paper

Health Diplomacy as Soft Power:
The PRC and Africa
Jeremy Youde
Assistant Professor of Political Science
Grinnell College
Grinnell, IA 50112
youdejer@grinnell.edu
641 269 4898 (phone)
641 269 4985 (fax)
Paper prepared for the International Studies Association Conference, 27-30 March
2008, San Francisco, CA
Draft versions; comments welcome, but please do not cite without author’s permission
How does health fit into a country’s diplomatic strategies? In recent years, we have seen
moves by various states to move away from supporting health care infrastructure in
developing countries as part of its foreign aid expenditures or as a quid pro quo for
natural resources. Instead, health appears to be coming into its own as a tool of
international diplomacy. Supporting health care in developing countries is becoming
another element of developed countries deploying their ‘soft power’ to help them achieve
their international diplomatic objectives. This represents a significant change in how
governments conceptualize health and its place in the diplomatic arsenal. Health is
moving from being auxiliary or an afterthought to a more central (though certainly not
the central) location.
This shift toward emphasizing health diplomacy is perhaps most striking when we
evaluate the burgeoning relationship between the People’s Republic of China and Africa.
China’s support for African health care systems has ebbed and flowed over the past 50
years, but it is currently on an upswing. While some may be inclined to dismiss Chinese
involvement as a cynical ploy to get access to the continent’s natural resources, the
evidence simply does not bear this contention out. Instead, supporting the health care
infrastructure in various African countries is an element of China’s efforts to deploy its
soft power and receive recognition as a good citizen within the international community.
To make my argument, I will first briefly discuss the concepts of soft power and health
diplomacy, demonstrating how the two are related to each other. I will then discuss the
history of Chinese health diplomacy in Africa before turning attention to its current
manifestation. The next section will discuss how these efforts fit into China’s larger
diplomatic strategies. Finally, I will discuss potential limitations of health diplomacy as a
strategy—both in the specific case of China in Africa and more generally.
I. Soft power and health diplomacy
With the end of the Cold War, scholars re-examined the notion of power and its use
within the international arena. If power is the ability to have control over others and
compel them to do things they would not otherwise do, how does one state hold such
sway over other states in a unipolar era? Joseph Nye answered this question in 1990 by
introducing the concept of ‘soft power.’ In this new ear, Nye explained, the traditional
measures of power, such as military strength, geographic presence, and population size,
no longer held the same level of effectiveness. The world had changed in such a way that
it was often prohibitively expensive for a country like the United States to use these
sources of power to compel other states to accede to its wishes1. Instead, a country’s
technological prowess, economic growth, and educational achievement mattered more2.
Through the attractiveness of its culture, political ideology, and foreign policy, a state
could employ soft power to “get other countries to want what it wants”3. Soft power is
thus
the ability to get what you want through attraction rather than coercion or
1 Joseph S. Nye, Jr. “Soft power,” Foreign Policy 80 (Autumn 1990), 159-160.
2 Ibid., 154.
3 Ibid., 166; emphasis in the original.
payment. When you can get others to want what you want, you do not
have to spend as much on sticks and carrots to move them in your
direction…Soft power arises from the attractiveness of a country’s culture,
political ideas, and policies4.
Nye delineates three sources of a country’s soft power: “its culture (in places where it is
attractive to others), its political values (when it lives up to them at home and abroad),
and its foreign policies (when they are seen as legitimate and having moral authority)”5.
This means that soft power is more than just culture; it encompasses many different
aspects of a state’s identity and actions—aspects which are not necessarily always under
the control of the same individuals (or anyone’s explicit control, for that matter).
This does not negate the importance and relevance of traditional power measures.
Instead, soft power recognizes the limits on hard power’s effectiveness. No country can
afford (in either a diplomatic or an economic sense) could rely solely on its military
might to achieve its foreign policy agenda. More importantly, though, it encourages
others to buy into the first state’s ideas. Country B does not go along with Country A
because it feels like it must; it does so because it wants to because it respects Country A.
Self-interest certainly plays a role in facilitating cooperation, but attractiveness can be
4 Joseph S. Nye, Jr., “Soft power and American foreign policy,” Political Science
Quarterly 119 (2004), 256.
5 Joseph S. Nye, Jr. “Think again: soft power,” Yale Global Online,
, accessed 8 January 2008.
even more important6. I am more likely to make accommodations for someone whom I
respect and admire as opposed to someone who simply tries to shove his or her ideas
down my throat. International relations often work in a similar manner.
While related, soft power and popularity are not identical. Popularity is more short-term
and often responds to discrete events. Soft power, on the other hand, concerns longerterm
assessments made by other countries. Country A may adopt a particular policy
unpopular with Country B, but that is unlikely to ruin the relationship between the two if
Country A’s overall attractiveness and respect remains intact. However, if a country pays
too little attention to developing its soft power capabilities or lacks an overall strategy,
this can lead to a deterioration of its soft power7. Soft power goes beyond popularity
because it affects a country’s willingness to make concessions. Popularity addresses how
much others like or dislike a particular country, but it does not necessarily require
sacrifices or policy changes. Soft power seeks to get states to change their policies and
embrace a new worldview. This is far more extensive than popularity.
How do we know when soft power is operating effectively? Huang and Ding offer a fourstep
process model to trace soft power’s use. Soft power is effective if Country A directs
its soft power resources (1) toward the policy actors in Country B (2), which in turn
changes the policy process in Country B (3) such that they accord with Country A’s
6 Nye, “Soft power and American foreign policy,” 257.
7 Joshua Kurlantzick, “The decline of American soft power,” Current History 686 (2005),
421.
desired outcomes (4)8. This model not only provides causal linkages, but it also shows
that soft power does not always allow a country to achieve its policy preferences.
We can see evidence of soft power’s effects throughout the international arena. Recently
released Soviet documents reveal that the Cold War’s end came in large part due to
Reagan’s late embrace of soft power. When he adopted a more hawkish position, Soviet
reformers like Gorbachev found their efforts stymied by hardliners within the
government. As Reagan later positioned himself as a peacemaker and advocate of
disarmament, relations between the two countries thawed to a point that economic and
political reform in the Soviet Union could happen9. These reforms, in the long run, led to
the Soviet Union’s demise. Reagan’s more peaceful posture made the United States a
more attractive country and less of a threat, thus facilitating better relations between the
two superpowers. More recently, recent American policy decisions have significantly
harmed the United States’ soft power. By taking unilateral action and publicly disdaining
international consensus over the war in Iraq, numerous surveys have shown that the
United States’ standing in the world has taken a severe hit10. Its foreign policies are
perceived as illegitimate and without moral authority, it is widely perceived as not living
up to its professed political values, and symbols of its culture have been targets of
vandalism and violence. A 2007 survey by the Pew Global Attitude Project finds that,
between 2002 and 2007, attitudes toward the United States declined in 26 out of 33
8 Yanzhong Huang and Sheng Ding, “Dragon’s underbelly: an analysis of China’s soft
power,” East Asia 23:4 (2006), 25.
9 Vladislav M. Zubok, “Soft power,” New Republic (21 June 2004), 11.
10 Kurlantzick, 421-422.
countries11. This has had a detrimental effect on the country’s ability to see its desired
foreign policies enacted.
Huang and Ding see China as taking more steps to bolster its soft power by joining
international organizations and portraying itself as a responsible member of the
international community. PRC’s 1997 “new security concept” emphasized mutual trust
and benefit in international relations, equality, and coordination. This strategy
emphasized how China accepted a variety of shared norms within the international
community to bolster its standing with developing countries around the world12. Hill sees
Russia’s increasing stature among former Soviet republics as coming from its embrace of
soft power. Instead of trying achieve cooperation with its neighbors solely through saberrattling,
the Russian government has increasingly turned toward promoting its popular
culture, encouraging people to learn and use Russian, and utilizing its newly-found oil
and gas wealth to make itself more attractive13. In both of these cases, the government’s
embrace of soft power is still somewhat tentative. That makes any assessment of the
long-term effect limited at this point, but we can already see evidence that countries
recognize the usefulness of soft power.
Health diplomacy is simultaneously a historical reality and a recent diplomatic
innovation. This paradoxical position comes from the evolving definition of health
11 Pew Global Attitudes Project, “Global unease with major world powers,”
, accessed 8 January 2008.
12 Huang and Ding, “Dragon’s underbelly,” 29.
13 Fiona Hill, “Moscow discovers soft power,” Current History 693 (2006), 341-342.
diplomacy and changes in how the international community has responded to health
concerns. Historically, health diplomacy focused on international collaboration to protect
human and commercial interests against the spread of particular infectious diseases. The
mere threat of bubonic plague or cholera was enough to close ports or impose quarantine
measures, both of which impeded the exchange of goods and people. In 1851, diplomats
and physicians from 11 European countries met in Paris at the first International Sanitary
Conference. They sought to create a uniform quarantine policy that would simultaneously
prevent any interruptions of trade. This first conference failed to produce any agreements,
thanks to disagreements over disease etiology, but it did help set the stage for future
international health diplomacy efforts14. Over the next 50 years, an additional ten
international sanitary conferences took place. Each conference attracted more delegates,
and did eventually lead to the creation of internationally agreed-upon standards for
quarantine and disease control measures15.
These conferences eventually led to the creation of bodies like the World Health
Organization and harmonized health policies among most nations. Despite these
successes, they represented a narrow conceptualization of health diplomacy and one quite
different from today. Three main differences stand out. First, these early efforts at health
diplomacy focused on disease rather than health. The agreements that emerged from
14 Alexandra Minna Stern and Howard Markel, “International efforts to control infectious
diseases, 1851 to the present,” Journal of the American Medical Association 292 (2004),
1475.
15 Norman Howard-Jones, The Scientific Background of the International Sanitary
Conferences, 1851-1938 (Geneva: World Health Organization, 1975).
these early international conferences focused solely on three diseases: cholera, yellow
fever, and bubonic plague16. Specific diseases, rather than a general concern for human
well-being, motivated this cooperation. Part of this may derive from understandings of
health and illness that dominated at the time. Especially during the first conferences, few
physicians accepted germ theory as an explanation for disease. Instead, many saw a
connection between personal morality or individual behavior and susceptibility to
infectious disease17. Such a mindset would not be conducive to a broader
conceptualization of health. Second, health diplomacy focused on preventing the spread
of particular diseases instead of preventing the actual diseases themselves. Again, this
likely arose initially from a lack of understanding about where cholera, yellow fever, and
bubonic plague came from. As physicians understood this better, though, the international
community did not press for a greater emphasis on prevention itself. Third, international
cooperation on disease prevention focused on those illnesses that threatened to interrupt
commerce. The diseases that threatened to exact economic consequences received
attention; others were essentially ignored. This also meant that the regulations addressed
the economic concerns of the dominant European commercial powers at the time.
In its more contemporary manifestation, health diplomacy refers to “mechanisms to
16 Dr. Margaret Chan, “Health Diplomacy in the 21st Century,” Address to Directorate for
Health and Social Affairs of Norway (13 February 2007),
, accessed 8
January 2008.
17 Sylvia Noble Tesh, Hidden Arguments: Political Ideology and Disease Prevention
Policy (New Brunswick, NJ: Rutgers University Press, 1988).
manage the health risks that spill into and out of every country”18. Doing so requires
“multi-level and multi-actor negotiation processes that that shape and manage the global
policy environment for health”19. A recent conference devoted to the issue defined global
health diplomacy simply as “political change activity that meets the dual goals of
improving global health and maintaining and improving international relations abroad,
particularly in conflict areas and resource-poor environments”20. These definitions, while
similar to the previous one on its surface, take a more holistic view of both health and the
international community. It moves beyond an explicit focus on particular illnesses and
instead recognizes how various manifestations of ill health can have negative
consequences for the international community. Drager and Fidler, for example, concern
themselves a great deal with the connections between health and international economics,
but they do so from a perspective that recognizes that healthier countries are more
economically productive and better able to engage with others on that level21. Health, in
this way, becomes a tool for promoting economic growth. The previous conceptualization
18 Nick Drager and David P. Fidler, “Foreign policy, trade, and health: at the cutting edge
of global health diplomacy,” Bulletin of the World Health Organization 85 (2007), 162.
19 Ilona Kickbusch, Gaudenz Silberschmidt, and Paulo Bass, “Global health diplomacy:
the need for new perspectives, strategic approaches, and skills in global health,” Bulletin
of the World Health Organization 85 (2007), 230.
20 University of California Institute on Global Cooperation and Conflict, “Global Health
Diplomacy—
Background,” ,,
accessed 8 January 2008.
21 Drager and Fidler, 145.
of health diplomacy saw disease as an economic impediment.
Current health diplomacy tends to manifest itself in three different ways. The first could
be described as “disaster diplomacy.” This entails going into areas ravaged by natural
disasters like earthquakes, tsunamis, and droughts to provide relief22. Such occurrences
often lead to extensive social chaos, but they also provide opportunities for outside
interveners to burnish their images within the affected region. The United States’ health
interventions in places like Banda Aceh and Thailand after the 2004 tsunami not only
provided much-needed medical relief, but also fit into a larger “hearts and minds”
strategy in the region23. The second form concerns international agreements and
conventions designed to bring many parties together to address health concerns. These
may focus on specific diseases, such as UNAIDS and the Global Fund to Fight AIDS,
Tuberculosis, and Malaria, or may address health more broadly, like the Alma-Ata
Conference of 1979. These efforts bring state and non-state actors together in some sort
of international forum to collaboratively address health concerns. The final form, and the
one on which I focus in this paper, deals with one country or a group of countries
22 See Scott C. Ratzen, “Beyond the 2004 tsunami: health diplomacy as a response,”
Journal of Health Diplomacy 10 (2005), 197-198 and Ilan Kelman, “Hurricane Katrina
disaster diplomacy,” Disasters 31 (2007), 288-309.
23 This is not to suggest that the United States’ response was motivated solely by
geopolitical concerns; rather, it is to acknowledge that such geopolitical concerns played
some role in motivating the immediate response. See William Vanderwagen, “Health
diplomacy: winning hearts and minds through the use of health interventions,” Military
Medicine 171 (2006), 3-4.
working to develop the health care infrastructure in a particular country or group of
countries. It differs from the second form of health diplomacy because it is specifically
targeted at capacity building and prevention efforts. They are not spurred by a specific
disease outbreak or immediate health crisis, but rather by recognition of the need to
develop a country’s infrastructure so that it could effectively respond to a crisis should
one arise.
Governments increasingly recognize how successful health diplomacy can be a key
component of soft power. Providing health services to those in need not only improves a
country’s reputation, but can also be done far more inexpensively than traditional hard
power means. The United States’ Presidential Emergency Plan for AIDS Relief
(PEPFAR) has provided US$15 billion to combat AIDS worldwide over the past five
years—the largest expenditure for a single disease by a single country in history. Nye
praised this initiative as contributing significantly to the country’s soft power and
counteracting some of the more negative elements of American foreign policy in the past
decade24. Tommy Thompson, the former United States Secretary of Health and Human
Services, promoted the use of what he termed “medical diplomacy” as an important
element of the government’s anti-terrorism strategy. Discussing the usefulness of
“exporting medical care, expertise, and personnel to those that need it most,” Thompson
wrote in a Boston Globe column, “America has the best chance to win the war on terror
and defeat the terrorists by enhancing our medical and humanitarian assistance to
vulnerable countries. By delivering hope we will deliver freedom… These are the
24 Nye, “Soft power and American foreign policy,” 268.
battlefields where we will be able to win the war on terror -- at a relatively low cost.”25.
In another interview, Thompson remarked, “What better way to knock down the barriers
of ethnic and religious groups that are afraid of America than to offer good medical
policy and good health to these countries?”26 As Thompson conceptualized it, medical
diplomacy would allow the United States to improve its image in regions of the world
currently hostile to it while also providing much needed medical services. Providing
these services would make America more attractive in the eyes of the residents of those
countries, thereby advancing the United States’ diplomatic interests in fostering stability
and eliminating support for terrorist organizations. This strategy has continued under
Thompson’s replacement, Mike Leavitt. Leavitt describes how the United States
government’s efforts at promoting health and reducing the HIV/AIDS burden in South
Africa and Rwanda have led to an outpouring of support among local residents for the
United States27. Commenting on the efforts by Leavitt, Fortin notes, “it [health
diplomacy] is critically important in demonstrating who we are as a nation and who we
want to be as global citizens”28. Supporting health care infrastructure demonstrates the
25 Tommy G. Thompson, “The cure for tyranny,” Boston Globe (24 October 2005),
_for_tyranny/>, accessed 8 January 2008.
26 John K. Iglehart, “Advocating for medical diplomacy: a conversation with Tommy G.
Thompson,” Health Affairs 10 (2004), 264.
27 Mike Leavitt, “Rural Rwanda,”
, accessed 8
January 2008.
28 Fred Fortin, “Health diplomacy and America’s ‘soft power’”,
United States’ concern for the general welfare of humanity, as opposed to intervening
only in ‘strategically important’ countries. Building this support now will build good will
toward the United States, allowing the country to further its diplomatic initiatives later
with the support of these countries.
Health diplomacy can thus figure prominently in at least two of the three components of
soft power. By making the provision of health care an important element of a country’s
foreign policy, it will allow a country to demonstrate its moral authority. Further, it
provides a concrete demonstration of a country’s political values; in this case,
demonstrating that all people deserve adequate health care. Providing health care could
also make a country’s culture more attractive if the care reflects upon the provider’s
country in some way. For instance, if the provider fails to offer care necessary or
appropriate to the needs of the local population, that may appear presumptuous,
condescending, and perhaps even imperial. In essence, health diplomacy can show the
receiving countries that the providing country respects and cares for people and has
interests beyond its own narrow economic and military needs.
II. China, Africa, and health diplomacy in history
Chinese diplomatic involvement in Africa goes back to the 1950s29. In many ways, China
,
accessed 8 January 2008 (emphasis in the original).
29 I do not wish to imply that no Sino-African relationships existed prior to the 1950s.
Indeed, Philip Snow’s remarkable book, The Star Raft, exhaustively details the activities
sought to frame its early interactions with African governments and, in particular, anticolonial
movements as a counterweight to the perceived hegemonies of both the United
States and the Soviet Union. The Chinese government portrayed itself to African
constituencies as a patron who rejected the imperial mandates of Western powers and
understood the unique struggles of ‘peasant movements’ unlike the Soviet Union. Sino-
African relations in the 1950s and 1960s saw the Chinese attempting to affirm its own
brand of Maoist communism as the most appropriate model for development and anticolonialism.
It also provided financial, logistical, and training support for revolutionary
movements on the continent. This relationship continued through the 1970s, but its
emphases changed. Instead of necessarily trying to promote its vision of communism,
Chinese support to Africa focused more on trying to keep the Soviet Union in check30. It
was less a pro-active strategy to promote a specific outcome and more of a reactive one
designed to prevent a competitor from getting too far ahead. To take one example, the
Chinese government supported the Zimbabwe African National Union (ZANU), headed
by Herbert Chitepo and, later, Robert Mugabe, after the Zimbabwe African People’s
Union (ZAPU), under the leadership of Joshua Nkomo, started receiving support from the
Soviet Union. Many have interpreted this move as based less on ideological affinities and
of Chinese traders in Africa going back to 1414. Most of the first 500 years of contact
between the two, though, focused largely on commercial interactions. See Philip Snow,
The Star Raft: China’s Encounter with Africa (New York: Grove Press, 1988).
30 Joshua Eisenman, “China’s post-Cold War strategy in Africa: examining Beijing’s
methods and objectives”, in Joshua Eisenman, Eric Heginbotham, and Derek Mitchell,
eds., China and the Developing World: Beijing’s Strategy for the Twenty-First Century
(Armonk, NY: M.E. Sharpe, 2007), 29-31.
more on pragmatic concerns about countering Soviet influence31.
Chinese involvement in Africa went beyond providing money and training to anticolonial
movements; it extended into supporting infrastructural development throughout
the continent. One of the key elements of this strategy was medical cooperation. In 1963,
Zhou Enlai dispatched the first Chinese medical teams to Algeria32. This inaugurated
Chinese efforts to support African health care systems by providing medical personnel,
equipment, and supplies throughout the continent. In some instances, the arrival of
medical teams coincided with other Chinese infrastructure- or economics-based
diplomatic involvement in Africa; for example, Chinese medical teams arrived in the
early 1970s in Tanzania along with laborers working on the TanZam Railway33. More
often, though, the deployment of medical teams followed treaty negotiations between
China and the receiving state absent any ostensible economic benefit. In a number of
instances, the arrival of Chinese medical teams followed the host country’s inability to
maintain its previous health care commitments34. Instead, the Chinese government sought
to improve its standing within the international community and build support among
developing nations. It has sought to develop the health care infrastructures in African
states without imposing a uniform vision of those infrastructures and through a strong
emphasis on development based on the country’s own unique characteristics and locally-
31 Joshua Eisenman, “Zimbabwe: China’s African ally,” China Brief 5:15 (2005), 9.
32 Eisenman, “China’s post-Cold War strategy,” 43-44.
33 Michael Jennings, “Chinese medicine and medical pluralism in Dar es Salaam:
globalization or glolocalization?” International Relations 19 (2005), 461.
34 Ibid.
appropriate technologies35. Chinese medical personnel were generally deployed in the
receiving country for a two-year term, often serving in rural, underserved communities.
In addition to sending general practitioners, these teams frequently included a broad array
of specialists. To facilitate the development of long-standing ties, the Chinese national
government did not arrange the logistical details of these deployments. The treaties were
negotiated at the national level, but the implementation occurred at the provincial level.
Particular Chinese provinces were linked with one or more particular African countries36.
Yunnan Province sends its medical personnel to Uganda, while Zambia, Ethiopia, and
Eritrea receive medical teams from Henan Province, for instance37. It was the provincial
government’s responsibility to recruit personnel, send equipment, and ensure smooth
exchanges.
Under the terms of most of the medical cooperation agreements, the receiving state paid
the expenses for the medical team. These included international airfare, stipends for the
doctors and support staff, and some of the pharmaceuticals and medical equipment
brought by the team. On occasion, the Chinese national government covered these costs
35 Bates Gill and Yanzhong Huang, “Sources and limits of Chinese ‘soft power’”,
Survival 48:2 (2006), 20 and Padraig R. Carmody and Frances Y. Owusu, “Competing
hegemons? Chinese versus American geo-economic strategies in Africa,” Political
Geography 26 (2007), 508.
36 Ambassador David H. Shinn, “Africa, China, and health care”, Inside AISA 3/4
(October/December 2006), 15.
37 Drew Thompson, “China’s soft power in Africa: from the ‘Beijing Consensus’ to
health diplomacy,” Asia Brief 5:21 (2005), 4.
through loans or grants. More often than not, though, these costs came directly from the
national health care budget38.
Most commentators remarked rather positively on Chinese medical cooperation in the
1960s and 1970s. Alan Hutchison visited a number of medical clinics sponsored by the
Chinese government throughout the continent in the early 1970s. He found that rural
Chinese medical teams represented one of the most successful forms of aid in Africa. The
so-called “barefoot doctors” adapted well to local conditions, demonstrating an ability to
provide quality medical care in resource-poor settings. Significantly for Hutchison, the
Chinese medical teams focused less on emergency medical care, instead focusing on
bringing basic preventative care to rural areas that had previously lacked any such care39.
Hutchison saw this as a positive sign that Chinese health diplomacy could promote the
sustainable development of the receiving country’s health care infrastructure. Indeed, it is
difficult to argue that the Chinese medical teams have not had a positive effect
throughout the continent. Since that first medical team arrived in Algeria, more than
15,000 Chinese medical personnel have served in 47 different African states and treated
180 million cases of illness and disease40. This represents a significant contribution to the
continent’s health and its health care infrastructures.
38 Thompson, “China’s soft power,” 3.
39 Alan Hutchison, China’s African revolution (Boulder: Westview Press, 1975),
220-221.
40 Eisenman, “China’s post-Cold War strategy,” 43-44 and Carmody and Owusu,
“Competing hegemons?”, 508.
Over time, Sino-African relations retreated to the backburner. China paid less and less
attention to Africa as it sought to find a place in the international marketplace. African
markets held little allure or promise for Chinese manufacturing interests, so they fell by
the wayside. Africa may not have ever been the primary focus of Chinese foreign policy,
but the continent lost what little relevance it had by the 1980s. One commentator went so
far as to remark, “It is hard to make a case that Africa matters very much to China…they
[Africans] count for little in the overall scheme of Chinese foreign policy objectives”41.
In recent years, Africa has regained a level of prominence in China’s overall foreign
policy strategy. The growing amount of attention paid to Africa has coincided with a
resurgence of health diplomacy.
III. Sino-African health diplomacy today
Over the past two decades, the Chinese government has engaged in a concerted effort to
portray itself as an active and responsible member of the international community. Some
of this is post-Tiananmen damage control; the Chinese government wants to prove to the
rest of the world that it can abide by the ideals undergirding the international community.
To do this, it has taken a greater effort to build bilateral relations with an increasing array
of countries, joined regional and international organizations, and demonstrated a
willingness to participate in international economic forums. At the same time, though,
Chinese government efforts have paid particular attention to developing countries in an
41 Gerard Segal, “China and Africa,” Annals of the American Academy of Political and
Social Sciences 519 (1992), 115.
effort to blunt international criticism of its policies and practices42. In bodies like the
United Nations, developing countries far outnumber developed ones. By building
relations with developing countries, the Chinese government hopes to have the numerical
clout to prevent the organization from passing General Assembly resolutions that
condemn its actions and policies.
This strategy has led to a resuscitation of earlier rhetoric about the natural ties between
the developing world and China. Indeed, Huang and Ding note that China has been
“particularly deft at using foreign aid to communicate favorable intentions or evoke a
sense of gratitude” among African states43. The Chinese government has, in statements to
developing countries, has frequently counted itself among their numbers and called itself
the leader of the developing world. It has also positioned itself as the only viable source
of support to challenge the neo-imperialism of Western states. It has a promoted a
strategy of non-interference in domestic affairs, emphasizing that its foreign aid comes
with none of the conditionality imposed by the United States44. Along with the lack of
conditionality, the Chinese government has also targeted a significant portion of its aid
42 Denis M. Tull, “China’s engagement in Africa: scope, significance, and consequences,”
Journal of Modern African Studies 44 (2006), 460-461.
43 Huang and Ding, “Dragon’s underbelly,” 37.
44 Ian Taylor, China and Africa: engagement and compromise (New York: Routledge,
2006), 13-15. For some perspective on the receptivity of African states to this language,
see Jeremy Youde, “Why Look East? Zimbabwean foreign policy and China,” Africa
Today 53:3 (2007), 3-19.
toward infrastructure development45.
Health diplomacy is just one element of China’s increased engagement with Africa, but it
plays a prominent role. Government leaders from China and 45 African states met in
Beijing in October 2000 for the inaugural China Africa Cooperation Forum (CACF). At
this time, the Chinese government forgave US$1.2 billion in foreign debt owed by
African states and pledged to increase its aid contributions to the continent in all realms.
Three years later, when the CACF re-convened in Addis Ababa, the Chinese government
made more explicit health diplomacy promises. It highlighted the treatment and
prevention of disease as one of its priority areas, pledging additional funds for these
efforts46. Health also featured prominently at the third CACF meeting in November 2006.
Not only did the Chinese government pledge to double its aid to Africa by 2009 and offer
US$5 billion in preferential loans to the continent, but it also emphasized the prominent
role of health and education programs in its African aid efforts47. At this same meeting,
the Chinese government pledged to build 30 hospitals in Africa, provide US$37.5 million
in grants for anti-malarial drugs, and develop 30 demonstration centers for the treatment
and prevention of malaria. It also renewed its commitment to send medical teams to the
best of its ability for the next three years48.
45 Joshua Eisenman and Joshua Kurlantzick, “China’s African strategy,” Current History
691 (2006), 221.
46 Sutter, Chinese foreign relations, 373.
47 Ibid.
48 “China, Africa vow closer cooperation in fighting HIV/AIDS: action plan,” People’s
Daily, 6 November 2006.
In releasing its Africa policy in 2006, the Chinese government highlighted four healthrelated
priorities in its relations with the continent. These were:
-Emphasizing the need to develop and promote effective treatments for
malaria,
-Enhancing exchanges of medical personnel and information between
China and Africa,
-Sending medical teams and equipment to improve facilities and train
doctors throughout the continent, and
-Assist with efforts into researching the usefulness of traditional medicines
in treating and preventing HIV/AIDS49.
These health diplomacy efforts play themselves out in a number of different ways. Most
prominently, Chinese provincial governments continue to send medical teams to their
assigned African countries. After dwindling in the 1980s, Chinese medical teams have
been increasingly deployed throughout the continent. In 2003, 860 Chinese medical
personnel were serving in 35 teams in 34 African states50. Two years later, the number of
Chinese medical personnel in Africa topped 900. In addition to the traditional medical
teams, the Chinese government started to include its medical personnel on United
Nations peacekeeping missions in Africa. Nearly 900 Chinese medical personnel served
, accessed 17
January 2008.
49 Shinn, “Africa, China, and health care,” 14.
50 Eisenman, “China’s post-Cold War strategy,” 44.
on 8 UN-sponsored African peacekeeping missions in 200551.
Deploying medical personnel is perhaps the most obvious and apparent element of
China’s health diplomacy strategy, but it is not the only one. Building medical clinics to
serve local populations, donating pharmaceuticals, and occasionally even providing
medical equipment have all played increasingly important roles in these efforts.
Interestingly, while the Chinese government provides some of the medical clinics as
assistance projects to countries in need, some are explicitly designed to be commercial
ventures52. These for-profit ventures may not exactly conform to the same idea of health
diplomacy as the donated clinics, but they do further the objective of providing health
care in underserved areas of Africa to help improve China’s stature on the continent. Few
patients will necessarily know whether a particular clinic comes from China as a nonprofit
or for-profit enterprise; the patients instead recognize that they now have access to
health care. Shinn notes that this more expansive health diplomacy with clinics, drugs,
and equipment has additional benefits for China. Donating pharmaceuticals is a “clever
and low-cost way to introduce Chinese-made medication to the African market”53. There
is also increased interest among a number of African governments on collaborating on
research projects with Chinese medical personnel and scientists on using African herbal
medical treatments to treat HIV/AIDS54.
51 Robert G. Sutter, Chinese foreign relations: power and policy since the Cold War
(Lanham, MD: Rowman and Littlefield, 2008), 375.
52 Shinn, “Africa, China, and health care,” 15.
53 Ibid.
54 Shinn, “Africa, China, and health care,” 16.
Not only does providing health care make China look better in the eyes of everyday
Africans, but it also inclines them to trust medical products produced in China. In this
way, China’s health diplomacy soft power efforts also offer the country an economic
payoff. That does not negate the soft power aspects of China’s health diplomacy efforts;
in fact, it reinforces them. Soft power works through the power of attraction, and that
attraction can lead others to take certain diplomatic, cultural, or economic decisions.
Attraction leads to trust, and trust can encourage economic decisions. Soft power’s
success in attracting an economic benefit reinforces the usefulness of soft power.
By its nature, it can be difficult to determine exactly when and how soft power operates
to alter the behavior of another state. Soft power works through attraction in a general
sense. It rarely has a specific policy objective attached to it; rather, it is about making a
state look better in the eyes of others. Since there is not a specific policy attached to these
efforts, the cause-and-effect relationship between soft power and state behavior is
somewhat more tenuous. No African ambassador would proclaim in the United Nations
General Assembly that it was voting with the People’s Republic of China because the
Chinese government had announced the shipment of one million doses of anti-malarial
drugs. In addition, soft power is a long-term strategy. It focuses less on altering specific
state behaviors at a given time and more on effecting a state’s reputation in other states.
Indeed, it is entirely plausible that members of a government may not necessarily connect
their favorable views of China to elements of soft power.
These difficulties do not negate the importance and usefulness of soft power. Indeed, we
can see some evidence of the success of China’s soft power strategies. A worldwide
survey by the Pew Global Attitudes Project found that majorities or pluralities of citizens
in 10 African states thought that China had at least a fair amount of influence on their
countries. In Mali and Cote d’Ivoire, respondents indicated that China’s influence was at
least on the same level as the United States. Indeed, throughout the continent, more
people indicate that China’s influence in their country is positive than say that about the
United States’ influence55.
Providing these medical teams appears to be paying off for the Chinese government and
its efforts to improve its standing among developing nations. It not only provides muchneeded
services to a large swath of the population in Africa, but it also reaches far more
people than other outreach programs can. Thompson acknowledges, “While university
scholarships promote closer ties between China and Africa, China has also promoted
‘health diplomacy’ with African partners, establishing a relationship between Chinese
doctors and millions of ordinary Africans, and earning the gratitude of many African
leaders eager to be seen providing public goods to their citizens”56. Soft power,
remember, seeks to make a country’s culture and politics attractive and worthy of respect.
In this instance, we see how providing health services allows the Chinese government to
grow in stature among the people and government leaders throughout the African
55 Pew Global Attitudes Project, “Summary of Findings: Global Unease with Major
World Powers,” 27 June 2007, ReportID=256>, accessed 17 January 2008.
56 Thompson, “China’s soft power in Africa,” 2.
continent.
IV. Limitations on Chinese health diplomacy
Chinese health diplomacy appears to further the country’s soft power and its diplomatic
ambitions, but it is not a fail-proof strategy. Two important limitations—one coming
from China, the other coming from Africa—could undermine this strategy.
First, pressures on the Chinese medical system may prevent it from continuing to deploy
medical teams throughout the continent. The 2006 CACF pledges obliquely acknowledge
these limitations, with the Chinese government offering to send medical teams to the
extent it could. Increased prosperity within China itself has increased demands on the
medical system, and Chinese citizens are increasingly demanding better health care57.
With a finite amount of medical resources available, increased demands for better health
care at home will likely lead to a questioning of the usefulness and appropriateness of
sending Chinese medical personnel to Africa at the expense of providing health care in
China itself. Popular pressures question the usefulness and appropriateness of sending
medical technologies and personnel abroad when the domestic Chinese population often
lacks access to these same technologies and personnel.
At the same time, the increased earning potential of medical personnel in China means
fewer have expressed an interest in spending two years in Africa, often living in less than
ideal circumstances. Some provinces have reported increasing difficulty in staffing their
57 Eisenman, “China’s post-Cold War strategy,” 44.
medical teams58. Eisenman suggests that difficulties in recruiting medical personnel will
lead the Chinese government to send more pharmaceuticals and medical technology
instead of actual doctors and nurses59. This may be a logical and rational reaction to the
shortage of available personnel, but it will also likely decrease health diplomacy’s
benefits. Without the physical presence of people, it is less likely that patients will
recognize that the drugs and medical equipment come from China instead of the United
States or somewhere else. Having bodies on the ground provides tangible evidence of the
commitment China has made to African health care systems. Medical technology and
drugs seem unable to replicate that evidence.
Second, some evidence suggests a growing backlash in various parts of Africa against the
increasingly pervasive Chinese presence. Pro-democracy and human rights activists in
Africa (and the West) have charged the Chinese government with propping up
authoritarian regimes and undermining efforts to increase freedom throughout the
continent60. The willingness of the Chinese government to provide support to dictatorial
leaders may “undercut[] its efforts to become a responsible power”61. Others allege that
Chinese-sponsored infrastructure projects are predicated upon African states giving
China access to natural resources as an explicit quit pro quo62. Trade unions have
58 Thompson, “China’s soft power in Africa,” 4-5.
59 Eisenman, “China’s post-Cold War strategy,” 44.
60 Craig Timberg, “In Africa, China trade brings growth, unease,” Washington Post (13
June 2006), A14.
61 Huang and Ding, “Dragon’s underbelly,” 38.
62 Ibid.
chastised China for paying low wages, offering little job security to local workers, hiring
Chinese workers even when qualifies local employees are available, and driving local
companies out of business63. Michael Sata, a Zambian opposition leader and candidate in
the 2006 presidential election there, went even further, exclaiming, “Zambia is becoming
a province—no, a district—of China…We’ve removed one foreign power, and we don’t
want another foreign power here, especially one that is not a democracy”64. These actions
may reduce the willingness of African states to accept China’s medical diplomacy efforts,
as they fear the damage to their reputations are higher than the benefits.
Ostensibly, China’s soft power strategy seeks to counteract these negative impressions
and encourage Africans to think about China in more positive terms. Indeed, the Chinese
government, in its official Africa policy, emphasizes, “Sharing similar historical
experience [sic], China and Africa have all along sympathized with and supported each
others in the struggle for national liberation and forged a profound friendship”65.
However, the upsurge in negative feelings about China and its intentions in Africa have
corresponded with greater Chinese investment in and activity on the continent. This
suggests that China’s African strategy may be working at cross-purposes or lack
coherency. While the average man and woman in Africa may appreciate China providing
63 “African backlash against China,” Asia Times (20 October 2006)
64 Cited in Yaroslav Trofimov, “In Africa, China’s expansion begins to stir resentment,”
Wall Street Journal (2 February 2007).
65 Ministry of Foreign Affairs of the People’s Republic of China, “China’s Africa Policy,”
January 2006. , accessed 21 January
2008.
medical care, they increasingly resent China’s economic and political activities on the
continent. China’s attempts to make their culture and ideals more attractive are not
translating into more positive feelings and attitudes toward China by Africans. A recent
report published by the Center for Strategic and International Studies highlighted this
oversight. Analyzing growing Sino-African ties, the CSIS report identified a failure to
take “evolving Africa popular opinion –the ‘African street’” into account66. Ignoring the
attitudes and opinions of everyday Africans could severely undermine China’s attempts
to forge a closer strategic relationship with Africa. A successful soft power strategy will
thus not only need to carefully consider public opinion, but also provide a means for
connecting China’s health diplomacy efforts on the continent with its larger strategic,
economic, and attitudinal goals.
V. Conclusion
China’s embrace of health diplomacy in Africa in recent years connects back to earlier
efforts to promote itself as a vanguard alternative to leading Western states. In its more
modern manifestation, health diplomacy figures prominently as an important element of
China’s soft power. Providing medical care and building the health care infrastructure of
African states improves China’s standing among developing countries and bolsters its
status as a credible alternative to the dictates of Western powers.
66 Bates Gill, Chin-hao Huang, and J. Stephen Morrison, China’s Expanding Role in
Africa: Implications for the United States (Washington: CSIS, 2007), vi.