated into everyday life, it’s much earlier than many countries. I see now, for example, in UK that many payment systems are also digital. Transports are also digital, so that’s a good sign. But in China, some of these began maybe 5, even 10 years earlier. There are very mature systems, super-apps that integrate people’s communication with their transport, with their social media, and the way in which they do payments.

Because of this, many people, particularly older people, are much more acceptable of digital technology. In many Western societies, the younger generation is very comfortable with phones and apps and are quite capable of understanding and using digital technology, including AI. But older people would be a little bit more skeptical and may make it difficult for AI hospitals to work, that still want to see the doctor and wants to interact with a person at the end of the consultation and so forth. But in China now, the young and old are equally acceptable of digital technology, which means that the older patients could trust an AI chatbot giving advice, providing a plan and following up with that plan, rather than in other countries where they might question the validity or distrust the AI, and that really hinders a lot of the development. So I think the population in China is very ripe for major technology including AI.

China’s relatively top-down approaches to this means that when the government is very keen to support, they roll out schemes, they roll out incentives, they encourage the healthcare systems to quickly adopt and to use and to integrate. With this kind of leadership, and very consistent messages from China’s government - which is not seen in many Western countries, (who do not have) a single coordinated message, I think it’s very difficult for Western institutions) to say, do we do it or do we wait for the government to give us a clearer message?

In China, it’s a simple clarity of that message, which is that they would like AI and technology to really revolutionise and uplift the entire healthcare infrastructure, as well as the other parts of the society and economy. And therefore, I think the chance of success is higher in China, maybe sooner in China than other places. We’ve seen this in the three areas that China is now currently a technological leader globally: electrical vehicles and probably the autonomous vehicles, new clean energy solar panels, and the ability to manage climate and environmental changes.

There’s a very clear and consistent message from the government, it filters down to provincial and city leadership, and then if it filters down to the next level of leadership at the hospitals, the whole country moves in that direction. So I think similarly with the AI Hospital, I think it will have a higher chance of success because of this singular vision and pathway that is being undertaken.

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Risks

Ruby: What are the risks you’re most cognisant of? whether that’s speed, access and inequalities or governance, privacy.

Prof. Wong: All those things are very important. China always balances the speed of innovation and the speed of progress with the ability to bring society along. Because once you have started, you need to) get the buy in from a vast majority of the population. For example, certain segments of population benefit from AI technology and the AI hospital of the future. But (if) the rest of the population does not benefit, then I think the risk will splinter the country. The speed of it, the equality of the major cities versus the less developed and less well-resourced cities and provinces. that’s also important.

Then, the patient’s benefit needs to be first. The first principle for physicians, as everyone would be aware, is first do no harm. The risk of using AI, it’s not so much the benefit of how many hundreds or thousands or millions, but the possibility of harming even a single patient. So healthcare and medicine, and therefore AI in healthcare and medicine, faces this very important high barrier. AI should do no harm. And if it doesn’t, if it’s not able to meet it, then I think (it needs to be) a little bit slower, with a little bit more patience, more safeguards in place. This would be a very important strategy, whether for AI in general, in medicine, or the AI hospital we are trying to build. That balance of pushing technology innovation, as well as protecting the individual patient, making sure that no harm is done to that patient, it’s very critical.

Ruby: The pace and the scale that China is building - and what you’re building within China’s system, leading the way - is unprecedented. For me, sitting here in London, integrating technology into the health system, it’s talked about, and I work on it, but it’s slow, and there’s so much resistance, due to the various reasons you’ve discussed: bureaucracy, attitudes, operational issues. It’s truly incredible to see what China’s doing, and to think about the lessons of what to do and what not to do, that other countries can learn from.

Global relevance

Ruby: You’re now building partnerships between the work you’re doing in China with the UK, with Singapore, with other countries. Building those collaborations - how has that been, to match the strengths of each side?

Prof. Wong: I think China needs to be a leader in innovation and in healthcare, not just for its own population - of which they have many challenges within its population and which we have just discussed - but it needs to be able to provide road maps for a broader population beyond China’s border.

China is a big country, but it’s still only 20% of the world’s population. So I think China being where it is today, must be a responsible and proactive citizen of the world, providing solutions, innovations, supporting the development of population and global health at a broader scale. And I think at Tsinghua, which is, China’s leading university, it’s ambitious and globally impactful - we have a responsibility. We need to build partnerships with places that we can work with, to find some shared vision, identity, shared problems, shared solutions.

Reflections

Ruby: You’re wearing so many different hats: you’re a practicing clinician still, a researcher, Dean and academic leader - and you’re continuing to build bridges across countries, How do you balance all of this, and what motivates you to go in one direction, or another - or all of them?

Prof. Wong: We have to follow very fundamental basic principles. You need goals and vision. You need to set it flexibly, adaptive to the current system and the current situation you can work in. The second very important attitude is to be always grateful and thankful for many opportunities and doors that’s open and to create or to play a part in some journey that’s the larger mission of society.

And I think the third is to have this attitude of always learning, whether it is success or failure, we learn from both. That is a very important attitude. I think that gives you balance, perspective of your role at different stages of career, at different times that you are younger or older and really trying to do something. That helps, if not larger populations, at least individual people, individual students, individual patients. I think sometimes those are very important to really hold on to. It really gives you the ability to balance and to put things in perspective.

I hope you enjoyed this first CHP podcast, as much as we enjoyed recording it. Subscribe on Spotify & Apple to stay updated.

In my next CHP post, I’ll zoom out to explain what the wider landscape of China’s digital health ecosystem is like currently, how internet hospitals have evolved nationwide, and why it’s all so far ahead of the digital health pathways that currently exist in other countries.

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