Emerging issues in international health governance: a Chinese view

Covid-19 offers an opportunity for rethinking the topic of China and global health governance. This paper first draws attention to the notion of “global health” by offering a brief contour of China’s contributions to solve the world’s health burden throughout modern history. The author argues that it may be wise for both developed and developing countries to view global health less as an extension of development aid and more as a public good. Assurance of health as a public good necessitates equity-based contributions by all. The paper then touches upon the renewed interest in linking health provision and national security, which pitches China as a competitor against established health industry leaders like the United States. International harmonization of the rules of trade in health products for emergency responses and the negative spillover effects produced on health provision by economic sanctions deserve continuous research attention.

 

Without a doubt, Covid-19 qualifies as a harbinger of new approaches to global governance in search of enhanced health security for humans, animals, and the environment. The ongoing pandemic will eventually end, either by the expiration of the pathogen’s lethality or by effective intervention by governments and societies around the world, but issues about China and global health merit continuous research attention.

The term “global health” started to gain currency in the 1970s, as an extension of the concern about global population problems. For decades, “global health” was part of developed countries’ broader development aid strategy, to improve health conditions in countries needing economic development.

China was among the states that founded the World Health Organization and restored its membership in 1972. Since the 1970s, China has been a beneficiary of international health and economic development agencies, as well as of government aids by developed economies. This, coupled with China’s drive for poverty elimination, helped to quickly improve the health of the population. Chinese life expectancy at birth increased from nearly 60 in 1970 to 77 in 2018, according to World Bank statistics.

The outbreak of the acute respiratory syndrome (SARS) in China in 2002- 2003 caught many Western nations off guard as, until that moment, they had considered themselves immune to epidemics. This has led some scholars of international public health to label SARS a “post-Westphalian pathogen”, to highlight that conventional reliance on and emphasis of the sovereign state as the primary actor to address global issues is no longer adequate.[1]

Such framing implies that China, in spite of the help received, failed to protect the West from the migration of deadly viruses. Similar sentiments populate the commentaries about the Covid-19 pandemic, with China increasingly seen as a burden on global health.

Yet, throughout modern history, China has contributed to global health solutions. For instance, the identification of the Yersinia Pestis bacteria out of the treatment of the 1894 plague in Hong Kong was a major success in Western medical science. But China’s organization of an international conference in 1911, in the wake of the northern Manchurian plague, helped to spread medical knowledge, including the utility of face masks.

Between 1850 and 1950, China played a role in the emerging global biomedicine industry, amid its incessant wars, revolutions and famine. The conventional question of whether medical ideas and institutions created in the West were successfully transferred to China is inadequate. International exchange and cooperation are crucial in achieving breakthroughs in epidemic control and the treatment of non-communicable diseases.[2]

Typically, Chinese studying medical sciences went to universities in the West. But also, Western physicians and medical researchers came to China in search of effective treatments. Even when China was under an economic blockade in the wake of the Korean war, doctors from abroad came to China in search of treatments for such diseases as schistosomiasis, which was described by Mao Zedong as “the God of plague”.

A more contemporary example of China’s contribution to global health is the internationalization of an inexpensive live attenuated vaccine against a strain of encephalitis common in Asian children. Developed and approved for use in China in the 1980s, it attracted interest from the US. After 15 years of collaboration between American and Chinese vaccine developers, the product passed World Health Organization’s (WHO) prequalification in 2013 and became available for adoption outside China. Three more Chinese vaccines have acquired WHO’s prequalification status, with more in the pipeline.[3]

The Nobel Prize in Physiology or Medicine in 2015 was shared by a team of Chinese scientists led by Tou Youyou, who found a way to extract artemisinin, used to treat malaria, from a plant (qinghaosu) used in traditional Chinese herb-based medicine. As a matter of fact, China is a major manufacturer of artemisinin and its derivatives, with an integrated industry encompassing the planting, exaction, research and development (R&D), drug production, and commercialization of Artemisia annua. In 2011, Guilin Pharmaceutical became the first WHO-prequalified pharmaceutical company worldwide to produce intravenous artesunate. This came after five years of training offered by an international malaria drug alliance.[4]

In one sense, China’s public health achievements affirm the value in seeing “global health” as part of Western development aid. In another sense, China’s help, especially to the Global South, should be viewed as enlarging the pie of health provision.

To promote further cooperation through agencies like the WHO, it would be useful to end their politicization. The organization, like many other specialized United Nations agencies, relies on funding from member states, with the United States being by far its largest contributor, given that fees are assessed on per capita income. Voluntary contributions from multinational pharmaceutical corporations enlarge the WHO’s operating budget. The Chinese government and the country’s health business corporations can and should make a larger monetary contribution to the WHO. Just as importantly, China should work with the WHO and help more countries reap the same public health benefits it has achieved.

Likewise, the Chinese vision of a “Health Silk Road” should not be dismissed as a geopolitical ploy. As no one can predict from where the next deadly pathogen may emerge, disease prevention is as crucial as treatment. Indeed, it would be wise for developed and developing countries to view global health less as an extension of development aid, and more as a public good. Assurance of health as a public good necessitates investment in improvement of public health on the domestic front and contributions to international collaboration on disease prevention and treatment. Such rethinking ought to lead to a renewed impetus for global health cooperation among countries rich and poor, particularly in times of a pandemic.

Over the years, China has emerged as a major healthcare market, considered the second largest after the United States in terms of market transactions. Since the 1980s, international pharmaceutical and medical device firms relocated production to China to take advantage of lower labor costs in production and to serve the needs of the local population more efficiently. One account reports China to have “provided 43 percent of world imports of face shields, protective garments, mouth-nose-protection equipment, gloves, and goggles in 2018”, the year before the outbreak of Covid-19.[5]

In the early months of the Chinese response to the spread of Covid-19, some of the world’s personal protective equipment (PPE) inventory was sold and donated to meet the sudden surge in Chinese demand. Disruptions to cargo transportation, resulting from government curtailment to interrupt the spread of the virus through human and cargo traffic, also complicated the functioning of supply chains. The Chinese government responded by investing in massive production of PPE. As the supply shortage of PPE within China became less acute, China began to export it.

Meanwhile, the deployment of PPE products in other countries needed to be approved through emergency authorizations by regulatory agencies, which must deal with a complex web of international, regional, and country standards. China’s role as a supplier became controversial. Criticism surrounding China’s practice of “mask diplomacy” is partly attributable to incompatibilities of technical standards. This criticism is also a reflection of the dividing lines between those who advocate for engagement with China and those calling for its containment. But the truly systematic challenge is for all major producing economies to harmonize the rules surrounding technical standards and the transfer of medicine and health-related products, particularly during an international health crisis. Such harmonization, coupled with the stockpiling of essential supplies, would enhance countries’ capacity of withstanding health supply shocks.

With the renewal of heightened geostrategic competition between China and the United States, the prospect of spillover effects on public health deserves discussion as well. Under the Trump administration, the dynamics of cooperation between the centers of disease control and prevention of the two countries, which strengthened in the wake of the SARS epidemic in parts of China in 2002-2003, came to a halt. Health cooperation with China was viewed as a loss because it supposedly assisted China to become a more capable rival to American power, influence, and status. This situation openly challenges the logic of international health as providing mutual protection and improving countries’ national security.

Pharmaceutical products and medical equipment have thus far been spared from the United States’ sanctions against China. Nor have Chinese corporations of medicine and health care equipment been put on American “entity lists” and, therefore, become subject to sanctions. But China has good reasons to be worried about the future prospect of adversarial economic sanctions by the United States, especially since the punitive regime can easily gain a life of its own once set in motion.[6]

Biotechnology is already a contentious area of competition between China and the United States and other industrialized economies. In “Made in China 2025,” an initiative that already caused international protest and opposition, biomedicine and bio-based materials are specifically considered parts of advanced manufacturing. With the United States working to constrain Chinese access to advanced semiconductors, including through secondary sanctions on suppliers of non-U.S. origin, adverse impact on Chinese progress in biomedicine manufacturing is an almost certain side effect.

Studies of public health consequences from economic sanctions, including those designed with humanitarian exemptions (usually food, medicine, and medical supplies), show that economic coercion might still inadvertently harm the physical well-being of civilians.[7] Whereas China is far more developed and resourceful in withstanding the effects of economic sanctions compared to countries like Cuba, Haiti, Iran, and Iraq — all traditional targets of economic sanctions by the United States — it cannot expect to escape international restrictions on the purchase of medical equipment and pharmaceutical products and their damage to its health infrastructure.

A causal link between a country’s access to advanced technology abroad and change in its public health situation is difficult to establish short of medicine and/or medical equipment being specifically included in economic sanctions. However, a lesson that ought to be drawn from the global spread of Covid-19 is that health effects from economic sanctions should no longer be viewed as an unintended and unavoidable consequence. Scholars of international studies should draw insights from how Covid-19 generated emergencies over PPE to assess international connectivity in standards and quality control and promote competition through innovation, regardless of the origin of an invention or a health product.

Admittedly, this commentary is by and large China-centric. Indeed, avoidance of unintended negative consequences on public health will depend as much on input from China as from other countries. It is therefore essential to consider these and other issues at the operational level of global health security, rather than abstractly discussing competition over vaguely defined national interests. When it comes to public health, identification of a country’s national interests must be based on the expert input from health professionals, instead of grand theorization about future events given the ongoing trends of geostrategic competition among major countries.


References

[1] Fidler, D.P. (2003) “SARS: political pathology of the first post-Westphalian pathogen”, The Journal of Law, Medicine & Ethics, 31(4): 485-505.

[2] Luesink, D., et al. (2019) China and the Globalization of Biomedicine, University of Rochester Press.

[3] Stevenson, M. (2018) “Geneva- Seattle collaboration in support of developing country vaccine manufacturing”, Global Public Health, 13(4): 426-44.

[4] Huang, Y., et al. (2016) “The production and exportation of artemisinin-derived drugs in China: current status and existing challenges”, Malaria Journal, 15(1): 365-373.

[5] Bown, C. (2020) “Covid-19: China’s exports of medical supplies provide a ray of hope”, Peterson Institute for International Economics, 26 March, available online

[6] Zha, D. (2021) “Non-traditional security and China-US relations”, Asian Perspective, 45(1): 75-81.

[7] Peksen, D. (2011) “Economic sanctions and human security: the public health effect of economic sanctions”, Foreign Policy Analysis, 7(3): 237-251.


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