How efficient is China's medical system

China's health diplomacy in times of Corona

On December 9 and 12, 2020, the United Arab Emirates (UAE) and Bahrain were the first states to approve a Chinese corona vaccine. Other countries, especially in the global south, have announced that they will soon do the same (for example, Egypt, Indonesia, Turkey and Brazil approved Chinese vaccines by January 18, 2021). It is realistic to assume that China will play a relevant role in vaccinating the world's population. This would correspond to a narrative spread by the Chinese leadership: China as a responsible great power. Since the beginning of the pandemic, Beijing has linked the Chinese contribution to the fight against corona with President Xi Jinping's prestigious foreign policy project, the Silk Road Initiative (BRI).

Health under the BRI

Health has been on the BRI agenda for over five years. The framework document "Vision and Actions on Jointly Building Silk Road Economic Belt And 21st-Century Maritime Silk Road" published in March 2015 listed cooperation in the prevention and containment of epidemics as a goal. According to official BRI documents, health cooperation also includes:

  • Training programs for medical personnel;

  • Capacity building in response to public health crises;

  • emergency medical aid;

  • Promotion of Traditional Chinese Medicine (TCM);

  • free treatments abroad by Chinese doctors.

The BRI framework document "The New Silk Road Initiative - Progress, Contributions and Perspectives" (April 2019) refers to 56 bilateral health agreements that China has concluded with the WHO and the Bill & Melinda Gates Foundation, among others. The “BRI Standardization Action Plans” from 2015–2017 and 2018–2020 also refer to Chinese efforts to set uniform standards in TCM and in the definition of medical terms. The BRI "Development Plan for the Promotion of TCM (2016–2020)" clarifies Beijing's intention to promote traditional Chinese medicine internationally.

As in all sub-areas of the BRI, Beijing is also acting strategically, flexibly and in parallel on several levels (bilateral and multilateral, regional and global) in the implementation of the “Health Silk Road”. The so-called “China + x mechanisms” play a key role in this. These are formats of Chinese cooperation, for example with the states of the Association of Southeast Asian Nations (ASEAN), Africa (FOCAC), Central and Eastern Europe (17 + 1) or the Arab League. Health cooperation within the framework of these mechanisms differs from region to region, but largely reflects the content (sometimes literally) of the Chinese BRI documents.

Since 2015 there has been a regular forum of the Chinese Minister of Health with 17 (until 2019: 16) Central and Eastern European counterparts (2015 in Prague; 2016 in Suzhou; 2017 in Budapest; 2019 in Sofia). The declared aim of the format is to promote TCM in Europe, programs for exchange and cooperation (from hospitals, the health industry and universities), market access (e.g. for drugs), but also cooperation in the fight against infectious diseases such as MERS and SARS (see Suzhou- Declaration of June 20, 2016). New structures have been created for this, including the »17 + 1 Hospital Alliance«, the »17 + 1 Cooperation Network for Public Health«, the »17 + 1 Cooperation Network for Health Workers«, the »17 + 1 Research Network for Health Policy« and the »17 + 1 cooperation forum for drug approval«.

In China's relations with the ASEAN countries, the issue of health played a prominent role even before the BRI was announced. In 2012 the parties signed a memorandum of understanding on health cooperation. The participants of the 1st China-ASEAN Health Cooperation Forum adopted the "Nanning Declaration" on October 26, 2016. The focus is on the exchange of information and the joint prevention and control of infectious diseases, the training of health care professionals, the promotion of TCM and the sending of Chinese doctors. With a view to the »Lancang Mekong« states (Cambodia, Laos, Myanmar, Thailand, Vietnam), China’s BRI health diplomacy focuses, among other things, on free eye surgeries.

The “China-Arab States Health Cooperation Forum” took place in September 2015 as part of a dialogue forum that China established with the states of the Arab League. According to the "Yinchuan Declaration" adopted at the same time, this cooperation includes technology cooperation, the promotion of TCM, the prevention and control of infectious diseases, programs for medical training, coordination on reforms of the public health system, exchange of medical facilities and personnel, and coordination on global health issues.

In Sino-African relations, cooperation in health matters is most pronounced and goes back well into the time before the BRI was announced (for example, the posting of medical personnel, which has been practiced for decades). Since 2015 it has been subsumed under the BRI within the framework of the “Forum on China-Africa Cooperation” (FOCAC). This includes the provision of medical supplies, training programs, the construction of hospitals and support in the fight against infectious diseases such as malaria or Ebola (see, among others, FOCAC Johannesburg Action Plan [2016-2018] and FOCAC Beijing Action Plan [2019-2021 ]).

The topic of health also played a relevant role at the bilateral level within the framework of the BRI even before the Covid pandemic. In regions where “China + x formats” are less common, China sends medical staff to offer free treatments. China's engagement in South Asia and Oceania deserves special mention (for example, Beijing sent teams of doctors to Nepal, Micronesia, Vanuatu, Tonga and Fiji). China is also active in Central Asia. The most important pilot project is the establishment of the "Medical Service Center of the BRI core region Xinjiang". This hospital cooperation platform provides medical help for patients from neighboring countries (such as free heart operations on Afghan children). It also aims to network Central Asian hospitals with Xinjiang (e.g. for medical tourism).

The "Memorandum of Understanding on Health Sector Cooperation under the Belt and Road Initiative", which China and the WHO signed on January 18, 2017, is particularly significant on a global level. This is the first time that the term "health silk road" is used. The explicit support of the BRI by the WHO reflects the increasing influence of the People's Republic of China within the WHO that has been observed for years. In August 2017, representatives of numerous states, international organizations and non-governmental organizations (NGOs) adopted the “Beijing Communiqué on the Silk Road Health Cooperation and the Health Silk Road”, which summarizes the essential elements of China's BRI health policy.

Activation of the BRI networks as part of the »mask diplomacy«

After the corona outbreak in Wuhan became known, China first appealed to the international community and received aid supplies and payments from over 58 countries (including Australia, Belarus, Djibouti, Germany, Pakistan, Bahrain, the USA and Suriname). Beijing also used smaller contributions (such as a donation of 100 euros from the Comoros) for propaganda purposes as a sign of solidarity and evidence of the spirit of the health silk road.

When the Chinese leadership gradually got the outbreak under control in their own country at the end of February, Beijing very quickly took over the role of the aid supplier. Since a large part of the global mask production facilities are located in China and numerous industrialized countries had delivered relief goods to Wuhan, the Chinese leadership was able to supply the world with masks and medical devices from a quasi monopoly. In particular, states that were medically inadequately equipped received donations of the aids they needed (masks, test equipment and ventilators) very quickly. Beijing also sent medical teams to 43 states. Almost all countries in the world received support from China (see map 1, p. 7).

The supplies came from a wide variety of actors, not just the Chinese central government and the Communist Party, and they often took into account China's strategic interests in the recipient country. Provinces and cities supplied their partner municipalities and regions. Mostly Muslim countries (such as Afghanistan, Egypt, Iraq, Iran, Lebanon and Jordan) received masks from the Xinjiang Autonomous Region. In Southeast Asia (e.g. Laos, Cambodia, Myanmar) soldiers from the People's Liberation Army delivered medical supplies. In countries where Chinese state-owned companies operate BRI projects (e.g. in Africa), banks, construction and raw materials companies were among the donors. The telecommunications company Huawei preferred to provide help where it pursued strategic interests in the 5G expansion; in Europe for example in the Czech Republic, Ireland, Italy, Lithuania, the Netherlands, Poland, Romania, Serbia and Spain. Corporate foundations (notably the Jack Ma and Alibaba Foundation) supplied masks, ventilators, and testing equipment to over 150 states. Business associations, overseas Chinese and NGOs were also involved. As part of the “mask diplomacy”, local Chinese actors who otherwise often live separately in a parallel society were involved in many recipient countries. The aid for the local population is in line with the goal formulated in many BRI documents of generating broad support for China's Silk Road policy.

China even offered aid to countries that do not (yet) have diplomatic relations with Beijing (especially in Latin America). In Paraguay, the parliamentary opposition called for diplomatic relations with Taiwan to be severed in order to receive aid from Beijing. And Belize has received aid donations from Chinese organizations that are alleged to be NGOs. A notable coup in Beijing were photos of the members of the Belize City council standing in front of Chinese flags.

China's propaganda machine has been running at full speed for months. The content basis for a streamlined Covid narrative is the white paper "Fighting Covid-19: China in Action". In local daily newspapers, Chinese diplomats publish articles in which they describe China's relations with the state to which they are posted, in accordance with the Covid 19 narrative formulated in the White Paper. In it, China stylizes itself as a savior who is on par with the aid recipient states, and as a responsible international great power. China's help, according to the narrative, is symbolic of the desired »global community of fate«, a central BRI term. The articles are reminiscent of the Chinese propaganda strategy at the beginning of the BRI. Back then, too, large-scale newspaper advertisements were placed (at the time primarily by members of the Chinese leadership, not by diplomats) to promote the BRI.

The Chinese involvement in "western" social media such as Twitter or Facebook that are not available in China is a new development. Chinese missions abroad broadcast updates on social networks almost daily about China's contribution to the fight against Covid-19 on the ground. Xi Jinping's wife, the singer and WHO special envoy Peng Liyuan, has a relevant role in China's health diplomacy. For example, she leads online ceremonies on the occasion of Chinese aid. Peng also personally donated protective masks to numerous African countries.

Even if China's mask diplomacy has been criticized, especially in Europe, the logistical performance, the activation of Chinese actors and their uniform external communication are remarkable. For numerous countries, China was a reliable partner, especially as there was a lack of traditional aid providers (especially the USA). For the first time, Beijing has given substance to the global BRI rhetoric.

Next act: vaccination diplomacy

Phase III studies are currently running on vaccines from five Chinese companies (Sinopharm, CanSinoBIO, Sinovac and Anhui Zhifei Longcom Bio, IMBCAMS) in 18 countries, primarily in Latin America, Southeast Asia and the Arab region. Agreements on vaccine deliveries have already been concluded with 26 countries, 10 (see Map 2, p. 8) have approved Chinese vaccines (as of January 18, 2021). Numerous other states want to use a Chinese vaccine or are in contract negotiations.

In this case, too, the Chinese leadership is concerned with being perceived globally as a “responsible great power”. In doing so, it acts bilaterally and multilaterally. On May 18, 2020, Xi Jinping announced in a speech to the WHO in Geneva that China would provide the world with a vaccine as a "global public good" at low cost. This is typical BRI rhetoric. The same words have been used to advertise the Silk Road Initiative for years. President Xi also promised the WHO $ 2 billion for the fight against Corona. In October, Beijing joined the vaccine platform COVAX, an initiative of the United Nations, the European Union and France to ensure fair vaccine distribution.

While bilateral aid deliveries shaped the first months of the pandemic, Beijing is increasingly using China + x formats for vaccination diplomacy. In these formats, Beijing combines vaccination promises with the prospect of economic support and long-term cooperation projects. The starting point was the “China-Africa Special Summit on Solidarity in the Fight against Covid-19” (June 2020). The Chinese leadership promised preferential vaccine delivery, "debt relief" and deepening economic relations after the end of the corona pandemic (such as help with investments in the digital economy, the promotion of renewable energies and the 5G expansion). A month later, Beijing hosted a health summit with the Arab League states. Here, too, in addition to the vaccination cooperation, China held out the prospect of deepening bilateral economic relations (within the framework of the BRI). Also in July, Beijing promised Latin America and the Caribbean US $ 1 billion to purchase vaccines. On August 24, Prime Minister Li Keqiang announced that the Lancang Mekong states had priority for vaccine shipments. He brought up a "Public Health Fund" for financing. Foreign Minister Wang Yi, in turn, identified ASEAN as a vaccine priority region in September. Similar promises (vaccination priority and expansion of economic relations) were made at the China-Pacific Island Forum. In November, high-ranking representatives from China and South Asian countries (Bangladesh, Nepal, Pakistan, Sri Lanka) held talks on the subject of vaccination.

It is noticeable that the institutionally most advanced 17 + 1 format only plays a subordinate role in China's vaccination diplomacy. In 2020, only two webinars were held at the state secretary level. China's vaccination diplomacy in Europe, on the other hand, is bilateral and is aimed primarily at Hungary and Serbia.

China's involvement in Latin America and the Arab region stands out in particular. These regions have recently also gained in importance within the framework of the BRI. The new "China-Pacific Islands" health cooperation forum once again underlines China's strategic orientation towards the South Pacific.

assessment

The BRI did not fail because of Covid-19, as some observers had prophesied at the beginning of the pandemic. On the contrary, Beijing is increasingly linking its own contribution to combating pandemics with the BRI narrative (e.g. advantages of global connectivity; building a »global community«). With a high degree of flexibility, strong political will and thanks to a logistically favorable starting position, the BRI has so far been able to pass the crisis test.

Beijing's health diplomacy shows how the initiative works and, in particular, how flexible it is. Health went from being a marginal to a core issue of the BRI almost overnight. China activated BRI networks worldwide within a very short time. The necessary infrastructure was already available from other BRI components. BRI rail connections orthe so-called "Air Silk Road" (with junctions in Luxembourg and Liège) were rededicated as supply lines for aid supplies. Linking the “Digital Silk Road” with the Health BRI is now on the agenda (for example to facilitate contact tracking). Institutionally, Beijing can fall back on numerous China + x mechanisms as drivers of the BRI.

While the US initially largely did not take part in international aid measures, China has filled a gap and continues to advance into traditional backyards of US zones of influence (Latin America and the Arab world).

The opinion widespread in Germany and Europe that Beijing's mask diplomacy failed, fails to recognize that China seeks success in countries outside Europe and is increasingly perceived there as a responsible great power. Beijing provided effective and comprehensive aid to many third countries.

After the end of the pandemic, China could further expand its influence in key BRI regions. Because Beijing is acting strategically and farsightedly with the (health) Silk Road initiative. Its health diplomacy links measures to combat pandemics with BRI promises (prosperity through connectivity with China). In order to counteract a further increase in Chinese influence by China in strategic regions, Europe would have to make offers (political cooperation and economic support) to third countries for the period after the pandemic. There is a lot of catching up to do in Europe for this. There is insufficient awareness of the geopolitical implications of Covid-19.

In the global vaccine race, Chinese candidates have not yet emerged as pioneers. There are promising Chinese vaccines. Despite doubts about its effectiveness, Beijing is likely to benefit from national production capacities in the next few months and be able to supply vaccines to the global south. Beijing plans to vaccinate 50 million people in its own country against corona by the beginning of February. In light of this, it would not be surprising if Chinese vaccination teams were deployed to developing countries under the banner of the BRI in the next few months.

Political decision-makers in Germany and Europe should take note that China's health diplomacy, like the entire BRI, is carried out in parallel on several levels (bilateral and multilateral, regional and global). It is important to react to this. There is a need to increase engagement at the multilateral level (e.g. within the WHO) and, where appropriate, to cooperate with China (e.g. within the framework of COVAX). But that in itself is insufficient. Because at the multilateral level, Beijing has massively expanded China's influence in recent years (especially within the WHO). In order to counteract this expansion in third countries, Germany and Europe would be recommended to increase their bilateral engagement as well. Regional »EU + x formats« with states in strategically relevant regions (e.g. Indo-Pacific or Africa) or corresponding measures coordinated with the new Biden administration in the USA would be conceivable options for action.

Map 1

Map 2

Moritz Rudolf is a scientist in the Asia research group.

© Science and Politics Foundation, 2021

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The current reflects the author's opinion.

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ISSN 1611-6364

doi: 10.18449 / 2021A05