The Health Security Outcomes of APEC and the Biden-Xi Dialogue

From November 14 to 16, leaders from the 21-member Asia-Pacific Economic Cooperation (APEC) group met in San Francisco to discuss promoting trade and economic growth across the Pacific region. On the sidelines of the forum, Presidents Joe Biden and Xi Jinping convened for their first in-person meeting in a year. While the meetings provided an opportunity to keep public health priorities on the diplomatic agenda, they led to few meaningful new commitments on U.S.-China health security cooperation.

The Covid-19 pandemic highlighted the importance of strong health cooperation between countries in times of emergency. As the world emerges from the acute phase of the Covid-19 crisis, diplomatic forums such as APEC provide critical touchpoints to reassess existing health agreements in preparation for the next transnational biological threat. No global health security strategy can be comprehensive or successful without support from both the United States and China, making opportunities for high-level diplomatic engagement on health between the two countries paramount.

The meetings did yield some useful dialogue. APEC economies agreed to cooperate on regulatory harmonization and the movement of goods in a public health emergency, and Presidents Biden and Xi reached an important agreement on curbing illicit fentanyl production and expressed a desire to reinvigorate people-to-people exchanges between the United States and China. But taken alone, these outcomes will not significantly strengthen global health security cooperation nor restore the bilateral relationship.

Q1: What health-related outcomes did the November APEC forum achieve?

A1: APEC ministers, chaired by U.S. secretary of state Antony Blinken and U.S. trade representative Ambassador Katherine Tai, met to discuss advancing an interconnected APEC region. Although the APEC Health Working Group met back in August for its 13th High-Level Meeting on Health and the Economy (HLMHE) to discuss health specific concerns in the region—such as preparedness and response, strengthening health systems, and supporting healthy populations across the life course—the November APEC forum touched on several areas of health security cooperation and diplomacy as well.

In a joint statement released following the conclusion of the November meetings, the APEC ministers laid out a framework for regional cooperation, expressing the importance of strengthening health systems for pandemic prevention, preparedness, and response and ensuring resilient, equitable, sustainable, and inclusive health systems. The ministers reiterated their commitment from the HLMHE to achieve universal health coverage, particularly through investments in workforce development. The desire to build a competent and skilled workforce provides a clear opportunity for the World Health Organization (WHO) to promote adoption of the Global Health Emergency Corps (GHEC) in the region. By highlighting that the GHEC’s mission of strengthening and scaling the health emergency workforce ties directly to APEC’s regional workforce goals, the WHO could further promote the potential value add of the GHEC. But how APEC economies prioritize and follow through on these commitments remains to be seen.

In November, APEC economies additionally endorsed the Non-Binding Guidelines on Logistics-related Services that Support the Movement of Essential Goods During a Public Health Emergency. These guidelines support regulatory practices, trade measures, and digitization of logistics-related services in a public health emergency. Although non-binding, the development of these guidelines comes as a direct response to the economic and social costs that APEC economies experienced as a result of disrupted supply chains during the Covid-19 pandemic. If followed, this agreement should help to strengthen regulatory and delivery systems in the region, particularly in their work to ensure access to safe and effective medical products.

Furthermore, the APEC ministers reiterated their support for APEC’s ongoing work to renew the terms of reference for the APEC Regulatory Harmonization Steering Committee (RHSC). As part of the APEC Life Sciences Innovation Forum, the RHSC works to promote a strategic approach to regulatory harmonization to achieve regional regulatory convergence of medical product approval procedures. The RHSC could be an important forum for dialogue as regulatory cooperation between the United States and China has slowly deteriorated over the past several years. Between April 2020 and March 2021, the U.S. Food and Drug Administration (FDA) did not conduct any regulatory drug inspections in China, and in 2022 annual U.S. foreign drug quality assurance inspections were still down nearly 79 percent from 2019. Dr. Michelle Limoli of the FDA serves as a cochair of the RHSC, and Dr. He Li of the Chinese Pharmaceutical Association National Medical Products Administration now serves as the RHSC vice chair, indicating a possible rebound in regulatory cooperation between the United States, China, and other APEC economies.

Q2: What did the United States and China agree to on fentanyl and why is it significant for global health security?

A2: On the sidelines of the forum, Presidents Biden and Xi reached an expected agreement to curb illicit fentanyl production, welcoming the resumption of bilateral cooperation to combat global illicit drug manufacturing and trafficking for synthetic drugs. The reality that curbing the fentanyl epidemic was one of the only subjects on which Xi and Biden reached a tangible and cooperative agreement indicates that despite geopolitical tensions, the window for health-related diplomacy and cooperation remains open.

Biden and Xi announced the establishment of a working group for ongoing communication and law enforcement coordination on counternarcotics issues between the two nations. Deaths related to illicitly manufactured fentanyl, a synthetic opioid, are on the rise in the United States—in 2022, more than two-thirds of the nearly 108,000 drug overdose deaths in the United States involved synthetic opioids other than methadone. As China is a leading supplier of fentanyl precursors, bilateral cooperation is critical to reduce the diversion of precursor chemicals to illicit manufacturers.

The extent to which a Biden-Xi fentanyl agreement will curb the flow of fentanyl into the United States remains unclear. China does not have an ongoing fentanyl epidemic comparable to that of the United States, but it is facing a growing illicit drug use problem, spurring domestic interest in curbing illicit fentanyl production. The fentanyl agreement may further pave the way for U.S.-China dialogue on advancing bilateral interests in the prevention and treatment of fentanyl addiction and wider strategic cooperation and dialogue on health. The speed and commitment with which China cracks down on illicit drug trafficking may depend on broader trends in the bilateral relationship and whether geopolitical winds point toward a softening or hardening approach to competition.

Q3: How could the resumption of people-to-people exchanges help promote health cooperation?

A3: During the Biden-Xi sideline summit, each leader expressed a desire to jointly promote people-to-people exchanges. Over the past several years, the number of student exchanges between the two countries has dropped significantly, with 11,639 U.S. students in China in the 2018–19 academic year and only 382 in 2020–21. In the United States, the number of Chinese students studying abroad has declined from more than 370,000 in the 2019–2020 academic year to around 290,000 in 2022. While much of this decline can be attributed to travel restrictions imposed during the Covid-19 pandemic, academic exchange between the United States and China is vital to ensuring strong health cooperation between the two countries. President Xi announced China will invite 50,000 young Americans overseas over the next five years on exchange and study programs. People-to-people exchanges in academia and in the scientific enterprise promote mutual understanding between the two countries, improve relationships between the two populations, and set the stage for bilateral cooperation throughout scientists’ careers.

Although the United States and China have lacked high-level ministerial dialogues focused specifically on strengthening health security cooperation between the two countries, the promotion of academic exchange is an important step in fostering some level of dialogue on health at a technical level, to begin repairing the contentious bilateral relationship. The extent to which China and the United States encourage the resumption of robust people-to-people exchanges will serve as an indication of their willingness and ability to transcend political rhetoric and cooperate on issues of mutual interest.

Q4: Did the November APEC meeting and Biden-Xi sideline summit increase the prospects for future health security cooperation?

A4: The November APEC meeting provided an important forum for high-level discussion on economic and development cooperation in promoting global health security. Similarly, the sideline Biden-Xi summit was an invaluable opportunity for the two global superpowers to ease rising tensions and cooperate on combating cross-border threats. While the November meetings did foster dialogue on regional health security cooperation, APEC economies should look for further opportunities to take tangible action to strengthen their collective health security.

Although global health security is a multi-sectoral, cross-cutting issue area, more high-level dialogue—particularly between the United States and China—focused strictly on improving collective health security is imperative. Health security provides an outlet for multilateral and bilateral cooperation at a time when the United States and China face deep geopolitical tensions. The ongoing pandemic accord negotiations provide one important forum for sustained, multilateral, high-level dialogue on advancing global health security. The United States and China have an upcoming opportunity to strengthen collective biosafety and biosecurity through talks aimed at addressing risks associated with advancements in artificial intelligence. But if the United States and China lack the political will to engage in bilateral health dialogues with one another, it may be useful to focus increasingly on regional or multilateral forums for progress.

The November APEC forum was an important multilateral touchpoint on health security, but its returns were modest at a time when health concerns are fading in the face of competing global challenges. The time is now for collective and sustained high-level action to strengthen global health security before another transnational biological threat emerges.

Sophia Hirshfield is a research associate for the CSIS Global Health Policy Center. J. Stephen Morrison is a senior vice president and directs the Global Health Policy Center at the Center for Strategic and International Studies (CSIS) in Washington, D.C.