By Christopher Foran
China remains a formidable competitor to the U.S. and its allies. However, recent cracks in China’s seemingly indomitable veneer, including a demographic crisis, a stalled economy, and a troublesome COVID-19 policy, leave open the possibility that the tools of diplomacy may still be deployed to deter China from using force to realize its geopolitical goals. To affect China’s risk-benefit calculation for armed conflict, there must be a clear, insurmountable advantage in a U.S.-led economic and military coalition compared with what China can reasonably expect to assemble. The U.S.’s ability to achieve and maintain this advantage is far from certain. Robust medical diplomacy is an effective instrument of soft power that cannot be overlooked by the U.S. as it works to realize this coalition.
With the Quadrilateral Security Dialogue (QUAD), the trilateral security pact between Australia, the United Kingdom, and the United States (AUKUS), and the Indo-Pacific Strategy, the U.S. has taken deliberate steps towards reaffirming dynamic alliances in the Indo-Pacific. But while the U.S. has consolidated its position in the Pacific, China has responded in-kind by increasing its footprint in Latin America. The COVID-19 global health crisis offered China a unique opportunity to deploy its version of medical diplomacy and expand its intended coalition into the western hemisphere. China’s successes and failures in this endeavor are instructive for future U.S. medical diplomacy in the region and warn against U.S. hubris and complacency with its hemispheric relationships.
By the start of the COVID-19 pandemic, China had already successfully targeted multiple Latin American nations as beneficiaries of its Belt and Road Initiative. In March 2020, Chinese President Xi Jinping announced that COVID-19 relief would factor heavily into building a “Health Silk Road,”; a healthcare-based complement to China’s Belt and Road Initiative. China aggressively deployed pandemic relief worldwide to establish itself as a viable alternative to the U.S. as the world leader in humanitarian global health initiatives. In Latin America, national leaders understandably sought to exploit the growing Sino-U.S. competition to their advantage during the early days of the pandemic by lobbying both powers for COVID-19 support. China responded first, delivering PPE and later vaccines to the region much sooner than the U.S. China initially received positive press while simultaneously allowing a narrative of “vaccine hoarding” by the wealthy U.S. to flourish in Latin America.
The Chinese made sure that the vast majority of their vaccine deliveries to Latin America came from direct bilateral agreements, many requiring public displays of gratitude from the receiving nation. China remained the principal source of vaccine deliveries to Latin America until the latter half of 2021, leading media outlets to report on disillusionment towards the U.S. among Latin Americans. The U.S. response was slower, needing to overcome the inertia of vaccine nationalism, and came primarily through more opaque multilateral efforts such as COVAX. While the U.S. quickly became far and away the leading financial and vaccine donation benefactor for COVAX, through which tens of millions of vaccine donations arrived in Latin America, the U.S. could not negate China’s shrewd public relations victories in the region. As Senator Robert Menendez of the U.S. Senate Committee on Foreign Relations lamented: “We failed. China was in there. They got the goodwill, and we failed.”
As China decisively outpaced the U.S. in vaccine distribution to Latin America in early 2021, it also enjoyed tangible diplomatic wins. After a period of staunch resistance, Brazil suddenly allowed the Chinese company Huawei to participate in constructing Brazil’s valuable 5G infrastructure. Nicaragua cut diplomatic ties with Taiwan after receiving one million COVID-19 vaccines from China.
But after winning the initial sprint on vaccine diplomacy in Latin America, China committed critical errors that halted its political progress. The first error was one of heavy-handedness in its diplomatic overtures, which proved overtly quid pro quo. While this strategy worked to effect in Brazil and Nicaragua, other Latin American nations such as Paraguay and Honduras publicly balked at Chinese demands to reverse diplomatic recognition of Taiwan in exchange for vaccines. Additional reporting on the matter demonstrated that Latin American nations which had previously severed ties with Taiwan quickly received vaccine distributions from China. At the same time, countries that maintained relations with Taiwan, such as Guatemala, did not. Further analysis of Chinese vaccine distribution demonstrated that in 2021, 96% of Chinese vaccines sent abroad were sold rather than donated. In a region experiencing record death tolls due to COVID-19, China selling aid with strings clearly attached proved detrimental to its broader goal of being recognized worldwide as a benevolent leader in global health and human security.
The second error undermining China’s broader political goals in Latin America was questionable vaccine efficacy. China’s use of inactivated virus rather than mRNA-derived technology, the technique utilized by Western manufacturers to generate its vaccines, resulted in a measurably less effective product. This led to increased skepticism about the choice laid before Latin American nations to accept Chinese over Western vaccine aid. This skepticism reached the individual Latin American citizen. A study published in the journal Nature found that among those reluctant to accept vaccination in Latin America, respondents were 20% less likely to accept a Chinese or Russian-manufactured vaccine and more likely to prefer a Western-manufactured vaccine because of safety concerns and “in the case of the Sinovac vaccine, would distrust their governments’ motives when inoculating with this particular vaccine.” To sway popular opinion in Latin America, China dangled an inferior carrot, and perhaps the carrot appeared more like a stick.
The U.S. erred in its conduct of medical diplomacy early in the pandemic. The Trump Administration famously refused to participate in COVAX and took steps to leave the World Health Organization, leading many in the global health community to see the U.S. as an unreliable partner in global health. This short-sighted approach created a leadership vacuum within the hemisphere that China enthusiastically exploited. Fortunately, the Biden administration quickly reversed the Trump-era policy in early 2021, and the U.S. soon became the leading financial supporter of the COVAX initiative. By September 2021, UNICEF confirmed that the U.S. was the largest donor of vaccines globally, more than tripling the number of vaccines donated by China.
Despite this late recovery, the U.S. must take a hard, sober look at its early failures and China’s later failures during COVID-19 to inform its future medical diplomacy policy. China’s aggressive and purposeful actions in Latin America during the pandemic netted only modest gains but heralded continued Chinese engagement in the western hemisphere.
The lessons learned can be summarized in a simple axiom: be first, be generous, and be effective. The U.S. must better balance multilateral versus direct bilateral humanitarian aid agreements to avoid the mistake of appearing aloof, selfish, and uncaring to our Latin American neighbors. Nationalist or isolationist sentiment cannot be allowed to leak into its humanitarian aid policy in regions where China seeks to make diplomatic inroads. Finally, the U.S. must avoid inelegant quid pro quo by being transparent and restrained in its use of medical diplomacy to elicit specific political outcomes in Latin America.
In the effort to build a daunting enough coalition to dissuade China from potentially disastrous military action, every device of soft power must be leveraged to its maximum effect. The financial cost to the U.S. of high-impact humanitarian aid pales in comparison to the cost of a shooting war with a near-peer power. It would be a grave mistake for the U.S. to ever cede the medical diplomacy contest again in its own backyard to its chief geopolitical rival.
Christopher Foran, MD, is a second-year M.S. Candidate at the School of Diplomacy and International Relations at Seton Hall University, specializing in Global Health and Conflict Resolution. He is the Senior Associate Editor for the Journal of Diplomacy and International Relations. Christopher completed his bachelor’s degree at Temple University in Spanish Language and Literature and completed his medical doctorate at Jefferson Medical College. Christopher is a practicing board-certified general surgeon. This is his third piece published with the Journal. The views expressed in this article are solely those of the author in his private capacity as a student of Seton Hall University and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, nor the United States Government.