Click here for a transcript of “We Need To Rethink Our Assumptions about China’s Strategic Goals”

Where China Was in the 1990s

Twenty years ago, the Chinese-Taiwan invasion plan was to take a couple of fishing vessels and paddle their way across the strait. In the 1990s, China had very limited, and often no ability to fly over water, or at night, or in weather, and their ships had no defenses.

For many, many years we knew that China was willing to fight if Taiwan declared independence. Fighting a war in any country that is big and resolved is problematic. But it was never the case that the United States was going to lose that war; it was always a matter of, “How many days?” How many days is it going to take us to win?

Where China Is Now

In the intervening years, China's military has changed both quantitatively and qualitatively. Now they have the largest navy in the world, and those ships are some of the most advanced surface ships that can be comparable to those of the United States. Same with their fighters; they have fifth generation airplanes and the largest airforce in the region. They’ve put all these capabilities online, and at the same time, they [have also] started developing capabilities to reach out and touch the United States with.

They developed the capability to hit moving ships at sea, which is something the United States doesn’t have the capability to do. They have a huge cruise and ballistic missile program that basically can take out a U.S. base like Kadena  in the region in a matter of hours, should they ever be willing to make a direct hit on the U.S.

This doesn't mean that China is more powerful than the United States; China still can’t project power outside the Indo-Pacific region, and even there it’s mostly through space, cyber, and nuclear weapons. But most of the contingencies we're talking about are really close to China, so it doesn’t really matter that they can’t project power. So, on the conventional side, I’m very concerned.

Why Taiwan Matters

The whole goal of the Communist Party, since its founding in 1949, has been to resolve this Taiwan issue.

Now they have the ships, the aircraft, and they’ve reorganized their whole military so that they can do joint operations, so that the navy and the air force can do an invasion of Taiwan. And a lot of those efforts came to a successful conclusion at the end of 2020. And that's why people like myself, not because of  the capabilities, but because when I was in Beijing and talked to the Chinese military and government officials, they said, “We could do this now, and maybe we should think about it.”

We know from behavioral economics that countries and people are much more willing to take risks to not lose something that they think is theirs, versus when they are trying to get something which they don't think is theirs. In the Chinese mindset, Taiwan, the South China Sea, East China Sea, etc. is already theirs, and the United States is trying to take it from them. That makes the situation even more problematic. 

What the United States Should Do

The Biden administration is doing a lot of political maneuvering to show that the United States is willing to defend Taiwan. And I think it’s just upsetting Beijing, because they think we’re changing the political status quo. It also does nothing to enhance our deterrence, because it doesn't signal anything about our capability to defend Taiwan.

The Chinese basically assume the United States will intervene. Their big question is, can they still win? We need to show China that they cannot win, and that’s about showing out capabilities in the region. It’s about aggressively negotiating new host arrangements, more access for the U.S. military, and new international institutions and treaties that constrain the ways China leverages power.

I'm a military person, but I'm totally on board with leading with diplomacy. But I don't see those types of efforts coming out of the Biden administration. They seem to want to double down and do the same things, just with more allies and partners.  I'm supportive of it, but I just don't think it's enough.

On October 21, 2021, the APARC China Program had the opportunity to host Peter Martin, Defense Policy and Intelligence Reporter for Bloomberg News, for a program on Chinese displomacy. In honor of his recently released book, China's Civilian Army: The Making of Wolf Warrior Diplomacy, Mr. Martin gave us a deep dive into the origins of this contentious diplomatic style and what it tells us about domestic politics in China. The panel was moderated by Professor Jean Oi, William Haas Professor of Chinese Politics and director of the APARC China Program.

As many who follow Chinese politics will be aware, Chinese diplomacy in the past several years has become increasingly assertive and its diplomats have used sharper language. Based on Chinese action movies of the same name, this pointed style of communication has earned these diplomats the title "wolf warriors." Some of the more stand-out examples of wolf warrior diplomacy include China’s Ministry of Foreign Affairs spokesperson Zhao Lijian's claim that COVID-19 was actually created by the United States, or the uncomfortable exchange between American and Chinese diplomats at the US-China Alaska summit in March, 2021.

In this program, Mr. Martin traced the roots of China's approach to diplomacy back to the communist revolution of 1949 and told the story of how it has evolved through social upheaval, famine, capitalist reforms, and China's rise to superpower status. His book draws on dozens of interviews and--for the first time--on the memoirs of more than 100 retired Chinese diplomats. The program was followed by a robust Q&A session between Mr. Martin and the audience. Watch now: 

For more information about China's Civilian Army: The Making of Wolf Warrior Diplomacy or to purchase a copy, please click here.

On October 6, 2021, the APARC China Program hosted the panel program, "Engaging China: Fifty Years of Sino-American Relations." In honor of her recently released book of the same title, Director of the Grassroots China Initiative Anne Thurston was joined by contributors Mary Bullock, President Emerita of Agnes Scott College; Thomas Fingar, Shorenstein APARC Fellow; and David M. Lampton, Professor Emeritus at Johns Hopkins School of Advanced International Studies (SAIS). Thomas Fingar also moderated the panel.

Recent years have seen the U.S.-China relationship rapidly deteriorate. Engaging China brings together leading China specialists—ranging from academics to NGO leaders to former government officials—to analyze the past, present, and future of U.S.-China relations.

During their panel, Bullock, Fingar, Lampton, and Thurston reflected upon the complex and multifaceted nature of American engagement with China since the waning days of Mao’s rule. What initially motivated U.S.’ rapprochement with China? Until recent years, what logic and processes have underpinned the U.S. foreign policy posture towards China? What were the gains and the missteps made during five decades of America’s engagement policy toward China? What is the significance of our rapidly deteriorating bilateral relations today? Watch now: 

For more information about Engaging China or to purchase a copy, please click here.

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Challenges for Primary Health Care Services

China, a large and rapidly developing middle-income country with a hospital-based service delivery system for its aging population, makes a suitable case study of efforts to promote PHC management. Over the past several decades, PHC use in China has significantly decreased relative to hospital-based care. This trend is a natural consequence of the country’s unprecedented increases in living standards and improvements in financial risk protection, which increase patients’ demand for quality care and spur self-referral to providers with higher-perceived quality like hospital outpatient departments.

The performance differences between PHC and hospital-based care are especially stark in China’s rural areas, where management of chronic diseases relies heavily on grassroots physicians, who have limited medical education and training. That is why Eggleston and her colleagues set out to provide new empirical evidence about the effectiveness of a program that promotes PHC management of hypertension and diabetes for rural Chinese. Part of the National Basic Public Health Service Program for rural Chinese, it financially rewards PHC grassroots physicians for managing residents with chronic diseases.

Collaborative Research in the Era of Great Power Competition

Eggleston’s co-authors include her colleagues at the Zhejiang Provincial Center for Disease Control and Prevention (Zhejiang CDC). Their study is the culmination of Eggleston’s multiyear collaborative research project with the Zhejiang CDC team, "Addressing Health Disparities in China," which looks to Tongxiang county in Zhejiang as a case study of China's responses to healthcare inequalities and population aging challenges in rural and urban areas. The project also involved two Stanford doctoral students who worked with Eggleston.

“This kind of collaboration, where we utilize the data that's available to answer an important question while respecting the privacy of the individuals and hopefully delivering benefits to them through more effective or affordable programs in the future perhaps is a promising model for researchers here and elsewhere to undertake,” she notes.

Disentangling the Effect of Primary Health Care Management

To study the program’s effectiveness, the researchers assembled a unique dataset linking individual-level administrative and health information between 2011 and 2015 for rural Chinese diagnosed with hypertension or diabetes in Tongxiang, a mostly rural county of Zhejiang province in southeast China. Collected by the Tongxiang CDC and Zhejiang CDC, the compiled database links basic demographic information, health insurance claims, PHC service logs, and health check-up records — four sets of data that are rarely linked and analyzed in combination in China healthcare research.

Targeting the program’s effects on healthcare utilization, spending, and health outcomes, Eggleston and her colleagues compare residents in neighboring villages that straddle township boundaries. These residents are similar in their individual and environmental characteristics that shape health care use but are subject to different PHC management practices. This “border sampling” allows the researchers to disentangle the effects of PHC management from other underlying spatial differences that impact health care utilization. For each township, the researchers use a management intensity index that reflects the cumulative efforts of PHC physicians to screen their communities and keep patients within the PHC management programs for controlling hypertension and diabetes. Each township’s experience with PHC management over the 5-year study period is thus a case study for rural China.

Net Value in Chronic Disease Management

The results are encouraging for China's investment in primary care management of chronic diseases. Eggleston and her colleagues find that patients residing in a village within a township with more intensive PHC management had a relative increase in PHC visits, fewer specialist visits, fewer hospital admissions, and lower spending compared to neighbors with less intensive management. They also tend to have better medication adherence and better health outcomes as measured by blood pressure control.

The results suggest that PHC chronic disease management in rural China improves net value in multiple ways — increasing PHC utilization, reducing avoidable hospitalizations, decreasing medical spending, and improving intermediate- and long-run health outcomes — all while leveraging existing resources rather than restricting care.

The findings also help inform investments in primary health care in LMICs. They highlight the latent potential of frontline healthcare workers in such settings to be more productive and show that financially rewarding these grassroots workers for managing residents with chronic diseases helps improve health outcomes. Moreover, they offer empirical evidence that supports the effectiveness of chronic disease management programs as part of broader regional initiatives to address population health.