Amidst the worsening COVID-19 situation in the world, China has shored up the dispatch of medical supplies, experts, and other technical assistance to countries now reeling under the effects of the pandemic. The Chinese government has so far extended medical aid to as many as 82 countries, and organisations like the World Health Organization (WHO) and the African Union.[i] Chinese medical assistance is not only targeted at the governmental level but is also carried out through its local governments, private companies, and non-governmental organisations.[ii] Along with the supply of thousands of masks, protective gear, and testing kits, Beijing is also leveraging its clout in public health technology by sharing technical know-how on the diagnostics, therapeutics either by sending the team of expert teams or through video-conferencing. In many instances, China has gone out of its way to help countries affected by COVID-19 and used even special trains to deliver essential medical supplies.[iii]
Large-scale assistance is conspicuous especially in the light of multiple controversies surrounding China’s handling of the outbreak. The prevailing view is that China’s initial cover-ups about the outbreak and attempts to obfuscate reality from the WHO have caused the virus to spread quickly around the world.[iv] The Trump administration strongly accused Beijing of (mis) using its influence within the WHO to conceal facts and delay the declaration of global “public health emergency”.[v] American experts have also questioned the WHO’s nomenclature[vi]‘COVID-19’ (coronavirus disease 2019), which apparently helped China to de-hyphenate the current epidemic from the 2003 Severe Respiratory Syndrome (SARS) outbreak and to deflect the scrutiny of its healthcare management.[vii] This begs an important question: Is China using health as an end in itself or as a means to serve larger foreign policy objectives?
Global Health in China’s Foreign Policy Calculus
In the context of China’s global health diplomacy, it is important to differentiate between its bilateral and multilateral approaches. The two approaches differ in their motives and have undergone strategic shifts over the years. In the early years of the cold war period, the health assistance programmes were part of China’s efforts to break-diplomatic isolation since the WHO did not formally recognise the Peoples Republic of China (PRC) under the Communist regime. China’s competition with Taiwan over the WHO membership and its deterioration of friendship with the Soviet Union in the 1950s were the key drivers behind its healthcare assistance.[viii] In its quest to gain formal recognition, Beijing targeted the “intermediate zones”, including newly independent states which were not under the direct influence of the two power blocs for its health aid programs to build and expand its political influence.
Most of China’s collaborations in the health sector in the 1960s were with African countries, mainly in the form of medical assistance, which included infrastructure investment, building hospitals, medical supplies, dispatching medical teams and other medical support.[ix] Thus, in the early years, the Chinese approach to healthcare aid was purely bilateral and a low priority area in its foreign policy agenda. Unlike the western donors whose interventions were disease-specific and financial, the Chinese medical outreach focussed on building national health systems in Africa which immensely helped China to gain the WHO membership and thereafter became part of various health and institutional building activities under WHO programmes.[x]
With China embarking on market-oriented reforms from the 1980s, its approach to healthcare assistance underwent a significant shift. Beijing began viewing medical collaborations as an important instrument for profit-making. A bulk of its foreign aid then comprised of concessional loans, which went into building hospitals and clinics, establishing treatment centers, dispatching medical teams as well as providing medicines and equipment in the recipient countries was used for securing markets for Chinese pharmaceutical companies, including Chinese traditional medicines.[xi] By the 1990s, China’s increasing foreign trade activities began to shape its conceptions about public health, foreign policy, and international cooperation.
However, China’s attempts to build its international image in global health received a major blow with the SARS outbreak in 2003. Beijing faced diplomatic isolation as it rejected international health assistance, denied entry of the WHO assessment teams, and resorted to secrecy around the outbreak, causing the virus to spread rapidly across China. SARS being the first global epidemic of the 21st century caused much panic internationally. Faced with strong international pressures, WHO recommended travel restrictions to China and demanded major changes in its national infection policy.[xii] The SARS epidemic nonetheless prompted new thinking about public health management. Beijing realised the significance of participating in international health networks, and especially developing close interactions with American scientists, WHO epidemiologists, and public health experts from other countries.[xiii] Many state-led research programs were initiated to study infectious diseases, antiviral drugs, and vaccines. China also built the much-needed Level 4 bio-safety laboratory to study the infectious disease pathogens.[xiv]
Under the leadership of Wen Jiabao and Hu Jintao, healthcare was high on China’s foreign policy agenda. In 2005, President Hu Jintao’s announcement of peaceful development strategy at the 60th anniversary of the United Nations brought about another significant shift in China’s healthcare approach.[xv] With the SARS outbreak denting China’s image to a large extent, the calls for “peaceful development” and “harmonious world” were used to project China as a benign power. China proposed win-win outcomes in its healthcare collaborations with foreign partners including WHO and passed laws which institutionalised government support to international cooperation on infectious disease surveillance and response.
China’s enhanced preparedness became evident in its handling of the 2009 HINI epidemic and 2013 outbreak of avian influenza (H7N9).[xvi] During the outbreak, the Chinese government not only acted swiftly but also opened an online disease reporting criteria for WHO, developed new diagnostic techniques and treatment procedures, marking a noticeable shift in Chinese attitudes towards infectious disease control. The period also marked the inclusion of health into the Chinese concept of non-traditional security threats, elevating the status of “health issues” and “global health cooperation” in its foreign policy discourse.[xvii]
In 2006 WHO elections, a Chinese national Margaret Chan was elected as WHO’s Director General (DG), which came as a diplomatic triumph for China.[xviii] The election of Chan as the DG of WHO reflected China’s newly acquired deftness in global health diplomacy to attain foreign policy goals. Bilaterally, China reinvigorated its Africa policy and doubled medical assistance for African states by granting preferential credits, increasing the number of medical teams, building hospitals, and most importantly extending collaboration on malaria controls through the supply of drugs, training, and establishment of treatment centers.[xix] Beijing’s health initiatives also helped it to win trust among the Southeast Asian neighbours and to expand its influence in the region.[xx]
Under the reign of President Xi Jinping, China’s global health ambitions witnessed a major boost. The bold reforms envisioned in “China Health Vision 2030” suggest the central importance that healthcare now enjoys in all other major policies, including foreign policy.[xxi] Announced in 2016, the vision sets five major targets; to improve the level of health, control major risk factors, increase health service capacity, expand health industry scale, and perfect the health service system.[xxii] The objective is to build a healthy China as well as to export Chinese healthcare models to other parts of the world through the Health Silk Road (HSR) initiative.
The HSR, unveiled in 2017, not only promises attractive benefits and innovative solutions to the national health problems of the BRI members but has also brought WHO on board for a “suspicion-free” implementation of its activities.[xxiii] China signed a memorandum of understanding (MOU) to strengthen the WHO-China cooperation through BRI.[xxiv] WHO, thereby, became the first UN organisation to sign an agreement with China to help implement health-related goals in countries along the BRI routes. Also, Beijing has expressed possibilities of innovative collaboration in its HSR projects over the conventional approaches taken by international and regional organisations.[xxv]
Prospects and Limits
In the current COVID-19 pandemic, China is leveraging the HSR initiative in various ways. First, it seeks to clear the controversy surrounding the “place of origin” for the coronavirus outbreak and divert global attention to health-related assistance and services. For instance, China’s Jack Ma foundation has offered millions of masks, thousands of protective gear, and testing kits to countries like Afghanistan, Bangladesh, Cambodia, Maldives, Laos, and others.[xxvi] The countries where China is sending medical supplies and technical assistance are either Beijing’s immediate neighbours or the members of China’s BRI project.[xxvii]
Second, China is trying to emerge as a leading global responder to the pandemic, especially after the United States and European nations displayed their unpreparedness in handling the virus outbreak, internally. With a worsening health situation at home, major powers like the US have largely failed to shoulder global responsibilities and to foster cooperation. Third, as the BRI projects came to a halt due to travel bans, quarantined cities, and disrupted labour lines, Beijing used its health diplomacy to keep the initiative alive and to defuse concerns arising out of fear of contagion in these host countries. Also, the use of the BRI rail networks (although very few are in operation) to transport medical supplies to the recipient countries signal Beijing’s desperation to revive its image as well as its flagship project.[xxviii]
China’s global health diplomacy efforts, however, face serious limitations in re-building its global image and reputation. China’s political system poses a serious limitation in this regard. For instance, certain steps taken by the Chinese government to stifle domestic dissent after the death of Dr. Li Wenliang have triggered widespread global criticism and debates about China’s domestic governance.[xxix] Some of these old sledgehammer tactics include censoring media, arresting the dissenters, and passing laws to hold-up the official narrative vis-à-vis the outbreak.[xxx] As per the recent legislation, all scientific papers dealing with COVID-19 and its origins are to be vetted and approved by the Ministry of Science and Technology before their publication.[xxxi]These domestic measures mar Beijing’s international reputation further, exacerbating bitterness and hostility towards the Chinese government.
Furthermore, China’s relationship with the WHO has also come under the scanner since the start of the outbreak. This is mainly so, as Taiwan drew international attention to China’s misinformation campaign relating to the cause and spread of the virus as well as raised questions on WHO’s lukewarm responses to Beijing’s mishandling of the outbreak.[xxxii]The alarm raised by Taiwan not only pointed to WHO’s limitations in handling such pandemics but also suggests the need to redefine the scope of the global health agenda to prevent future crises. Thus, Beijing now ironically faces greater competition from Taiwan, who has set an example of effectively dealing with the virus despite being outside the WHO for decades.[xxxiii]
The road to redeem its reputation and seek leadership in the field of global health is not going to be easy for Beijing. Challenges will continue to grow for the Chinese leadership as the current pandemic-induced health crisis rolls into an economic and liquidity crisis in the coming days. What, therefore, remains to be seen in the post-COVID-19 period is whether realpolitik (power maximisation) will continue to drive Chinese ambitions vis-à-vis global health diplomacy or if Beijing would work out cooperative strategies of healthcare amongst states, multilateral organisations, private players and civil societies to avoid the outbreak of future health crises.
*Dr. Priyanka Pandit is a Research Fellow at the Indian Council of World Affairs, New Delhi.
Disclaimer: The views expressed are that of the Researcher and not of the Council.
[i] MOFA (2020), “MFA: China Has Announced Assistance to 82 Countries, WHO and African Union to Fight COVID-19”, March 20, URL: https://www.fmprc.gov.cn/mfa_eng/topics_665678/kjgzbdfyyq/t1759145.shtml, Accessed on April 14, 2020.
[iii] Shepard, W (2020), “China’s ‘Health Silk Road’ Gets A Boost From COVID-19”, Forbes, URL: https://www.forbes.com/sites/wadeshepard/2020/03/27/chinas-health-silk-road-gets-a-boost-from-covid-19/#3fd02c9e6043, Accessed on April 14, 2020.
[iv] Nossel, S (2020), “Truth Has Become a Coronavirus Casualty”, Foreign Policy, URL:https://foreignpolicy.com/2020/03/09/truth-coronavirus-china-trump-pence/, Accessed on April 14, 2020.
[v] Feldwisch-Drentrup,H (2020), “How WHO Became China’s Coronavirus Accomplice”, Foreign Policy, URL:https://foreignpolicy.com/2020/04/02/china-coronavirus-who-health-soft-power/, Accessed on April 14, 2020.
[vii] SARS was caused by the virus called SARS-COV-1and COVID is cause by the virus called SARS-COV-2. Since the two viruses namely, SARS-COV-1 and SARS-COV-2 belong to same virus families, according to experts SARS-2 would have been a more appropriate nomenclature for the current disease.
[viii] Tuangratananon, T., Tang, K., Suphanchaimat, R., Tangcharoensathien, V., & Wibulpolprasert, S. (2019). “China: leapfrogging to become a leader in global health?”, Journal of global health, 9(1), doi: 10.7189/jogh.09.010312Accessed on April 14, 2020.
[x] Huang, Y. (2010). Pursuing health as foreign policy: the case of China. Indiana Journal of Global Legal Studies, 17(1), 105-146, Accessed on April 14, 2020.
[xi] Tuangratananon, T., Tang, K., Suphanchaimat, R., Tangcharoensathien, V., &Wibulpolprasert, S. (2019). “China: leapfrogging to become a leader in global health?”, Journal of global health, 9(1), doi: 10.7189/jogh.09.010312,Accessed on April 14, 2020.
[xii] Goldizen, F. C. (2016). From SARS to Avian influenza: The role of international factors in China's approach to infectious disease control. Annals of global health, 82(1), 180-188,Accessed on April 14, 2020.
[xiii] Interview with a Chinese health academic, April 17, 2020.
[xiv] Huang, Y. (2010). Pursuing health as foreign policy: the case of China. Indiana Journal of Global Legal Studies, 17(1), 105-146,Accessed on April 14, 2020.
[xv] MOFA (2009), “Hu Jintao Addresses the General Debate of the 64th General Assembly Session”, September 24,URL:https://www.fmprc.gov.cn/mfa_eng/zxxx_662805/t616864.shtml, Accessed on April 14, 2020.
[xvi] Goldizen, F. C. (2016). From SARS to Avian influenza: The role of international factors in China's approach to infectious disease control. Annals of global health, 82(1), 180-188,Accessed on April 14, 2020.
[xvii] Huang, Y. (2010). Pursuing health as foreign policy: the case of China. Indiana Journal of Global Legal Studies, 17(1), 105-146,Accessed on April 14, 2020.
[xviii] Chan, L. H., Chen, L., & Xu, J. (2012). China's engagement with global health diplomacy: was SARS a watershed?. In Negotiating And Navigating Global Health: Case Studies in Global Health Diplomacy (pp. 203-219),Accessed on April 14, 2020.
[xix]Tuangratananon, T., Tang, K., Suphanchaimat, R., Tangcharoensathien, V., &Wibulpolprasert, S. (2019). “China: leapfrogging to become a leader in global health?”, Journal of global health, 9(1), doi: 10.7189/jogh.09.010312, Accessed on April 14, 2020
[xx] Huang, Y. (2010) “Pursuing health as foreign policy: the case of China” Indiana Journal of Global Legal Studies, 17(1), 105-146,Accessed on April 14, 2020.
[xxi] Lancaster,K, Rubin, M & Rapp-Hooper, M (2020), “Mapping China’s Health Silk Road”, Council on Foreign Relations, URL;https://www.cfr.org/blog/mapping-chinas-health-silk-road, Accessed on April 14, 2020.
[xxii] Tan, X., Liu, X., & Shao, H. (2017) “Healthy China 2030: a vision for health care”, Value in health regional issues, 12, 112-114,Accessed on April 14, 2020.
[xxiii] Interview with a Chinese Official, 02 February 2018.
[xxiv] Lancaster,K, Rubin, M & Rapp-Hooper, M (2020), “Mapping China’s Health Silk Road”, Council on Foreign Relations, URL;https://www.cfr.org/blog/mapping-chinas-health-silk-road,Accessed on April 14, 2020.
[xxv] Tuangratananon, T., Tang, K., Suphanchaimat, R., Tangcharoensathien, V., & Wibulpolprasert, S. (2019). “China: leapfrogging to become a leader in global health?”, Journal of global health, 9(1), doi: 10.7189/jogh.09.010312,Accessed on April 14, 2020.
[xxvi] (2020), “For the greater good: Jack Ma to donate 1.8 mn masks, protective suits and other aid to poor Asian countries”, The Economic Times, March 21, URL: https://economictimes.indiatimes.com/magazines/panache/for-the-greater-good-jack-ma-to-donate-1-8-mn-masks-protective-suits-and-other-aid-to-poor-asian-countries/articleshow/74745855.cms?from=mdr, Accessed on April 14, 2020.
[xxvii] Shepard, W (2020), “China’s ‘Health Silk Road’ Gets A Boost From COVID-19”, Forbes, URL: https://www.forbes.com/sites/wadeshepard/2020/03/27/chinas-health-silk-road-gets-a-boost-from-covid-19/#3fd02c9e6043, Accessed on April 14, 2020.
[xxix]Li, the Chinese whistle-blower who first alerted the Wuhan local authorities about the unknown virus was booked for spreading misinformation and made to apologise for his “misdemeanour”.
[xxx] (2020), “China's online censors tighten grip after brief coronavirus respite”, Reuters, URL: https://www.reuters.com/article/us-china-health-censorship/chinas-online-censors-tighten-grip-after-brief-coronavirus-respite-idUSKBN2051BP, Accessed on April 14, 2020.
[xxxi] Silver, A., & Cyranoski, D. (2020) “China is tightening its grip on coronavirus research”, Nature, URL: https://www.nature.com/articles/d41586-020-01108-y, Accessed on April 14, 2020.
[xxxii] Timsit, A. (2020), “The China-Taiwan conflict is disrupting the WHO’s fight against Covid-19”, Quartz, URL: https://qz.com/1831093/taiwan-china-conflict-is-disrupting-whos-fight-against-covid-19/, Accessed on April 14, 2020.
[xxxiii] Pu, V. (2020), “The Coronavirus Outbreak: How Democratic Taiwan Outperformed Authoritarian China”, The Diplomat, URL: https://thediplomat.com/2020/02/the-coronavirus-outbreak-how-democratic-taiwan-outperformed-authoritarian-china/, Accessed on April 14, 2020.