PRC medical internationalism: From Cold War to Covid-19
While the outgoing Trump administration has for months consistently blamed China and Chinese people for the catastrophic disaster of the coronavirus pandemic in the United States, China has been endeavouring to position itself as a global health leader.
On the phone with Italian Prime Minister Giuseppe Conte on 16 March 2020, Chinese President Xi Jinping brought up Beijing’s initiative to build a ‘Health Silk Road’ (HSR) to facilitate international cooperation on pandemic control.
A signature component of this plan was China’s quick move to send expert teams with free medical supplies to Italy. Going beyond simply reciprocating the aid it had received from Europe when the pandemic broke out, China sent medical supplies to 82 countries in March alone, mostly to developing countries in Asia and Africa with which it has long had development ties.
These initial donations of medical supplies were followed by surging purchase orders from all over the world. Meanwhile, Chinese provinces were paired with some of the worst-hit countries, such as Italy and Iran, providing health experts and material assistance according to a model based on earlier experiences of bilateral health cooperation.
The HSR, a health dimension added to China’s Belt and Road Initiative (BRI), is not an entirely new concept. In 2015, China’s National Health and Family Planning Commission (NHFPC, formerly the Ministry of Health) laid out a three-year plan to promote health cooperation with Silk Road countries.
In 2017, the HSR became better known to the world when Beijing signed a communiqué aimed at advancing access to health care with more than 30 countries, WHO, UNAIDS, the GAVI Alliance, and the Global Fund.
Opposing views exist regarding the HSR initiative and its relation to an increasingly hegemonic China. Health policy observers welcome the inclusion of health in China’s BRI and its vision of strengthening national health systems and promoting universal health coverage through international cooperation.
Critics of the gigantic infrastructural development project, on the contrary, have been wary of the Chinese government’s attempt to pitch itself as a responsible global leader through commitment to global health development.
Whilst Covid-19 appears to be helping accelerate the timeline for China’s ambition to take the lead in multilateral health governance, the critics have further warned about China’s use of HSR as a means to ‘shape the post-pandemic world to its advantage.’
[C]ritics have further warned about China’s use of HSR as a means to ‘shape the post-pandemic world to its advantage.’
The vision of the HSR is no doubt a significant initiative in advancing global health. But it did not appear overnight as a rhetorical extension of the BRI, nor was it solely formulated on the geographies of trade routes. Some of its initiatives, such as the stationing of medical teams overseas, have been in place for more than 50 years.
The mechanism in which a province is paired with a country for aid operations in the current pandemic, for example, is a unique system developed during China’s earlier bilateral health aid to Africa.
If global health became officially identified as a key foreign policy objective by the Chinese government only in this decade, responding to doubts about the HSR requires a better understanding of its political history and technical evolution. In my view, the HSR should not be purely measured in 21st-century geopolitical terms when in fact it is the latest instalment of a long tradition of health diplomacy of the PRC.
My research examines an important pre-history of the HSR. It is a case study of the Chinese medical missions to Algeria, which spearheaded China’s medical aid programmes and set the pattern for its proud, but little-known, tradition of providing health care assistance to other developing countries (mainly in Africa).
It explores the history of China’s medical diplomacy and seeks to uncover China’s neglected role in the arena of Cold War international health. I examine what a globalising China has done as an international health actor, how Chinese health bureaucrats and medical professionals had implemented what was initially and essentially a political task in faraway locations, and with what local impact China’s medicine and health care model had gone global.
This little-studied history of the early years of the PRC’s engagement in international health will further our understanding of the contemporary policy’s formation, the institutional foundation for overseas health operations, and the role of Chinese medical professionals in the history of international health.
The neglected role of the PRC in international health
New research in recent years has started to challenge the singular emphasis on the hegemonic role of the Western world in medical interventions in postcolonial societies. A major trend in this new scholarship is to reappraise the place of the Soviet Union and the Socialist Bloc in Cold War international health.
The recently published new history of the World Health Organization critically examines the sudden exit of the Soviet Union and Eastern Europe from the WHO in 1949 and the subsequent dominance of U.S. interests in setting goals and designing programmes for the organisation.
In this context of split and rivalry between the two camps in international health politics, some pioneering historians of medicine and Cold War development studies have called attention to alternative solutions to health issues outside the framework of WHO and big NGOs like the Rockefeller Foundation, by either looking at the development projects of certain Eastern European countries in the Third World or health cooperation within the Soviet-led Socialist Bloc. An even more recent anthology enriches this scholarship by including Latin America as a battleground and active agent in Cold War international health.
China has been largely missing from these narratives of post-war international health despite the fact that diplomats of the Republic of China, like Dr Szeming Sze, had played a key role in the establishment of the WHO in 1945. After 1949, the PRC, often seen as a country in self-isolation, has not been considered to have a role in international health beyond its borders.
Scholarly attention has focused on its domestic rural health scheme—the ‘barefoot doctor’ system—as well as public health campaigns against infectious diseases such as schistosomiasis and malaria.
My research shows, however, that medical internationalism was important to China’s Cold War political manoeuvres and that China has been an active participant in medical interventions and an avid builder of alternative health solidarities in the Third World. Without the inclusion of the Chinese story, we cannot fully grasp the past of international health nor can we understand China’s revised commitment to global health today.
Without the inclusion of the Chinese story, we cannot fully grasp the past of international health nor can we understand China’s revised commitment to global health today.
‘Socialist’ medical missions to Algeria, 1963-1980s
In April 1963, in response to newly independent Algeria’s call for international health aid, China sent a medical team of 24 members to a rural province in the Saharan Atlas, in the north-western region of the country. Thereafter, a steady trickle of Chinese doctors and nurses followed suit, providing health services for rural and suburban communities in Algeria.
Chinese medical professionals soon expanded their care throughout the African continent along similar lines. Throughout the half-century that followed, more than 23,000 medical personnel travelled back and forth between China and Africa. Between 1963 and 1992, a total of 2,034 personnel were deployed to 15 hospitals in Algeria. Of these, 157 went twice and 6 for a third time.
The average duration of an overseas assignment was two years. The team members were selected, trained, and financed by the Ministry of Health and, when abroad, overseen by the office of the economic and commercial counsellor in the Chinese embassy.
When the Chinese government responded positively to Algeria’s request in 1963, Chinese leaders were keen to compete with the Soviet Union for African hearts and minds. After the Sino-Soviet split, they figured that the outcome of the struggle against the Soviet Union in Africa was crucial to the ultimate balance of power both in the world and in the Communist camp. Medical aid was taken as a means of building solidarity with Third World countries, and as a form of soft power that Mao hoped to extend to Africa.
Within this geopolitical framework, questions remain unanswered about on-the-ground practices. For example, what kind of health care experiments did the Chinese mission conduct in Algeria? How did China build global health networks outside the World Health Organization and the Soviet-led socialist health framework?
I have found that two features stood out in Chinese medical practices in Algeria over the first three decades. The first was a proactive approach to health care delivery. In contrast to medical teams from the Soviet Union and other socialist countries, the Chinese teams chose to be posted to hospitals in the hinterland to provide services to people who had difficulties accessing health care.
In addition, they sought their patients out instead of waiting for them to visit the hospital. Part of their manpower was allocated for mobile services for nearby rural areas. Such activities, inspired by the model of the ‘barefoot doctors’, sought to alleviate the problem of accessibility, addressing an underlying social determinant of health.
It is worth noting that although the Chinese teams provided rudimentary medical care in remote areas, the practitioners were mostly fully trained professionals—not ‘barefoot doctors’—from Hubei’s best reservoirs of medical personnel.
From the 1960s to the 1980s, many teams formed the sole source of medical authority in their designated hospitals. Each team was composed of specialists in diversified branches of medicine or with different focuses to address a wide range of medical concerns. Public health skills were not prioritised, although Chinese doctors did join their Algerian colleagues in efforts to control cholera outbreaks.
It was not until the 1990s that the coverage of their clinical services narrowed down to those specialties in short supply, such as obstetrics and gynaecology, orthopaedics, and acupuncture.
The second feature of China’s medical service in Algeria was the use of a body of hybrid and serviceable medical technology. The Chinese focus on practical technology contrasted sharply with both the Soviet and Western ideals, which insisted upon a correlation between technical advances and improvement of health.
This difference occurred in the first place due to China’s lack of capacity to operate on par with Western or Soviet technological prowess. China chose to target primary health care rather than eradicate single diseases (a vertical approach adopted by the WHO), and developed an emphasis on financial feasibility and efficiency. The use of traditional Chinese medicine, in particular acupuncture, in combination with biomedicine, was an illustrative example of this pragmatic and partly improvisational orientation.
Continuities and changes in the post-socialist era
Despite the fundamental overhaul of China’s domestic ideological orientation and economic policies from the late 1970s through the end of the Cold War, the mechanisms and practices of Chinese medical teams today remain largely unchanged, with the exception of rural mobile services. The Chinese government continues to sponsor this bilateral form of medical aid in a post-Cold War world where multilateral frameworks for international health are the norm.
While Algeria has developed the capacity to produce physicians and medical specialists, it continues to turn to China to supply doctors for laborious positions in remote areas where Algeria’s own doctors refuse to go. The high demand for Chinese OB-GYN specialists, anaesthesiologists, and acupuncturists in Algeria, for example, is a typical case of reliance on health care provided by China.
In China itself, however, the institutional base for socialist medicine has been largely dismantled. Since 1985, the Chinese government has increasingly reduced the state’s role in health care. It has withdrawn funding for hospitals, reduced subsidies to health care professionals, turned professionals into entrepreneurs in a cash nexus with patients, and reduced its control over the management of health care facilities.
Officials from provincial health bureaus complain about ‘unprecedented difficulties’ in recruiting doctors and managing medical teams. The Chinese medical aid programme finds itself today split between an internal market-driven reform and an outbound political imperative to provide socialist-style health care.
Still, the deployment of long-term medical teams abroad will remain an important component in China’s reconfigured global health initiative, the HSR. It is written into the abovementioned 2015 document of the NHFPC.
On the one hand, the long-established practice of sending medical professionals to serve local communities requires reforms to accommodate the new economic and political circumstances. On the other hand, the fact that the government insists on maintaining the programme speaks to the faith of Chinese leaders and health bureaucrats in its unique strengths to deliver health assistance to developing countries.
Toward a new global health governance
China’s solidarity-based medical internationalism over the past half century informs the design of the HSR. Its medical aid programmes in Africa that have outlived the socialist system and the Cold War will continue to act as a vehicle for China’s health solidarities to support health and medicine regionally and globally. Specifically, in our current era that sees the general failures of neoliberalism, primary health care principles like equity and state-sponsored care, which were enshrined in the Alma-Ata Declaration of ‘Health for All’ in 1978, are revamping contemporary global health practice.
The Chinese experience of medical interventions in Algeria and across the African continent becomes particularly fitting for understanding varied sources of influence on health and medicine as well as the health implications of the BRI.
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The views expressed in this forum are those of the individual authors and do not represent the views of the Asia Research Institute, National University of Singapore, or the institutions to which the authors are attached.
Dongxin Zou
Postdoctoral Fellow
Asia Research Institute