Mention China to a medical journal editor, and their mind will leap to studies on irrelevant research questions drawn from the UK Biobank. It might also jump to numerous analyses of Global Burden of Disease study data. It will inevitably dwell on risks of research misconduct and ethical breaches. The overriding sentiment, however, might be: how do we get through an avalanche of substandard submissions seeking an international journal with an impact factor?
On a recent trip to China I championed the advice of Doug Altman, The BMJ’s former chief statistician who not only led the field of medical statistics but helped establish it. In a landmark editorial in The BMJ in 1994 describing the “scandal of poor medical research,” Altman wrote, “We need less research, better research, and research done for the right reasons” (doi:10.1136/bmj.308.6924.283).1 Good advice travels slowly, in time and place. Urging China’s researchers to abide by Altman’s wisdom is an editor’s equivalent of putting your finger in the dike, except that your finger will never fit the hole.
And yet there’s another version of China—a better China that has rapidly modernised its research infrastructure, invested heavily in building research capacity, turbocharged the sophistication of its clinical research enterprise, and embraced international collaboration to propel it to a leadership position in medical research. The US’s political myopia and self-harm leave the science race open for China to dominate now and for decades to come. With every US retreat, be it national or international (doi:10.1136/bmj.r2088),2 China is driving forward, producing higher quality research in more impressive volumes. While President Donald Trump celebrates the “amazing” experience of his trade negotiations with President Xi Jinping,3 China is playing the long game of investment in science and technology.
Bringing order
The contradiction in China’s research ecosystem is neatly captured by our editorialists in considering the potential and risks inherent in China’s flourishing cohort studies. China has the population numbers, the technology, and the planning and execution to develop a valuable resource for itself and the outside world (doi:10.1136/bmj.r2026).4 As work is incentivised on China’s domestic datasets, international collaborations are being encouraged (doi:10.1136/bmj-2024-083354).5 On the flip side, a free-for-all on access to data feeds the perverse academic incentives that are creating a damaging excess of unnecessary, irrelevant, and fraudulent studies. China, then, is both the role model and the basket case.
While taming the wild horses of China’s research enterprise seems to be near impossible, the signs are that China will not shirk the challenge of bringing order to the maelstrom. The expansion of high quality datasets is proof enough, as is a new determination to stamp out research misconduct.
Yet structural problems complicate the picture. Let’s take the Balkanised landscape of China’s proliferating hospital sector, for example, with each institution producing its own data, focusing on its own priorities, and competing for recognition and impact. The ensuing “data fragmentation, heterogeneity, and lack of standardisation” become barriers to integration with registries and electronic health records (doi:10.1136/bmj-2024-083354).5 Community based data might be better knitted together but face challenges with length of follow-up and sustainable funding. Large sample sizes also bring their own methodological challenges. Bigger isn’t necessarily better.
China knows that it must orientate its medical research for the benefits of its own population. It has major hurdles to overcome in terms of medical ethics, research misconduct, and data privacy. But it also knows that it can’t do it alone—that collaboration extends power and doesn’t diminish it. However, international trust in China’s science is far from universal. What’s true of geopolitics is also true of medical research. The message from our collection of papers on China’s cohort studies6 is that international collaboration can benefit both China and the rest of the world. The potential is clear.
China, then, is a serious player. It’s playing the long game. It’s playing to win. Indeed, by some estimates, China may have already won the medical research arms race. A strategy attributed to China in Chairman Mao’s era was one of “protracted war.” China would hide its capabilities and bide its time7—crouching tiger, hidden danger. The tiger of China’s medical science is no longer hiding. But ethical concerns about its medical science remain barriers to collaboration, three prominent examples being its mistreatment of the Uyghurs (doi:10.1136/bmj.p2374),8 controversies over organ removal from prisoners (doi:10.1136/bmj.l4287),9 and disputed cooperation with the World Health Organization over the origins of covid-19 (doi:10.1136/bmj.n2023 doi:10.1136/bmj.r1358).1011
The China question is not one of capability. It is one of restoring trust in the ethical conduct of its medical science.
