China and Proactive stance in Global Health Diplomacy

A More Proactive Stance in Global Health Diplomacy (from PLos Medicine)

At the international level, there have been signs since the SARS outbreak that public health is high on China's foreign policy agenda. First, Beijing has become more proactive in participating in global health governance. China had for a long time played a passive role in the WHO since gaining its membership in the organization more than three decades ago. The SARS outbreak let China experience the power of the WHO, which has become increasingly more influential while other international organizations, such as the United Nations Security Council, International Monetary Fund, World Bank, G8, and the World Trade Organization, are facing legitimacy, accountability, and representativeness challenges. WHO's authority in dealing with disease outbreaks is still widely recognized . Without China's prior consent, the WHO issued a travel advisory against unnecessary travel to Guangdong province, putting China under the global spotlight for spreading infectious disease to other countries. Perhaps this lesson has prompted the Chinese government to realize the political importance of the WHO and to increase its participation in global health governance.

In the WHO Director-General election in 2006, China, for the first time since it gained its membership in UN agencies in 1971, nominated and supported a Chinese national, Margaret Chan, as a candidate for the top post. It is widely believed that Chan's success was a diplomatic triumph both for her and for China. Wang Yizhou, then with the Chinese Academy of Social Sciences, Beijing, told one of the authors (LHC) in March 2008 that Margaret Chan's nomination as the Director-General of the WHO was not a fortuitous incident. The health officials we spoke with in Beijing concurred with Wang's view and explained that China has recently realized and valued the increasing importance of the WHO at the world stage. It is also a source of national pride to have a Chinese national at the top post of the global health organization [22]. Chan was the Director of Health of Hong Kong during the SARS outbreak in 2003. Her nomination could be seen as a case of China's smart play and rising clout at the global stage, displaying its confidence in her managing of Hong Kong affairs and the successful implementation of China's “One Country, Two Systems” policy [23].

Furthermore, China's WHO role politically could be regarded as a pre-emptive measure to block Taiwan's attempts to seek WHO membership [23]. On the other hand, with improved relations with the Ma Ying-jeou administration in Taiwan, China has become more flexible in seeking cross-strait cooperation in health. For example, as a consultant for the Chinese Medical Association, Chinese Vice Minister of Health Huang Jiefu attended a conference on “Cross-Strait Cooperation in Preventing H1N1” in Taiwan in January 2010. During the meeting, Huang emphasized an extensive cross-strait collaboration in the area of public health, including disease notification and food safety [24]. In addition, Beijing dropped in 2009 its objection to Taiwan's application for an observer in the World Health Assembly. That being said, Taiwan's participation is allegedly required to be in line with Beijing's “One China” policy [25].

More Public Health Assistance and Diplomacy 

The second sign that China has put public health high on their foreign policy agenda since SARS is their provision of development assistance and global public goods for health. As such, China is now using public health as a means to strengthen its diplomatic relations with the developing world, including African countries. China began in the 1960s to send “angels in white” and “barefoot doctors” to the sub-Saharan region to provide some of the poorest African countries with medical services. However, as argued by Huang Yanzhong of Seton Hall University, China's health diplomacy was “flimsy, passive, and asymmetric,” at least until the 1980s [3]. After the SARS outbreak, in spite of its own failing health system, the Chinese government reiterated in its China's African Policy, published in early 2006, the nation's commitment to improving Africa's public health service.

To balance the criticisms that its energy and resource extraction in Africa grab the scarce resources there and that it shields disreputable regimes in such countries as Sudan and Zimbabwe from international opprobrium, China has stressed “win-win” relations in its deepening engagement with African countries. In response to the claims of exploitation in the natural resource sectors [26],[27], China emphasizes a no-strings-attached policy in offering financial aid and technical support to less developed countries, including those in the African continent. In contrast, donor countries in the West and international financial institutions often attach conditionalities to their foreign aid programs, which are linked to market and political liberalization and good governance [28]. China has expanded its public health initiatives, such as in infrastructural building and health practitioner training, in Africa in recent years [29], as well as commitment to cooperation with many African countries to help prevent and treat infectious diseases, particularly HIV/AIDS and malaria [30]–[34]. In his African visit in June 2006, Chinese Premier Wen Jiabao asserted that China would promote sustainable development and help African countries tackle their burning social problems, of which public health was one of the top priorities [35]. Again in November 2009, during the fourth ministerial meeting of the Forum on China-Africa Cooperation in Egypt, Wen announced eight new measures to strengthen China-Africa cooperation in the following three years, including a 500 million yuan (US$73.2 million) assistance package that allows China to build 30 hospitals and 30 malaria prevention and treatment centers and to train 3,000 practitioners in the continent [36].

Undoubtedly China has been learning from itself as well as from other developed countries the importance of providing sustainable development and global public goods for improving one's reputation on the world stage. At the “First International Roundtable on China-African Health Collaboration – New Health Initiative” in December 2009 in Beijing, one of us (LC) observed representatives from the WHO, World Bank, and the Bill & Melinda Gates Foundation praising China's development packages for their positive contributions to African development.

In addition, China's State Council has established in recent years a coordinating mechanism to facilitate cross-ministry dialogues and cooperation in global health and foreign aid initiatives. Chinese scholars have noted that a State Council “Global Health Diplomatic Coordination Office” (quanqiu weisheng waijiao xietiao bangongshi, ), led by a senior official at vice-Premier level, is crucial to effectively coordinating and developing policies of health diplomacy [37]. In order to increase the capacity of China's health diplomats to deal with global health challenges, a training course, the first in a series, for Chinese officials, including officials from the Ministries of Foreign Affairs and Health, was held in August 2009 in the Institute for Global Health at Peking University [38].

Was SARS a Watershed?

Following the Chinese government's acknowledgement of a SARS outbreak in the country, it began to acknowledge the importance of public health to national development and to accordingly strengthen its multilateral cooperation in combating contagious diseases inside and beyond its borders. For example, in the midst of the recent global economic downturn, the Chinese government announced in 2009 an injection of 850 billion yuan (US$125 billion) into its health care system to improve its operation. Since the SARS outbreak, it has not only deepened its engagement with other nations and international organizations, and cooperated with a variety of actors in dealing with its own fledgling health care system including the problem of HIV/AIDS, but China has also developed a vision for global health diplomacy. A ground-breaking implication of the SARS outbreak for China is that it was struck to realize that public health is not simply a domestic, social issue that can be isolated from foreign-policy and security concerns. In a globalizing world, the Chinese government appears to have learned that its health policy will be scrutinized by the world, and hence, it has become more open to and actively participates in global health governance. The government is now learning from such European countries as the UK, France, and Switzerland in the provision of the global public goods for health. Its substantial health assistance to sub-Saharan Africa in building hospitals and training health practitioners forms part of its health diplomacy and contribution to global health governance. It has also been proactively engaging with both regional and global health institutions since 2003 and set up different health surveillance networks with its ASEAN partners as well as other intergovernmental organizations, such as the Asia-Pacific Economic Cooperation (APEC) forum [12].

Despite its increasing engagement with global health governance since the SARS outbreak, China's approach remains, however, fundamentally state-centric, contrary to the essence of global health diplomacy and governance. With grave concern about the loss of national sovereignty to external or nongovernmental actors, Chinese senior leaders have therefore attached primary significance to intergovernmental organizations, particularly the UN agencies. In evaluating the impact of SARS, Andrew Price-Smith has put the same point succinctly: “while the SARS epidemic may have generated moderate institutional change at the domestic level …, it resulted in only ephemeral change at the level of global governance” [2]. In other words, national sovereignty is still of paramount importance for the Chinese leadership. Because of its sensitivity to foreign interference into its internal affairs, the Chinese government has not yet formally or officially endorsed the notion of “human security.” Under the umbrella concept of national security, “human safety,” instead of “human security,” is discussed throughout all of China's five white papers on national defense since 2000 (i.e., 2000, 2002, 2004, 2006, and 2008). Taiwan's participation in the World Health Assembly is predicated on the condition that it is considered part of China, not an independent entity. Having no tolerance in ceding its supreme authority, the central government has adopted a multi-faceted attitude towards its civil society organizations. While Beijing shows its willingness to cooperate with a wide array of actors inside China, it refuses to let its domestic NGOs and activists establish direct links with their counterparts overseas.

It is still uncertain whether this sovereign concern will trump the provision of global public good for health. Nevertheless, in a highly globalizing world, infectious diseases know no border. While China is seeking to adhere as much as possible to the underlying norms and rules of global health governance (and sometimes even applies them to their extremes), as evidenced by its handling of the recent swine flu outbreak, the major step forward is perhaps to reframe health as a global public good that is available to each and every individual of the world, rather than merely as an issue of concern to nation-states.

Acknowledgments 

We are grateful to Dr. Pak K. Lee for his perceptive comments on earlier drafts of this article. Our thanks also go to Richard Scott Hutchinson for his technical support in producing the figure. We are, however, solely responsible for any remaining errors.

Author Contributions 

ICMJE criteria for authorship read and met: LHC LC JX. Wrote the first draft of the paper: LHC. Contributed to the writing of the paper: LHC LC JX. Enrolled interviewees: JX.

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