China’s Health Silk Road and the BRI Agenda in the Middle East

This piece is part of the series “All About China”—a journey into the history and diverse culture of China through short articles that shed light on the lasting imprint of China’s past encounters with the Islamic world as well as an exploration of the increasingly vibrant and complex dynamics of contemporary Sino-Middle Eastern relations. Read more ...

Health diplomacy, which entails the use of diplomatic and other tools of statecraft for the dual purpose of improving health and enhancing relations among nations,[1] has long been an instrument of China’s international engagement.[2] Beginning in the early 1960s, China deployed teams of doctors, nurses, and health workers to provide clinical care in developing countries, mainly in Africa,[3] with the explicitly articulated aim of furthering political solidarity.[4]

The severe acute respiratory syndrome (SARS) outbreak in 2003, which highlighted weaknesses in China’s ability to detect and respond to public health threats, catalyzed the development of the country’s modern health system.[5] It also set China on a path toward a more proactive stance in global health diplomacy and a scaling up of its provision of development assistance for health (DAH).[6] This trend has accelerated since the launch of the Belt and Road Initiative (BRI) in 2013 and especially since the COVID-19 outbreak.

The BRI, whose remit is primarily economic, has expanded to encompass the health as well as the space and digital domains.[7] In the midst of the COVID-19 pandemic, with great-power competition stiffening, the Belt and Road facing challenges, and a reputation damaged by the early handling of the Coronavirus, Beijing has placed global health diplomacy at the service of recasting China’s image as that of a responsible and resourceful leader.

During the pandemic era, the Health Silk Road (HSR), interlinked with the Digital Silk Road (DSR), has emerged as a vehicle for powering the nascent third phase of the BRI, which has retained its prominence as a “major platform” for international development cooperation.[8] This development is evident in China’s involvement in the Middle East and North Africa (MENA) region.

China’s Health Silk Road (HSR) and the BRI Agenda

Prior to the onset of the COVID-10 pandemic, the BRI had evolved in two phases: an initiation phase focused on publicly financed physical infrastructure projects; and a readjustment phase begun in 2019, which promised “high quality development cooperation” and an upgrading of corridor connectivity through an expansion into technology.[9] The development of the Health Silk Road has roughly followed the arc of the BRI’s evolution.

The HSR, first mentioned in a speech delivered by President Xi Jinping in 2016 in Uzbekistan,[10] can be traced back to the framework document “Vision And Actions On Jointly Building Silk Road Economic Belt And 21st-Century Maritime Silk Road” issued in March 2015, which listed eight priority areas for health cooperation with BRI countries:

• Securing political support for health cooperation
• Epidemic information sharing
• Exchange of prevention and treatment technologies
• Training of medical professionals
• Capacity-building to address public health emergencies
• Institutionalization of the provision of medical assistance and emergency medical aid
• Expansion of cooperation on traditional medicine.
• Exploring the potential of healthcare industry collaboration[11]

Nine months after the release of this document, China’s then-National Health and Family Planning Commission (now the National Health Commission, or NHC) rolled out a three-stage implementation plan (2015-2017, 2017/2020-2022, and 2020-2030) featuring a wide range of projects and activities to promote the development of health and safeguard health security on the Silk Road.[12]

The Chinese government subsequently took various steps to broaden and invigorate health diplomacy. Among them, in January 2017 China and the World Health Organization (WHO) signed a Memorandum of Understanding (MoU) on Health Sector Cooperation under the BRI.[13] Later that year, China hosted a high-profile conference of senior health officials from 30 countries and representatives from a number of international health organizations that culminated in the adoption of a joint communiqué laying out the lines of effort to strengthen health cooperation under the BRI.[14] Seeking to institutionalize health cooperation within the HSR framework, Beijing also organized and sponsored numerous health-themed plurilateral forums.[15]

Here it is important to mention that the Health Silk Road, like the BRI to which it is tied, is a highly adaptive endeavor — an overarching concept rather than a detailed blueprint. Activities branded as HSR initiatives have built upon China’s existing health diplomacy practices and have been merged with domestic health policy measures, notably the Healthy China 2030 campaign.[16] However, with the onset of the COVID-19 pandemic, Beijing’s health diplomacy acquired a prominence and urgency that it had not previously achieved, in turn, elevating the importance of the HSR as a vehicle for pursuing health cooperation along the Belt and Road.

China’s Health Silk Road and the Covid-19 Pandemic

The COVID-19 era constitutes a nascent third phase in the development of the BRI featuring a revitalized Health Silk Road. Since the COVID outbreak, the Chinese response to the pandemic has proceeded along several tracks, beginning in March 2020 with a massive medical aid operation designed to assist countries struggling to deal with the disease.[17] Nearly every country in the world received some form of assistance from China to combat COVID-19.[18] However, the scope of the Chinese response to the pandemic expanded well beyond so-called “mask diplomacy” as Beijing moved to convert the crisis into an opportunity to reframe the BRI and to enhance the role of health diplomacy in advancing China’s place in the world.

The pandemic has ushered in new aspirational slogans, such as the expression “community of common health for mankind,” which has come to enjoy wider currency than “Health Silk Road” in Chinese officials’ public statements and in official documents. Claiming the spotlight at the 73rd World Health Assembly video conference in May 2020, Xi Jinping deployed his concept of a “shared future for the people of the world to work as one.”[19] A white paper on China’s fight against COVID-19 issued by the State Council the next month contains an entire chapter on “Building a Global Community of Health for All.”[20]

The pandemic has also led to a shift away from the BRI’s singular focus on capital-intensive infrastructure projects towards a heightened emphasis on the management and operation of medical facilities; the production of medical equipment for diagnoses and treatments; the provision of healthcare services; and the manufacture of pharmaceuticals and vaccines. In this way the nascent BRI 3.0 incorporates measures aimed at interlinking the Health Silk Road (HSR) and the Digital Silk Road (DSR).

In addition, the pandemic has presented an opportunity whereby Beijing, through practicing “vaccine diplomacy,” has sought to advance its long-term diplomatic as well as economic interests. Having cast vaccines as international public goods (IPGs) and stepped in to fill the ‘leadership vacuum,’ [21] China has taken steps to localize production in developing countries as a means of ‘bridging the immunization gap.’ [22] Here, it is important to emphasize that China has undertaken this effort at a time when outbound investment and contract activities along the BRI have declined.[23] It has also come at a time when Beijing has sought to boost the commercial prospects of the biotech sector, which is identified as a “strategic emerging industry” in the 14th Five Year Plan covering the years 2021-2025.[24] Thus, China’s vaccine diplomacy can best be described as a “mixed model of business and politics”[25] that is employed in accordance with Beijing’s “Going Out” strategy and links overseas aid with investment opportunity.

China’s Health Silk Road and the MENA Region in the COVID-19 Era

Chinese health diplomacy in the Middle East and North Africa (MENA) region, which has deep historical roots,[26] has broadened and deepened since the inception of the BRI. Plurilateral dialogues with MENA countries on health-related issues, for example, are now staple features of the China-Arab States Cooperation Forum (CASCF) and the Forum on China-African Cooperation (FOCAC).[27] Indeed, health cooperation has become a strategic element of China’s engagement with MENA countries, as Beijing has sought to employ the Health Silk Road for the purpose of adapting the BRI to the COVID-19 pandemic and thereby strengthening China’s foothold in the region.

Much as elsewhere across the Global South, China has deployed “mask diplomacy” and “vaccine diplomacy” throughout the MENA region during the pandemic.[28] Having been the first country to be struck by the virus, China was well positioned to dispatch medical teams, and provide shipments of medical supplies — some as donations (e.g., to Jordan, Iran, Lebanon, and Palestine[29]) and others for purchase (e.g., to Saudi Arabia and UAE[30]) — to MENA countries.  

It is worth noting that the commercial exports of Chinese medical supplies to the region during the pandemic have included not simply hospital masks and gowns but various medical devices, thermal cameras, diagnostic imaging systems, drones, and video teleconferencing (VTC) systems. China’s use, repurposing, and sale of such technology to MENA and other partners might well pay off as Chinese companies seek to grow their market share.

But it is vaccine diplomacy that perhaps best exemplifies China’s effort to link health cooperation to broader economic cooperation in the MENA region under the BRI framework. China, the world’s leading exporter of vaccines[31] — provided through donations and commercial partnerships — has found the MENA region to be a welcoming market for its vaccine supply and licensing campaign.[32] In December 2020, the United Arab Emirates (UAE) and Bahrain were the first countries to approve a Chinese coronavirus vaccine. Turkey, Iran, and Morocco have emerged among the top takers of the 110 countries where Sinopharm and Sinovac vaccines have been administered since then.[33]

Building on the success of its vaccine exports, China has established four joint vaccine production hubs in the MENA region: in Algeria, Morocco, Egypt, and the UAE.[34] It is not a coincidence that all four are critical nodes along the BRI. Neither is it surprising that Chinese biotech companies have their sights set on building their vaccine portfolios and expanding their market reach in, and from these very locations. In Morocco, for example, China’s Walvax Biotech Co. is selling a vaccine against childhood pneumonia. In Egypt, Sinovac is developing a portfolio of vaccines including for polio and chicken pox.[35]

The joint vaccine production operations underway in the MENA region, it should be emphasized, represent a marriage of commercial ambitions between China and its regional partners. In the longer term, Morocco intends to produce and develop vaccines for pathologies other than COVID-19.[36] Algeria’s partnership with Sinovac aims at meeting domestic vaccine demand and exporting the surplus.[37] Egypt’s state-run Holding Company for Biological Products and Vaccines (VACSERA), keen to tap into the African market, has ramped up production of the Sinovac vaccine.[38]

Similarly, the collaboration between Sinopharm and Abu Dhabi’s G42 to produce the Hayat-Vax COVID-19 vaccine has paved the way for more ambitious undertakings. With the production facility currently under construction in the Khalifa Industrial Zone of Abu Dhabi (KIZAD),[39] the cornerstone is being laid for Dubai’s Vaccine Logistics Alliance (VLA) — composed of Emirates SkyCargo, Dubai Airports, DP World, and International Humanitarian City — for expedited global vaccine distribution to developing countries.[40]

Conclusion

The Belt and Road is an infrastructure ecosystem within which health diplomacy has become a more salient feature since the COVID-19 outbreak. Beijing’s efforts to invigorate the Health Silk Road during the pandemic have been driven by political and economic considerations. In political terms, they have served to repair and enhance China’s reputation as a responsible and resourceful member of the international community; to reaffirm the importance of and showcase its commitment to South-South cooperation; and to capitalize on the shortcomings of Western countries’ covid responses for the purpose of cementing its position as a global health leader.[41] In addition, China’s health diplomacy during the pandemic has functioned as a vehicle for generating commercial gains and providing market access for Chinese firms along the BRI.[42]

China’s health diplomacy in the Middle East and North Africa during the pandemic has reflected these two sets of considerations and has been grafted onto its multifaceted and extensive relationships in the region. Beijing’s soft-power campaign of copious Arabic-language messaging[43] and aid deliveries to MENA countries appears to have inoculated it against heightened scrutiny and public criticism associated with its initial mishandling of the COVID-19 outbreak. And Beijing’s promotion of the Health Silk Road through mask and vaccine diplomacy has filled a gap left by Western countries and donors. As a result, Chinese med-tech and biotech companies are well positioned to forge partnerships that could enable them to expand their presence within and beyond the MENA region in the post-pandemic era.