How Foes Can Defeat a Common Enemy: U.S.-China Collaboration to Combat Ebola

A joint CSIS-Brookings project

The Issue

As intense geostrategic rivalry becomes an enduring feature of the U.S.-China relationship, CSIS and the Brookings Institution have launched a joint project, Advancing Collaboration in an Era of Strategic Competition, to explore and expand the space for U.S.-China collaboration on matters of shared concern. In this essay, Gayle Smith, CEO of the ONE Campaign and former administrator of the U.S. Agency for International Development (USAID), discusses the threatening appearance of the Ebola virus in the mid-2010s and how the United States and China came together to address the crisis. Drawing on her first-hand experience, she identifies key lessons that should inform future collaborative efforts, including separating the key problem area and bilateral relations into two separate tracks, keeping focus on the right adversary, rooting discourse and communication in facts, and leaving the talking points on the table.

Combating Ebola, Together

There are three things to know about defeating viruses:

First, the goal is to move faster than the virus—unleashed, viruses spread at alarming speed. Given the opportunity, infections spread exponentially, and when challenged, the most capable of viruses can mutate to their advantage. Viral control is a race against a competent opponent.

Second, viral spread cannot be constrained or contained if there are holes in the net. Viruses are adept at seizing opportunity and targeting populations that enable them to multiply, mutate, grow stronger, and spread; they neither know nor care about international borders. In an epidemic or pandemic, progress is enhanced by regional and global cooperation and undermined without it.

Third, as daunting as viral threats have proven to be and will be into the future, viruses are easier to defeat than other transnational dangers because they are more quantitative than human-inspired security threats. Scientists can track, measure, and counter viruses based on data and evidence. On the other hand, strategies to counter terrorism, acts of aggression, or nuclear threats are informed significantly by assumptions about and analyses of human behavior, beliefs, and decisions. While human behavior can negatively impact a viral crisis, viral threat response strategy relies on hard and measurable information—data and scientific facts and trends.

Progress in the fight against HIV/AIDS shows how these three things play out. In the late 1990s, the HIV virus was spreading unchecked, but major moves—including the launch of the President’s Emergency Plan for AIDS Relief (PEPFAR) by President George W. Bush; the creation of the Global Fund for AIDS, Tuberculosis, and Malaria; and negotiated reductions to the price of testing and treatment—brought enough scale and speed to the response that, according to UNAIDS, AIDS-related deaths declined by 69 percent between 2004 and 2022. Getting to scale required extensive international cooperation. Today, countries routinely track the virus, testing and treatment are more widely available (even in some conflict zones), and responders have learned how to target the most vulnerable populations. The generation and sharing of scientific evidence has been a gamechanger, yielding both improved treatment regimens and new prevention strategies.

The Covid-19 pandemic showed us what happens if these facts are ignored. Four years in, the virus is still moving faster than the humans it infects, with yet another new strain on deck and tens of thousands of new cases reported weekly. Perhaps most damaging, there were—and remain—major holes in the response net, some due to the decline of multilateralism and others rooted in the decision by some leaders to frame the threat in geopolitical rather than scientific terms. Leaders still do not regularly convene, collaborate, or cooperate to counter the virus. While most governments attempt to lead with quantitative, fact-based analyses, the rise of disinformation about vaccines and the virus itself has meant that human behavior—not science—is driving the global response.

The Ebola epidemic of 2014 played out differently, including with respect to cooperation between the United States and China. The threat that became the first-ever Ebola epidemic crept up on the world and then revealed itself in ways that can only be described as horrific. The first reported case was an unidentified illness in Guinea in March 2014; once Ebola was identified, the World Health Organization (WHO) declared an outbreak. Initially, it was thought that it might be contained, as had been the case with previous outbreaks in Central Africa. That was not to be.

Ebola is a terrifying disease. Designated as hemorrhagic, Ebola causes the body to bleed to death. It is as deadly as it is contagious. The treatment and burial of Ebola victims had to be managed with extreme care, and through the course of the epidemic, frontline health workers, families of patients, and members of burial teams were among the victims. Medical countermeasures were, at the time, few and of limited availability.

Ebola quickly spread across Guinea, Liberia, and Sierra Leone. As people infected with the virus moved from rural to more crowded urban areas in search of care, the virus took off running, moving much faster than the humans who tried to control it. Foreign and domestic NGOs and frontline health workers sounded the alarm as they innovated, developing the model for Ebola Treatment Units that would be used throughout the response. They raced against time, often absent the treatment facilities, protective gear, testing equipment, and medical supplies that were needed at scale.

By the summer, external assistance had increased substantially. The Centers for Disease Control and Prevention (CDC) established an Emergency Operations Center in Atlanta and ultimately deployed hundreds of medical personnel, while USAID deployed the first of what would be eight Disaster Assistance Response Teams (DARTs) across the region. Other major donors provided aid, and China, which had delivered its first tranche of assistance in May, assisted with medical supplies and a limited number of personnel.

In August, the WHO declared a public health emergency of international concern. Through the late summer and into the early fall, it was clear that the virus was winning, and President Barack Obama made clear to the National Security Council (NSC) team coordinating the U.S. response that defeating the epidemic was a top priority. He put considerable time into the effort, calling heads of state all over the world to ask in specific terms what they could put on the table—such as healthcare workers, Ebola Treatment Units, mobile labs, and protective gear. National Security Advisor Susan Rice convened meetings of the Principals Committee at least once and sometimes twice a week. The president attended many of these meetings, and he requested and received daily briefings on the state of the epidemic, number of cases, and gaps in needed assistance. He also made clear that our job was to enlist the tangible support of and coordinate with the entire international community—and that included China.

The backdrop at the time was a China policy that was tough where it needed to be—on Taiwan, trade, cybersecurity, human rights, and other issues—but sought engagement where dialogue might yield changes in China’s policies or mutually beneficial cooperation. Over the course of the Obama administration, officials met frequently at high-level forums. But the guidance to engage China on the Ebola response did not emanate from China policy—it was driven by the need to achieve the policy goal that the president had set for the Ebola response, which was to bring the epidemic to an end. The president judged that China’s contributions could bring that objective within reach.

Several events in September 2014 laid the groundwork for cooperation between the United States and China in response to the epidemic. By that time, China was increasing its assistance and had civilian and People’s Liberation Army (PLA) personnel on the ground. It had become clear that despite the ramp-up in international assistance and the substantial increase in the number of health workers involved, the virus was still outpacing the response. It was critical that all countries, including China, provide more assistance. Of particular concern was the need for mobile laboratories that would enable operators on the ground to test for Ebola on site, particularly in rural areas, and thus constrain the movement of infected people into the more crowded urban areas where the virus spread like wildfire.

While in Beijing preparing for a meeting of Presidents Obama and Xi Jinping on the margins of the 22nd Asia-Pacific Economic Cooperation (APEC) Summit, National Security Susan Rice made the case for increased cooperation and the provision of additional Chinese assistance. Later that month, President Xi endorsed China’s plan for an expanded response, and the United States and China joined forces in strongly supporting a UN Security Council resolution that declared the Ebola epidemic a threat to international peace and security. While the resolution was widely supported, the signal sent by the simple fact that the United States and China were on the same page helped shape a collective international response devoid of politics and instead focused squarely on the enemy at hand.

It was then that my colleague at the National Security Council, China Director Ryan Hass, approached me about meeting with Chinese officials. I led the NSC Directorate that spearheaded both the global public health and humanitarian response and convened the Ebola interagency group daily. I am not a China expert by any stretch of the imagination, and my direct engagement with China over the years had been limited to the occasional discussion about Sudan or HIV/AIDS. Ryan and I proceeded to meet with Ambassador Cui Tiankai at the Chinese embassy in Washington.

The ambassador was polite, and we spent the bulk of the meeting sharing our analyses of the threat and reciting what each of our countries was doing in response. There was a lot of agreement, but not much more than that. I then pulled out a slide prepared by U.S. experts at the CDC, a graph which showed an upward curve representing the projection of viral spread if the caseloads in West Africa were not reduced. It looked like a hockey stick. As I walked the ambassador through it, we both recognized what it meant—hundreds of thousands and likely millions of people were at risk, and unless the world’s response achieved scale, the virus would spread at alarming speed across the continent, and then across oceans to the rest of the world. In the throes of urgency and desperate that we increase the number of mobile labs and other equipment needed, I looked the ambassador straight in the eye and said, “Mr. Ambassador, there are only two countries in the world that are big enough to sit on that curve and bend it.”

The meeting soon ended, and as we concluded, the ambassador took my hand in both of his and said, “Madame, you are very passionate and very persuasive. I will speak with my government.” That was that.

Back at the White House, the urgency of the situation intensified. In late September, I polled my U.S. government counterparts from USAID, the CDC, and the Departments of Defense and Homeland Security and asked whether they thought we could outpace the virus if we provided more civilian assistance—DART teams from USAID, doctors from the CDC, and other additional aid. All replied “no,” and we agreed unanimously that we needed the U.S. military to provide the lift, workforce, and logistical capabilities that were beyond the scope of civilian agencies. Following a prompt and efficient decisionmaking process in late September, the president announced the deployment of 3,000 U.S. troops, and the force commander was on the ground in Liberia by early October.

In November, Ambassador Cui requested a private meeting with Ryan and me in our offices at the National Security Council, where he proudly shared a photograph of U.S. military personnel offloading mobile labs from Chinese planes. He told us he had a copy of the same picture framed for his own office. He smiled and told us, “We are bending the curve together.”

In the coming weeks, Chinese and U.S. experts worked together in labs in Sierra Leone, and Beijing and Washington upped assistance levels. Both governments helped build additional Ebola Treatment Units. While there was no practical coordination between U.S. military and PLA personnel on the ground, both were represented at the same planning and coordination meetings.

Compared to “traditional donors”—such as the United States, European Union, United Kingdom, Germany, Japan, France, and Canada—China was not a major donor to the Ebola response, and its assistance fell far short of what the United States provided. But China’s contributions were greater and more visible than had been the case in other international emergencies, where China largely acted as a free-rider and did not contribute to international responses. In contrast, the United States and China made clear to the rest of the world throughout the Ebola crisis that they were on the same side in this battle.

Building on the cooperation demonstrated at the United Nations in September, Presidents Obama and Xi went on at the APEC Summit that November to, in the words of Xi, “leverage our respective strength(s) and work with the rest of the international community” to defeat the threat posed by the virus. Both the United States and China maintained personnel on the ground in West Africa into 2015, and Ebola-related cooperation continued for the next two years.

China was an active participant in the Global Health Security Agenda, which was launched by the United States and led to agreement within the G7 and G20 to allocate resources and training to build the capacity of low-income countries to prevent, detect, and respond to viral outbreaks. At the U.S.-China Symposium on Ebola, Research, and Global Health Security, China’s vice premier signaled China’s desire to collaborate on global health security going forward. At the U.S.-China Development Dialogue in 2016, global public health was one of two priority issues on the table. Also in 2016, though separately, the United States and China signed memoranda of understanding in support of the African Union’s establishment of the African Centres for Disease Control and Prevention—an institution that proceeded to play a vital role on the continent during the Covid-19 pandemic.

While it is only possible to surmise China’s intentions, it is reasonable to assume that Beijing’s cooperation with Washington was guided by several factors. First, China had by that time gained considerable experience with viral threats, including SARS, and even the highest levels of government understood the science of viral spread sufficiently to be open to all means of containment, including cooperation with the United States. Second, China had significant financial investments in West Africa at the time, particularly in Guinea, as well as thousands of Chinese workers on the ground who were vulnerable to infection. Third, China saw an opportunity to gain recognition for acting as a responsible power—and took it.

Much has changed since then. Cooperation between the United States and China had already declined by the time of the Ebola outbreak in the Democratic Republic of the Congo in 2018. But it remains the case that when future viral threats strike, international cooperation—even among adversaries—will be one of the determining factors in the success or failure of any global response. U.S.-China cooperation during the Ebola epidemic in multilateral forums and on the ground yielded some lessons worth considering for the future.

• Keep the quantitative challenge of countering a viral threat and the qualitative challenge of bilateral relations on two separate tracks.
  Both the president and the national security advisor made clear that securing more assistance from and cooperation with China was not about China per se, but was about the need to mobilize the international community, and in particular a country with resources and capabilities. The guidance handed down focused not on politics or the bilateral relationship but on the outcome we needed to achieve.
• Focus on the right adversary.
  The goal of the two presidents in this case was neither to win an international competition or upstage the other. The United States and China were at the time competitive on multiple fronts, but the target in this case was the virus. At the highest levels, both governments acted in ways that demonstrated an understanding that viral threats are transnational and necessitate collective responses.
• Root the discourse in the facts.
  In my own exchanges with my Chinese counterparts—but also exchanges between U.S. scientists and their counterparts, U.S. and Chinese personnel on the ground in West Africa, and political interlocutors from the two governments—it was a focus on the logistics, science, and data that was key to an effective response. Politics did not enter into operational discussions.
• Leave the talking points on the table. 
  There are times when the formality and precision of agreed-upon talking points can enable a “safe” discussion that yields the desired outcome. But there are also times when informality, frankness, and less-scripted exchanges can move things faster, particularly in cases where an emergency is unfolding in real time. Our meeting with the Chinese ambassador lacked the formality of most bilateral engagements between the United States and China, but it afforded us the ability to make a passionate case—less as representatives of two governments that were somewhat wary of one another, and more as people who could, together, counter a threat that posed risks to us all.

Gayle Smith is the former CEO of the ONE Campaign and served as coordinator for Global Pandemic Response and Global Health Security at the State Department. She was the administrator of USAID from 2015 to 2017 and served on the National Security Council in the Obama and Clinton administrations.

This brief was made possible by generous support from the Gates Foundation and the Hewlett Foundation.

This project is part of a partnership between CSIS and the Brookings Institution’s Foreign Policy program.