NO. 9 JANUARY 2021 Introduction

China’s Health during Covid-19 The Belt and Road Initiative (BRI) in Action Moritz Rudolf

International cooperation in the health sector has been a firm component of China’s Belt and Road Initiative (BRI) for over five years. Since the outbreak of the Covid-19 , the Chinese leadership has been promoting this aspect of the initiative (“health silk road”) as essential to building a “global community of common destiny”. The pandemic has revealed the strengths of the BRI and the way it functions. China’s health diplomacy is farsighted and strategic. Beijing has been linking measures to combat the Covid-19 pandemic in recipient countries with the prospect of post- pandemic cooperation within the BRI framework. Above all, Beijing wants to be per- ceived internationally as a “responsible great power”. The West’s often narrow focus on the qualitative defects of Chinese aid fails to recognise that, in the absence of traditional aid donors, Beijing has supported many third countries effectively and extensively. To counter China’s increasing influence in regions that are strategically important for Germany and Europe, greater sensitivity is needed to the geopolitical implications of the pandemic, as well as specific Euro- pean proposals for third countries for the post-pandemic period. In parallel with more commitment at the multilateral level (for instance within the World Health Organisa- tion, WHO), other options include strengthening bilateral initiatives (e.g. via regional EU+x formats) and coordination with the new US government under Joe Biden.

On 9 and 12 December 2020 the United Chinese leadership: China is a responsible Arab Emirates (UAE) and Bahrain were the great power. Since the outbreak of the pan- first countries to approve a Chinese corona- demic, China has linked its contribution virus . Other countries, especially in combating the virus to President Xi Jin- in the Global South, have announced that ping’s foreign-policy prestige project, the they intend to do likewise soon (by 18 Janu- Belt and Road Initiative (BRI). ary 2021, Egypt, Indonesia, and Brazil, among others, had approved Chinese ). It is realistic to assume that China Health as Part of the BRI will play an important role in vaccinating the world’s population. This would be con- Health has been on the BRI agenda for over sistent with the narrative promoted by the five years. In March 2015 the framework

document Vision and Actions on Jointly grammes for exchange and cooperation (for Building Silk Road Economic Belt And 21st- hospitals, the health industry, and univer- Century Maritime Silk Road already listed sities), access to markets (for example for cooperation to prevent and contain epi- medicines), and cooperation in combating demics among its objectives. According to infectious diseases like MERS and SARS (see official BRI documents, health cooperation the Suzhou Declaration of 20 June 2016). also includes: New structures have been created for this training programmes for medical staff; format, including the 17+1 Hospital Alliance, capacity-building for public health crises; the 17+1 Cooperation Network for Public ∎ emergency medical relief for crises; Health, the 17+1 Cooperation Network for ∎ promoting Traditional Chinese Medicine Health Workers, the 17+1 Research Net- ∎ (TCM); work for Health Policy, and the 17+1 Co- ∎ free treatment abroad by Chinese operation Forum for Approval of Medicines. doctors. Health was already a prominent part of ∎ The BRI framework document The Belt China’s relationship with the ASEAN coun- and Road Initiative – Progress, Contribu- tries before the BRI was announced. In 2012 tions, and Perspectives (April 2019) refers to the parties concluded a Memorandum of 56 bilateral health agreements that China Understanding on health cooperation. On has concluded, inter alia with the WHO and 26 October 2016, the participants in the first the Bill & Melinda Gates Foundation. The China-ASEAN Health Cooperation Forum BRI Standardisation Action Plans of 2015– adopted the Nanning Declaration. It focuses 2017 and 2018–2020 also mention Chinese on exchanging information, jointly prevent- efforts to set uniform standards for TCM ing and controlling infectious diseases, train- and the definition of medical terms. The ing health sector professional, promoting BRI Development Plan for Promoting TCM TCM, and deploying Chinese doctors. For (2016–2020) makes it clear that Beijing the “Lancang-” countries (, plans to promote traditional Chinese medi- , , , and ), cine internationally. one focus of China’s BRI health diplomacy In realising the Health Silk Road, as in is on free eye operations. all other areas of the BRI, Beijing acts strategi- In September 2015 the China-Arab States cally, flexibly and at several levels simulta- Health Cooperation Forum was held as part neously (bi- and multilateral, regional, and of a dialogue forum that China has estab- global). The so-called China+x mechanisms lished with Arab League countries. Accord- are essential here. These are formats for ing to the Yinchuan Declaration that it Chinese cooperation, for instance with coun- adopted, this cooperation includes techno- tries from the Association of Southeast logical collaboration, promoting TCM, pre- Asian Nations (ASEAN) countries, Africa venting and controlling infectious diseases, (FOCAC), Central and Eastern Europe (17+1), medical training programmes, coordinating or the Arab League. Health cooperation public health system reforms, exchanges within these mechanisms does present between medical establishments and staff, differences from region to region, but it and coordinating on global health issues. reflects large swathes of the content (at Health cooperation is most significant in times verbatim) of the Chinese BRI docu- China-Africa relations, where it dates back ments. to long before the BRI was announced (for Since 2015 there has been a regular example, the deployment of medical per- forum of the Chinese health minister with sonnel, a decades-old practice). Since 2015 17 (until 2019: 16) Central and East Euro- it has been absorbed into the BRI as part of pean colleagues (2015 in Prague; 2016 in the Forum on China–Africa Cooperation Suzhou; 2017 in Budapest; 2019 in Sofia). (FOCAC). It consists, inter alia, of providing The declared objectives of the format are medical supplies, training programmes, the promotion of TCM in Europe, pro- building hospitals, and support for com-

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2 bating infectious diseases such as malaria Comoros) were used for propaganda by Bei- and (see e.g. the FOCAC Johannesburg jing as a sign of solidarity and evidence of Action Plan [2016–2018] and the FOCAC the Health Silk Road mentality. Beijing Action Plan [2019–2021]). In late February, when the Chinese Health was also important within the leadership had gradually regained control BRI on a bilateral level before the Covid of the outbreak in the country, Beijing pandemic. China has been sending medical quickly took on the role of relief supplier. personnel to offer free treatment in regions Since a majority of the world’s mask fac- where China+x formats are less widespread. tories are in China and many industrialised Here China’s commitment in South Asia nations had delivered relief aid to Wuhan, and Oceania must be emphasised (Beijing the Chinese leadership was in an almost has sent teams of doctors to , Micro- monopolistic position to provide the world nesia, Vanuatu, Tonga and Fiji, for exam- with masks and medical kits. In particular, ple). China is also active in Central Asia. Its countries that had inadequate medical most important pilot project is the Medical equipment very quickly received donations Services Centre of the BRI Core Region Xin- of much-needed aid supplies (masks, test jiang. This hospital cooperation platform kits, and respirators). Beijing also sent teams provides medical help for patients from of doctors to 43 countries. Nearly all the neighbouring countries (such as free heart world’s countries have received support operations for Afghan children). It also aims from China (see Map 1, p. 7). to network Central Asian hospitals with Aid supplies came from a variety of Xinjiang (for example for medical tourism). actors, not only from China’s central gov- Most important at the global level is the ernment and the Communist Party, and Memorandum of Understanding on Health often took into account China’s strategic Sector Cooperation under the Belt and Road interests in the recipient nation. Provinces Initiative signed by China and the WHO and cities supplied their partner municipal- on 18 January 2017. It uses the term Health ities and regions. Majority Muslim countries Silk Road for the first time. The WHO’s ex- (such as Afghanistan, Egypt, Iran, Iraq, plicit support for the BRI reflects the grow- Lebanon and Jordan) received masks from ing influence of the People’s Republic with- Xinjiang Autonomous Region. In Southeast in the WHO, which has been noticeable for Asia (e.g. Laos, Cambodia, Myanmar), sol- years. In August 2017 officials from many diers from the People’s Liberation Army countries, international organisations and delivered medical aid supplies. In countries non-governmental organisations (NGOs) where Chinese state-owned companies run signed the Beijing Communiqué on BRI BRI projects (for instance in Africa), donors Health Cooperation and the Health Silk included relevant banks, construction com- Road, which summarises the fundamental panies, and raw material companies. The elements of China’s BRI health policy. telecoms company Huawei preferentially gave support to countries in which it was pursuing strategic interests in the 5G ex- Activating the BRI Networks as pansion: in Europe these included the Part of “Mask Diplomacy” Czech Republic, Ireland, Italy, Lithuania, the Netherlands, Poland, Romania, Serbia, Once the coronavirus outbreak in Wuhan and Spain. Business foundations (especially became known, China initially appealed to the Jack Ma Foundation and the Alibaba the international community and received Foundation) delivered masks, respirators, material and financial aid from more than and testing apparatus to over 150 countries. 58 countries (including , Belarus, Trade associations, overseas Chinese, and Djibouti, Germany, , Bahrain, the NGOs were also involved. As part of “mask USA and Surinam). Even smaller contribu- diplomacy”, many recipient countries saw tions (for instance a €100 donation from the involvement of locally resident Chinese

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3 actors, who normally tend to live apart China’s mask diplomacy has been criti- in parallel societies. These forms of help cised, particularly in Europe; the necessary for the local population correspond to the logistics, activation of Chinese actors, and objective formulated in many BRI docu- uniform external communications are never- ments of generating broad support for theless remarkable achievements. For many China’s Silk Road policy. countries China was a reliable partner, espe- China even offered aid supplies to states cially since traditional aid donors (above that do not (yet) have diplomatic relations all the USA) were absent. For the first time, with Beijing, especially in . Beijing has given its global BRI rhetoric In Paraguay the parliamentary opposition some substance. demanded that relations with be broken off so as to receive aid from Beijing. Belize received donations of auxiliary ma- Next Act: Vaccination Diplomacy terials from Chinese organisations that were supposedly NGOs. A remarkable PR coup Phase III trials are currently running in for Beijing were the photos of Belize City 18 countries, especially in Latin America, councillors posing in front of Chinese flags. , and the Arab world, for the China’s propaganda machine has been vaccines produced by five Chinese compa- running at full speed for months. The con- nies (Sinopharm, CanSinoBIO, Sinovac and tent for this streamlined Covid-19 narrative Anhui Zhifei Longcom Bio, IMBCAMS). China comes from the white book Fighting Covid- has already concluded contracts for vaccine 19: China in Action. Chinese diplomats deliveries with 26 countries; 10 (see Map 2, have been publishing articles in local daily p. 8) have approved Chinese vaccines (as newspapers in which they describe China’s of 18 January 2021). Many other countries relations with the country to which they would like to use a Chinese vaccine or are have been posted according to this narra- currently negotiating contracts. tive. These articles present China as a On this issue, too, the Chinese leadership rescuer that is the equal of the aid recipient wants to be perceived as a “responsible great countries, and as a responsible internation- power”. Once again it is acting bi- and al great power. China’s help, the narrative multilaterally. On 18 May 2020 claims using a key BRI expression, is sym- announced in a speech to the WHO in bolic of the “global community of common Geneva that China would be providing the destiny” to which it aspires. The articles are world with an inexpensive vaccine as a reminiscent of China’s propaganda strategy “global public good”. This is typical BRI in the early days of the BRI: similarly, back rhetoric. The Initiative has been promoted then sizeable newspaper adverts were used using the same vocabulary for years. Presi- (though primarily by members of the leader- dent Xi also promised the WHO US$2 bil- ship, not diplomats) to promote the BRI. lion for the fight against corona. In October A new development is China’s presence Beijing joined the vaccine platform COVAX, on “Western” social media such as an initiative by the United Nations, Euro- or Facebook, which are not available in pean Union and France, which aims to en- China. Almost every day, China’s diplomatic sure a fair distribution of vaccines. missions disseminate updates on social net- While the first months of the pandemic works about China’s local contributions to were marked by bilateral aid supplies, Bei- combating Covid-19. Xi Jinping’s wife, the jing has been increasingly using China+x singer and WHO special envoy Peng Liyuan, formats for its vaccine diplomacy. These also has a role in China’s health diplomacy, formats link vaccine promises with the for instance by leading online ceremonies prospect of economic support and long- to mark Chinese assistance. Peng has also term cooperation projects. The starting- personally donated protective masks to point was the Extraordinary China-Africa many African countries. Summit on Solidarity against Covid-19

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4 (June 2020). The Chinese leadership prom- jing has increasingly been linking its con- ised preferential vaccine deliveries, “debt tribution to combating the pandemic with cancellation”, and reinforced economic the BRI narrative (e.g. the advantages of relations after the pandemic (such as help global connectivity; the construction of with investments in the digital economy, a “global community of common destiny”). boosting renewable energies, and expand- With its high degree of flexibility, strong ing the 5-G network). One month later, political will, and logistically advantageous Beijing organised a health summit with the starting position, the BRI has so far been Arab League states. Here too China held out able to weather the test of this crisis. the prospect of vaccination cooperation as Beijing’s health diplomacy has revealed well as strengthened bilateral economic the way the initiative functions, and espe- relations (under the BRI framework). Also cially its adaptability. Virtually overnight, in July, Beijing promised Latin American health was promoted from a marginal to and countries US$1 billion for a key subject of the BRI. In the briefest of purchasing vaccines. On 24 August Prime times, China activated BRI networks around Minister explained that the Lan- the world. The necessary infrastructure cang-Mekong countries would be prioritised was already available from other BRI com- for vaccine deliveries and that funding ponents. BRI rail links and the so-called Air could come from a Public Health Fund. In Silk Road (with hubs in Luxembourg and turn Foreign Minister identified Liège) were repurposed as supply lines for the ASEAN as a priority region for vaccines. aid goods. Now the interlinking of the Digi- Similar promises (vaccine priority and ex- tal Silk Road with the health BRI is also on pansion of economic relations) were made the agenda (for instance to facilitate con- at the China-Pacific Island Forum. In Novem- tact tracing). Institutionally China can here ber high-ranking officials from China and draw on numerous China+x mechanisms South Asian countries (, Nepal, to drive the BRI forward. Pakistan, ) held talks about vac- While, in the early days of the pandemic, cinations. the USA mostly did not participate in inter- What is remarkable is that the most national aid measures, China filled this gap advanced format institutionally, the 17+1, and is now advancing further into the tra- has played a subordinate role in China’s ditional backyards of the USA’s spheres vaccine diplomacy. In 2020 only two of influence (Latin America and the Arab webinars were held at vice-ministerial level. world). China’s vaccine diplomacy in Europe, on The widespread view in Germany and the other hand, has been designed bilater- Europe that China’s mask diplomacy has ally and is aimed primarily at Hungary and been unsuccessful, fails to recognise that Serbia. China has been targeting success in coun- China’s commitment to Latin America tries outside of Europe, where it is increas- and the Arab world is particularly promi- ingly viewed as a responsible great power. nent. These regions have recently also Beijing has been helping third states effec- gained importance for the BRI. The new tively and extensively. China-Pacific Islands health cooperation After the pandemic, China might well be forum in turn emphasises China’s strategic able to further expand its influence in key orientation towards the southern Pacific. BRI regions: it has been acting strategically and far-sightedly in its (health) initiative. Its health diplomacy links measures to combat Assessment the pandemic with BRI promises (prosperity through connectedness with China). To The BRI has not floundered on Covid-19, as counteract further growth of China’s influ- some observers had predicted in the early ence on strategic regions, Europe should days of the pandemic. On the contrary, Bei- make proposals to third countries for the

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5 post-pandemic period (political cooperation and economic support). Europe has a lot of catching-up to do in this respect. Its under- standing of the geopolitical implications of Covid-19 is insufficient. Chinese competitors have so far not emerged as forerunners in the vaccine race. Yet there are promising Chinese vaccines. Despite growing doubts over their efficacy, Beijing will profit from national production © Stiftung Wissenschaft capacities in the coming months and be in und Politik, 2021 a position to provide the Global South with All rights reserved vaccines. Beijing plans to vaccinate 50 mil- lion of its own citizens against the corona- This Comment reflects virus by early February. It would not be the author’s views. surprising therefore if Chinese vaccination The online version of teams were deployed in developing nations this publication contains in the coming months under the BRI functioning links to other banner. SWP texts and other relevant Political decision-makers in Germany and sources. Europe need to realise and react to the fact SWP Comments are subject that China’s health diplomacy, just like the to internal peer review, fact- entire BRI, operates on several levels simul- checking and copy-editing. taneously: bi- and multilateral, regional, For further information on and global. Multilateral commitments (e.g. our quality control pro- within the WHO) should be strengthened; cedures, please visit the SWP website: https://www.swp- where appropriate, China should be co- berlin.org/en/about-swp/ operated with (for instance under COVAX). quality-management-for- However, this alone is insufficient. Over swp-publications/ the past few years, Beijing has massively expanded China’s influence at the multi- SWP lateral level (especially within the WHO). Stiftung Wissenschaft und Politik To oppose this expansion in third countries, German Institute for Germany and Europe would do well to International and strengthen their own bilateral commit- Security Affairs ments as well. Regional EU+x formats with countries in strategically relevant regions Ludwigkirchplatz 3–4 10719 Berlin (e.g. Indo-Pacific or Africa), or appropriate Telephone +49 30 880 07-0 measures coordinated with the new Biden Fax +49 30 880 07-100 administration in the USA, would be poten- www.swp-berlin.org tial courses of action. [email protected]

ISSN 1861-1761 doi: 10.18449/2021C09

Translation by Tom Genrich

(Updated English version of SWP-Aktuell 5/2021)

Moritz Rudolf is an Associate in the Asia Research Division at SWP.

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Map 1

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7 Map 2

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