Captain Kimberly Sandberg, USN, Captain Kevin Pickard, Jr., USN, Lieutenant Colonel Jay Zwirblis, USAR, and Lieutenant Colonel Speight H. Caroon, USAF, wrote this essay while attending the Joint and Combined Warfighting School at the Joint Forces Staff College, in Norfolk, Virginia. It won the Strategy Article category of the 2022 Chairman of the Joint Chiefs of Staff Essay Competition.
Today, China is looking to compete with the United States for influence and access across Africa. Policy experts within the Department of Defense have focused on China’s effort to reach parity with the United States within traditional military domains; however, they have contributed less regarding the military policy implications of China’s expansion of medical and pharmaceutical assistance, an area that likely will continue to be a key line of operation in the post-pandemic world.
In its purest form, health diplomacy has been characterized as a moral imperative that carries the obvious benefit of building trust and amity that can be leveraged to develop mutually beneficial partnerships. The 2021 Interim National Security Strategic Guidance (INSSG) emphasizes continued partnership developments in Africa by investing in civil society and strengthening longstanding political, economic, and cultural connections. It also highlights the need for global partnerships to achieve national security objectives, specifically, the need to strengthen health diplomacy to combat instability in Africa.1 While the motivations behind China’s efforts to expand health diplomacy are not entirely clear, this guidance suggests that it cannot be viewed as a purely altruistic effort to better the lives of Africans, but remains a deliberate, and not necessarily new, component of China’s continuing efforts to expand its influence. Understanding Chinese health diplomacy and methods used, U.S. goals for Africa, and our strengths will help to provide policy prescriptions for U.S. Africa Command (USAFRICOM) to reinforce the INSSG and the role of the United States as the partner of choice in Africa.
Health Diplomacy and Chinese Foreign Policy
The Chinese Communist Party has significantly invested in health diplomacy since “the 1950s and ’60s, [when] a still-impoverished China sent a total of 6,500 trained medical personnel on assistance missions to over 40 countries and funded the construction of more than 20 medical institutions around the world.”2 China’s efforts to contain its domestic outbreak of the hepatitis B virus in the 1980s and its response to the SARS (severe acute respiratory syndrome) outbreak in 2003 point to China’s inability to mount a successful domestic response to a health emergency and highlighted an unwanted reliance on Western pharmaceutical capacity and medical technology.3 With the COVID-19 pandemic, China’s renewed emphasis on displaying competence within the health and pharmaceutical industries has created a fertile ground for it to generate greater international goodwill while seeking to portray itself as a country whose political governance is superior to Western democracy.4
Recently, China has made efforts to provide high-visibility aid that exemplifies both its benevolence and largesse. At the beginning of the COVID-19 pandemic, it rapidly sent 5.4 million facemasks, more than 1 million test kits, and thousands of protective suits to African countries.5 It also sent medical teams to several African countries to combat the pandemic. The primary beneficiaries of China’s medical diplomacy efforts have been poorly governed countries in Africa.6
Assistance was provided through multiple channels, including Chinese state-owned enterprises (SOEs) and private entities.7 According to R. Maxwell Bone and Ferdinando Cinotto, “SOEs tend to target institutions which they intend to do business with directly, while private companies aim their donations toward both central governments and consumers.”8 Chinese SOEs are usually considered an extension of the central government, but they often operate semi-autonomously and under the looser regulatory frameworks of developing countries. PalmPay, an Africa-focused mobile payment startup backed with funding from Transsion Holdings (a major Shenzhen-based cellphone maker), waived transfer fees and even gave direct “cash” handouts to customers hit by COVID-19.9 These efforts produced results. In a Pew research survey that focused on public opinion of the United States in 13 countries in North America, Europe, and the Asia-Pacific region, China’s response to the pandemic received better reviews than the U.S. response.10
Health Diplomacy and U.S. Foreign Policy
The recently released INSSG places a renewed emphasis on global health security and specifically addresses the need to bolster the commitment to mutual health security. It calls for deeper engagement in Africa and stresses that the United States should “continue to build partnerships in Africa . . . even as we provide assistance to countries suffering from poor governance, economic distress, health, and food insecurity exacerbated by the pandemic.”11
In response to the pandemic, the United States allocated $20.5 billion for the development of vaccines and therapeutics, preparedness efforts, and other foreign assistance. Additionally, the U.S. Government allocated more than $1.6 billion in Department of State and U.S. Agency for International Development (USAID) emergency health, humanitarian, economic, and development assistance aimed at helping governments, international organizations, and nongovernmental organizations fight the pandemic.12 In alignment with the INSSG, 30 percent of U.S. global funding aid for COVID-19 was directed to Africa, including Ethiopia, Nigeria, South Sudan, and Sudan, and approximately $500 million was allocated to Africa to respond to the global pandemic. Although less publicized than China’s efforts, American private businesses, nonprofit groups, charitable organizations, faith-based organizations, and individuals provided more than $4.9 billion in donations and assistance globally for COVID-19 response—more than any other nation.13
Working in collaboration with other governmental, nongovernmental, and international organizations, USAFRICOM strove to maintain security; provide logistical support for food, medicine, and other commodities; maintain communications; and provide augmented medical care.14 USAFRICOM contributed to the building of several United Nations (UN) hospitals and field hospitals. To date, USAFRICOM has provided COVID-19 assistance to 43 countries, including the delivery of nearly $500 million in medical supplies.15 Despite these efforts, the initial response by the United States was seen as less successful in the public eye. In that same Pew survey of 13 advanced economies, 15 percent of those surveyed thought the United States had done a good job of handling the pandemic, while 85 percent had a negative or neutral view.16
USAFRICOM and Continued Health Diplomacy
Without additional U.S. engagement and leadership in the healthcare realm to serve as a counterpoint to China, U.S. influence in Africa will continue to diminish and lead to significant political instability, dramatic humanitarian challenges, and an erosion of U.S. influence on the world stage. Former UN Ambassador and current administrator of USAID Samantha Power argued that “the coronavirus pandemic provided just such an opening. By spearheading global vaccine distribution, the United States could beat China at the biggest soft-power contest in generations, regain its reputation as the world’s ‘indispensable’ nation and, not incidentally . . . do good.”17
Global health diplomacy will continue to be a crucial tool for U.S. foreign policy and will need to be a key effort of USAFRICOM’s operational and strategic approach. To effectively counter Chinese health diplomacy efforts, USAFRICOM must first recognize a key component of the INSSG: an emphasis on the need to strengthen health diplomacy to combat instability in Africa.18 While certainly one must be wary, the United States and USAFRICOM should recognize that not all Chinese aid is necessarily counterproductive to stated U.S. objectives and should look for opportunities to cooperate and not undermine compatible Chinese efforts.
USAFRICOM must be able to support partner nations with better alternatives and products. A recent example of USAFRICOM’s use of partnerships to build partner capacity is Obangame Express, an annual naval exercise including the United States and multiple West African nations. Part of the exercise focused on training for and preventing outbreaks onboard ships.19 While large responses will be necessary, dedicated small engagements such as Obangame Express, which bring multiple nations together to work toward a common utilitarian good, can not only help prevent a health emergency but also provide that qualitative difference for our African partners. The United States has developed logistics capability, training, communications, and command and control over decades of partnership with African nations. It is in these areas that the United States and USAFRICOM have a distinct advantage and must look to leverage and align to a broader health strategy. JFQ
1 Interim National Security Strategic Guidance (Washington, DC: The White House, March 2021), 10–11.
2 Tang Bei, “A Brief History of Chinese ‘Health Diplomacy,’” Sixth Tone, May 20, 2020, available at <https://www.sixthtone.com/news/1005687/a-brief-history-of-chinese-health-diplomacy>.
3 J. Sun and J.L. Hou, “Management of Chronic Hepatitis B: Experience from China,” Journal of Viral Hepatitis 17, suppl. 1 (March 2010), available at <https://doi.org/10.1111/j.1365-2893.2010.01274.x>.
4 Benjamin Tze Ern Ho, “China’s Strategic Objectives in a Post COVID-19 World,” PRISM 9, no. 1 (October 2020), available at <https://ndupress.ndu.edu/Portals/68/
5 Priya Gauttam, Bawa Singh, and Jaspal Kaur, “COVID-19 and Chinese Global Health Diplomacy: Geopolitical Opportunity for China’s Hegemony?” Millennial Asia 11, no. 3 (2020), 318–340, available at <https://doi.org/10.1177/0976399620959771>.
6 Lennart DoDoo, “Medical Diplomacy to Face the Global Health Challenges: A Case Study of COVID 19,” Front Page Africa (Monrovia), March 23, 2020, available at <https://frontpageafricaonline.com/opinion/commentary/medical-diplomacy-to-face-the-global-health-challenges-a-case-study-of-covid-19/>.
7 Ho, “China’s Strategic Objectives in a Post COVID-19 World.”
8 R. Maxwell Bone and Ferdinando Cinotto, “China’s Multifaceted COVID-19 Diplomacy Across Africa,” The Diplomat, November 2, 2020, available at <https://thediplomat.com/2020/11/chinas-multifaceted-covid-19-diplomacy-across-africa/>.
10 Richard Wike, Janell Fetterolf, and Mara Mordecai, U.S. Image Plummets Internationally as Most Say Country Has Handled Coronavirus Badly (Washington, DC: Pew Research Center, September 15, 2020).
11 Interim National Security Strategic Guidance, 11.
12 “Ebola: From Recovery to Self-Reliance,” U.S. Agency for International Development, April 16, 2021, available at <https://www.usaid.gov/ebola>.
13 Wike, Fetterolf, and Mordecai, U.S. Image Plummets Internationally.
15 General Stephen J. Townsend, USA, Commander, U.S. Africa Command, Statement Before the House Armed Services Committee, Africa: Securing U.S. Interests, Preserving Strategic Options, 117th Cong., 1st sess., April 20, 2021, available at <https://www.africom.mil/document/33691/usafricom-statement-for-record-hasc-20-apr-2021-gen-townsendpdf>.
16 Wike, Fetterolf, and Mordecai, U.S. Image Plummets Internationally.
17 Karen DeYoung, “Samantha Power Wants to Restore U.S. Prestige by Getting American-Made Vaccines ‘into Arms’ Around the World,” Washington Post, May 11, 2021.
18 Interim National Security Strategic Guidance, 10–11.
19 Townsend, Africa.