Modeling Health Outcomes Among East Asian Populations

The chronic progression to diabetes-related complications is apt for computer simulation modeling due to the long-term nature of health outcomes and the time lag for interventions to impact patient outcomes. It is problematic, however, to estimate the impacts of health interventions on East Asian populations with diabetes using existing models, which were developed and validated in European and North American populations with different epidemiology and outcomes.

To fill in this gap, Eggleston and her colleagues set out to develop and validate an outcomes model for the progression of diabetes and related complications in Chinese populations. They compared this new model, called the Chinese Hong Kong Integrated Modeling and Evaluation (CHIME), to two widely used existing models developed and validated in the United Kingdom (known as the United Kingdom Prospective Diabetes Study Outcomes Model 2, or UKPDS-OM2) and in the United States/Canada (called Risk Equations for Complications of type 2 Diabetes, or RECODe). Despite the continuum of risk across the spectrum of risk factor values, these two existing models ignore the progression from prediabetes to diabetes.

The CHIME integrates prediabetes and diabetes into a comprehensive model comprising 13 outcomes. These include mortality, micro- and macrovascular complications, and the development of diabetes. The researchers developed the CHIME simulation model using data from a population-based cohort of 97,628 participants in Hong Kong with type 2 diabetes (43.5%) or prediabetes (56.5%) from 2006 to 2017. Known as the Hong Kong Clinical Management System (CMS), this cohort makes one of the largest Chinese electronic health informatics systems with detailed clinical records. 

The next step was to externally validate the CHIME model against individual-level data from the China Health and Retirement Longitudinal Study (CHARLS) cohort (2011-2018), a nationally representative longitudinal cohort of middle-aged and elderly Chinese residents age 45 and older. The researchers validated the CHIME model against six outcomes measures recorded in the CHARLS data and an additional 80 endpoints from nine published trials of diabetes patients using simulated cohorts of 100,000 individuals.

Towards Reducing the Disease Burden of Diabetes

The researchers found that the CHIME model outperformed the widely used UKPDS-OM2 and RECODe models on the data used, meaning that the validation of the CHIME model was more accurate for trials with mainly Asian participants than trials with mostly non-Asian participants. The results indicate that the CHIME model is a validated tool for predicting the progression of diabetes and its outcomes, particularly among Chinese and East Asian populations, for which the existing models have been unsuitable.

With the new model, clinicians and health economists can evaluate population health status for prediabetes and diabetes using routinely recorded data and therapies related to the long-term management of diabetes. In particular, the CHIME outcomes model enables them to assess patients' quality of life and measure cost per quality-adjusted life-years over the long-time horizon of chronic disease conditions. The new model thus supports the economic evaluation of policy guidelines and clinical treatment pathways to tackle diabetes and prediabetes, address micro- and macrovascular complications associated with these conditions, and improve life expectancy.

This commentary was first published by The Lowy Institute.

Two recent naval exercises demonstrate the potential for Russia-China cooperation in the Indian Ocean, and how the two present a much greater threat to a continued US role and influence in the region than either would individually.

Last year, South Africa hosted a maritime exercise with Russia and China, the first-ever trilateral exercise among the three countries. Exercise Mosi was designed, according to the South African Navy, to “enhance interoperability and maritime security“ and showed the three countries’ willingness to work together to counter security threats at sea, such as terrorism and piracy. There were the obligatory social and cultural activities, and then military maneuvers that focused on a surface gunnery exercise, helicopter cross-deck landings, boarding operations and disaster control exercises.

China and Russia followed this up in December 2019 with another trilateral maritime exercise with Iran in the Gulf of Oman called Exercise Marine Security Belt. The exercises included live-fire drills and an anti-piracy exercise involving Iranian commandos. According to the Iranian naval commander, the exercises’ message was that “Iran cannot be isolated.” A Chinese spokesman stated: “The naval drills aim to deepen exchange and cooperation among the navies of the three countries, and display their strong will and capability to jointly maintain world peace and maritime security”.

Both China and Russia have gradually been increasing their presence in the Indian Ocean. Russia recently announced it would establish a naval facility in Port Sudan on the Red Sea. China opened its first overseas base in Djibouti in 2017, and China’s navy has increased operations in the Indian Ocean region over the past three decades.

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The Covid-19 crisis may have slowed further moves towards cooperation this year. Moscow just hosted the 12th BRICS summit virtually, which doesn’t lend itself to deep military engagement. But the trilateral exercises are notable because they signal Moscow’s and Beijing’s desire to cooperate in the region. And more importantly, they reveal that regional powers such as South Africa and Iran, as well as other countries, welcome the increased role of China and Russia.

Relations between South Africa and the United States were already strained when Pretoria agreed to the trilateral exercises last year. Under the Trump administration, the United States grew critical of South Africa’s UN voting record. Washington also declined to exempt the country from hikes in tariffs on US imports of steel and aluminum. In contrast, China has pledged the most investments of any country in South Africa. Russia has followed in its footsteps in building political, military and trade ties across sub-Saharan Africa.

Iran has even more reason to build relations with China and Russia. Since the US withdrawal from the Iran nuclear deal in 2018, Iran has strengthened its ties to China and Russia, using multi-billion-dollar loans from the two countries to resist US sanctions and deepening defense cooperation and intelligence sharing.

Smaller countries can also find the Russia-China nexus useful. According to a Chinese-language source, Sudan, a long-standing regional partner of China, first proposed hosting a Russian base in 2017 as a counterbalance “against aggressive acts of the United States”.

In other words, China and Russia together may be better equipped to compete with the United States and its allies in the Indian Ocean region for influence, for several reasons.

Moscow may be more willing than Beijing to play the ringleader role in organizing and directing opposition against the United States, but it doesn’t have the economic heft to make such cooperation a winning proposition for Indian Ocean states.

While China has considerable resources, it is more concerned about provoking the United States and potentially worsening already poor relations. China often argues that it is a different type of great power, one that does not engage in hegemonic behavior such as alliance formation. China is also keen to avoid sparking a countervailing coalition against it.

For these reasons, Beijing often tones down its rhetoric about the nature of its relationship with Russia. China claimed the Indian Ocean exercises do “not target any third party”. For Russia, however, overtly undermining the United States is a key component of its strategy and plays well domestically for Putin.

On the other hand, China has the economic resources to wield influence and invest heavily in Indian Ocean countries. In Pakistan alone, Beijing has pledged an estimated $87 billion in funding and completed roughly $20 billion worth of projects. Recently, Beijing and Tehran reportedly agreed to a 25-year deal to expand China’s investment in Iranian banking, telecommunications, ports and railways in exchange for oil.

While China and Russia are nowhere near dominating the Indian Ocean region militarily, their combined influence may promise trouble for the United States and its partners. The two countries will likely work together to inure their partners to international pressure, including over human rights violations. And those partners will receive security benefits (such as military access) and economic benefits (such as preferential economic ties) in return. Although it seems a bit exaggerated, there is some truth to Iranian Admiral Hossein Khanzadi’s declaration that strategic coordination with Russia and China means “the era of American free action in the region is over”.

China and Russia may be slow in enhancing their strategic coordination in the Indian Ocean slowly, but the intent is there. The United States and its allies may still be dominant militarily. But we should be careful not to fall under the illusion that this guarantees influence. With China and Russia presenting themselves as strong alternative powers, the United States and like-minded countries have to work that much harder to promote sustainable economic development, protect international rules and norms, and ensure peace and security in the region.

This blog post was first published by the Australian Strategic Policy Institute's The Strategist analysis and commentary site.

The Quad is stronger than ever. The informal ‘minilateral’ grouping of Australia, India, Japan and the United States has in the past year held its first stand-alone ministerial meeting and its first leaders’ summit, and launched an ambitious project to deliver Covid-19 vaccines. This ‘golden age’ of the Quad is a product of newfound Indian enthusiasm for the grouping, in turn, spurred by the military crisis in Ladakh, where India faces ongoing Chinese troop incursions across the two countries’ disputed border.

But the Quad is not bulletproof. Some experts have suggested that the economic and diplomatic effects of the devastating second wave of the pandemic in India will preoccupy the Indian government, sapping the Quad of capacity for any new initiatives. Others counter that India remains committed to competition with China—which is what really matters for the Quad—although its partners always expected ‘two steps forward, one step back’ from India.

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Related: On the Conversation Six podcast, Tarapore discusses the policy paper on which this blog post is based with Jawaharlal Nehru University Professor of International Politics Rajesh Rajagopalan. Listen:

The pandemic may well prove to be a hiccup in the Quad’s evolution, but a potentially much larger disruption may come from the ongoing Ladakh crisis itself. As I argue in a new ASPI Strategic Insights paper, the crisis has greatly increased the risk of a border war between India and China, which would present a defining test of the Quad. A possible war could either strengthen or enervate the Quad—depending on how India and its partners, including Australia, act now to shape the strategic environment.

Risk is a function of likelihood and consequence. The likelihood of war on the India–China border is still low—both countries would prefer to avoid it—but has risen since the crisis began. Both countries have greatly expanded their military deployments on the border and backed them with new permanent infrastructure to resupply and reinforce them. China has proved its revisionist intent with large and costly military incursions, although its specific objectives and plans remain unknown. And the interaction of both countries’ military strategies and doctrines would, on the threshold of conflict, promote escalation.

The consequences of a possible conflict would be dire for both belligerents and for the region. China — assuming it is the provocateur of conflict—would likely face some political rebuke from states that consider themselves its competitors, but it will work strenuously to reduce those costs, and would likely have priced them in to its calculations of whether to fight. India will suffer high tactical costs on the border, and may also suffer wider harm if China uses coercive cyberattacks against strategic or dual-use targets.

In a costly war, the repercussions may spill over to damage India’s recently developing strategic partnerships, especially with the United States and Australia. Despite generally favorable views of the US, the Indian strategic elite still harbors some latent suspicions. This was highlighted in two episodes in April 2021, when the US Navy conducted a freedom of navigation patrol through the Indian exclusive economic zone, and when the US was slow in delivering Covid-19 vaccine raw materials and other relief. Both instances quickly receded from the Indian public imagination—thanks to quick correctives from Washington—but they did reveal that, under some conditions, Indian perceptions of its new partnerships can be quickly colored by distrust.

A China–India border war may create exactly those conditions. There is a chance that conflict may result in a redoubled Indian commitment to the Quad, if New Delhi judges that it has no option but to seek more external assistance. Conversely, unless a conflict is managed well by India and its partners, it is more likely to result in Indian disaffection with the Quad. India deepened Quad cooperation during the Ladakh crisis partly as a deterrent signal to China, and partly because the Quad is still full of promise. However, after a conflict—when China hasn’t been deterred and has probably imposed significant costs on India—the Quad’s utility would have been tested, and probably not ameliorated India’s wartime disadvantage.

The task before Quad governments is to be sensitized to this risk and implement mitigation strategies before a possible conflict, to buttress the coalition in advance. As I outline in the ASPI paper, they could do this at three levels. First, they could offer operational support—such as intelligence or resupply of key equipment, as the US already has done in the Ladakh crisis—although Quad partners’ role here would be limited. Second, they could provide support in other theatres or domains—with a naval show of force, for example, although cyber operations would probably be more meaningful in deterring conflict or dampening its costs. Third, they could provide political and diplomatic support — signaling to Beijing that a conflict would harm its regional political standing.

For Quad members, the main goal would be to deter conflict in the first place, and, failing that, to preserve the long-term strategic partnership with India for the sake of maintaining as powerful and energetic a coalition as possible to counterbalance China in the long term.

In collaboration with Global:SF and the State of California Governor’s Office of Business and Economic Development, the China Program at Shorenstein APARC presented session five of the New Economy Conference, "Navigating Chinese Investment, Trade, and Technology," on May 19. The program featured distinguished speakers Ambassador Craig Allen, President of the US-China Business Council; David K. Cheng, Chair and Managing Partner of China & Asia Pacific Practice at Nixon Peabody LLP; James Green, Senior Research Fellow at the Initiative for U.S.-China Dialogue on Global Issues at Georgetown University; and Anja Manuel, Co-Founder and Principal of Rice, Hadley, Gates & Manuel LLC. The session was opened by Darlene Chiu Bryant, Executive Director of GlobalSF, and moderated by Professor Jean Oi, William Haas Professor of Chinese Politics and director of the APARC China Program.

U.S.-China economic relations have grown increasingly fraught and competitive. Even amidst intensifying tensions, however, our two major economies remain intertwined. While keeping alert to national security concerns, the economic strength of the United States will depend on brokering a productive competition with China, the world’s fastest growing economy. Precipitous decoupling of trade, investment, and human talent flows between the two nations will inflict unnecessary harm to U.S. economic interests--and those of California.  

Chinese trade and investments into California have grown exponentially over the last decade. But they have come under increasing pressure following geopolitical and economic tensions between the two nations, particularly in the science and technology sectors. Ambassador Craig Allen, David Cheng, James Green, and Anja Manuel explored the role of Chinese economic activity in California in the context of the greater US-Chinese relationship. Watch now: 

Space strategy is central to great-power competition and China believes it needs to excel and compete effectively in space, whether in civilian, commercial, or military usage, says Center Fellow Oriana Skylar Mastro on Space Strategy, a podcast from the American Foreign Policy Council (AFPC). Listen below:

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Mastro joined podcast host Peter Garretson, Senior Fellow in Defense Studies at AFPC, to examine how China views space and why space is key to any military conflict, particularly across the Taiwan strait.

The U.S. military is far superior to the Chinese, says Mastro, yet one main reason China might prevail in a conflict over Taiwan is that it might achieve its goals before the United States can amass enough forces to respond. “Whether the United States can do this is largely dependent on space."

During this conversation, Mastro discusses China's approach to negotiation, deterrence, diplomacy, and inducements; the potential for misunderstanding and escalation in targeting U.S. space assets; and the considerations that impact U.S.-China space cooperation. She also explains how freedom in space is critical to avoiding foreign dependence and why the United States must build a resilient military space architecture and not surrender global leadership in pursuing aspirational and inspirational space goals.

This essay was originally published in Foreign Affairs magazine.

Chinese leaders will continue to pay lip service to peaceful unification until the day the war breaks out, but their actions increasingly suggest that they have something else in mind. As tensions with the United States have heated up, China has accelerated its military operations in the vicinity of Taiwan, conducting 380 incursions into the island’s air defense identification zone in 2020 alone. In April of this year, China sent its largest-ever fleet, 25 fighters and bombers, into Taiwan’s air defense identification zone. Clearly, Xi is no longer trying to avoid escalation at all costs now that his military is capable of contesting the U.S. military presence in the region. Long gone are the days of the 1996 crisis over Taiwan, when the United States dispatched two aircraft carrier battle groups to sail near the strait and China backed off. Beijing did not like being deterred back then, and it spent the next 25 years modernizing its military so that it would not be so next time.  

Much of that modernization, including updates to hardware, organization, force structure, and training, was designed to enable the People’s Liberation Army to invade and occupy Taiwan. Xi expanded the military’s capabilities further, undertaking the most ambitious restructuring of the PLA since its founding, aimed specifically at enabling Chinese forces to conduct joint operations in which the air force, the navy, the army, and the strategic rocket force fight seamlessly together, whether during an amphibious landing, a blockade, or a missile attack—exactly the kinds of operations needed for armed unification. Xi urgently pushed these risky reforms, many unpopular with the military, to ensure that the PLA could fight and win wars by 2020.

The voices in Beijing arguing that it is time to use these newfound military capabilities against Taiwan have grown louder, a telling development in an era of greater censorship. Several retired military officers have argued publicly that the longer China waits, the harder it will be to take control of Taiwan. Articles in state-run news outlets and on popular websites have likewise urged China to act swiftly. And if public opinion polls are to be believed, the Chinese people agree that the time has come to resolve the Taiwan issue once and for all. According to a survey by the state-run Global Times, 70 percent of mainlanders strongly support using force to unify Taiwan with the mainland, and 37 percent think it would be best if the war occurred in three to five years. 

The Chinese analysts and officials I have spoken to have revealed similar sentiments. Even moderate voices have admitted that not only are calls for armed unification proliferating within the CCP but also they themselves have recommended military action to senior Chinese leadership. Others in Beijing dismiss concerns about a Chinese invasion as overblown, but in the same breath, they acknowledge that Xi is surrounded by military advisers who tell him with confidence that China can now regain Taiwan by force at an acceptable cost. 

Battle Ready

Unless the United States or Taiwan moves first to alter the status quo, Xi will likely consider initiating armed unification only if he is confident that his military can successfully gain control of the island. Can it? 

The answer is a matter of debate, and it depends on what it would take to compel Taiwan’s capitulation. Beijing is preparing for four main campaigns that its military planners believe could be necessary to take control of the island. The first consists of joint PLA missile and airstrikes to disarm Taiwanese targets—initially military and government, then civilian—and thereby force Taipei’s submission to Chinese demands. The second is a blockade operation in which China would attempt to cut the island off from the outside world with everything from naval raids to cyberattacks. The third involves missile and airstrikes against U.S. forces deployed nearby, with the aim of making it difficult for the United States to come to Taiwan’s aid in the initial stages of the conflict. The fourth and final campaign is an island landing effort in which China would launch an amphibious assault on Taiwan—perhaps taking its offshore islands first as part of a phased invasion or carpet bombing them as the navy, the army, and the air force focused on Taiwan proper. 

Among defense experts, there is little debate about China’s ability to pull off the first three of these campaigns—the joint strike, the blockade, and the counterintervention mission. Neither U.S. efforts to make its regional bases more resilient nor Taiwanese missile defense systems are any match for China’s ballistic and cruise missiles, which are the most advanced in the world. China could quickly destroy Taiwan’s key infrastructure, block its oil imports, and cut off its Internet access—and sustain such a blockade indefinitely. According to Lonnie Henley, a retired U.S. intelligence officer and China specialist, “U.S. forces could probably push through a trickle of relief supplies, but not much more.” And because China has such a sophisticated air defense system, the United States would have little hope of regaining air or naval superiority by attacking Chinese missile transporters, fighters, or ships. 

But China’s fourth and final campaign—an amphibious assault on the island itself—is far from guaranteed to succeed. According to a 2020 U.S. Department of Defense report, “China continues to build capabilities that would contribute to a full-scale invasion,” but “an attempt to invade Taiwan would likely strain China’s armed forces and invite international intervention.” The then commander of U.S. Indo-Pacific Command, Philip Davidson, said in March that China will have the ability to successfully invade Taiwan in six years. Other observers think it will take longer, perhaps until around 2030 or 2035. 

What everyone agrees is that China has made significant strides in its ability to conduct joint operations in recent years and that the United States needs adequate warning to mount a successful defense. As Beijing hones its spoofing and jamming technologies, it may be able to scramble U.S. early warning systems and thereby keep U.S. forces in the dark in the early hours of an attack. Xi’s military reforms have improved China’s cyberwarfare and electronic warfare capabilities, which could be trained on civilian, as well as military, targets. As Dan Coats, then the U.S. director of national intelligence, testified in 2019, Beijing is capable of offensive cyberattacks against the United States that would cause “localized, temporary disruptive effects on critical infrastructure.” China’s offensive weaponry, including ballistic and cruise missiles, could also destroy U.S. bases in the western Pacific in a matter of days.

In light of these enhanced capabilities, many U.S. experts worry that China could take control of Taiwan before the United States even had a chance to react. Recent war games conducted by the Pentagon and the RAND Corporation have shown that a military clash between the United States and China over Taiwan would likely result in a U.S. defeat, with China completing an all-out invasion in just days or weeks.

Ultimately, on the question of whether China will use force, Chinese leaders’ perceptions of their chances of victory will matter more than their actual chances of victory. For that reason, it is bad news that Chinese analysts and officials increasingly express confidence that the PLA is well prepared for a military confrontation with the United States over Taiwan. Although Chinese strategists acknowledge the United States’ general military superiority, many have come to believe that because China is closer to Taiwan and cares about it more, the local balance of power tips in Beijing’s favor. 

As U.S.-Chinese tensions have risen, China’s state-sponsored media outlets have grown more vocal in their praise for the country’s military capabilities. In April, the Global Times described an unnamed military expert saying that “the PLA exercises are not only warnings, but also show real capabilities and pragmatically practicing reunifying the island if it comes to that.” If China chooses to invade, the analyst added, the Taiwanese military “won’t stand a chance.”

Go Fast, Go Slow

Once China has the military capabilities to finally solve its Taiwan problem, Xi could find it politically untenable not to do so, given the heightened nationalism of both the CCP and the public. At this point, Beijing will likely work its way up to a large-scale military campaign, beginning with “gray zone” tactics, such as increased air and naval patrols, and continuing on to coercive diplomacy aimed at forcing Taipei to negotiate a political resolution. 

Psychological warfare will also be part of Beijing’s playbook. Chinese exercises around Taiwan not only help train the PLA but also wear down Taiwan’s military and demonstrate to the world that the United States cannot protect the island. The PLA wants to make its presence in the Taiwan Strait routine. The more common its activities there become, the harder it will be for the United States to determine when a Chinese attack is imminent, making it easier for the PLA to present the world with a fait accompli.

At the same time that it ramps up its military activities in the strait, China will continue its broader diplomatic campaign to eliminate international constraints on its ability to use force, privileging economic rights over political ones in its relations with other countries and within international bodies, downplaying human rights, and, above all, promoting the norms of sovereignty and noninterference in internal affairs. Its goal is to create the narrative that any use of force against Taiwan would be defensive and justified given Taipei’s and Washington’s provocations. All these coercive and diplomatic efforts will move China closer to unification, but they won’t get it all the way there. Taiwan is not some unoccupied atoll in the South China Sea that China can successfully claim so long as other countries do not respond militarily. China needs Taiwan’s complete capitulation, and that will likely require a significant show of force. 

If Beijing decides to initiate a campaign to forcibly bring Taiwan under Chinese sovereignty, it will try to calibrate its actions to discourage U.S. intervention. It might, for example, begin with low-cost military options, such as joint missile and airstrikes, and only escalate to a blockade, a seizure of offshore islands, and, finally, a full-blown invasion if its earlier actions fail to compel Taiwan to capitulate. Conducted slowly over the course of many months, such a gradual approach to armed unification would make it difficult for the United States to mount a strong response, especially if U.S. allies and partners in the region wish to avoid a war at all costs. A gradual, coercive approach would also force Washington to initiate direct hostilities between the two powers. And if China has not fired a shot at U.S. forces, the United States would find it harder to make the case at home and in Asian capitals for a U.S. military intervention to turn back a slow-motion Chinese invasion. An incremental approach would have domestic political benefits for Beijing, as well. If China received more international pushback than expected or became embroiled in a campaign against the United States that started to go badly, it would have more opportunities to pull back and claim “mission accomplished.”  

But China could decide to escalate much more rapidly if it concluded that the United States was likely to intervene militarily regardless of whether Beijing moved swiftly or gradually. Chinese military strategists believe that if they give the United States time to mobilize and amass firepower in the vicinity of the Taiwan Strait, China’s chances of victory will decrease substantially. As a result, they could decide to preemptively hit U.S. bases in the region, crippling Washington’s ability to respond.

In other words, U.S. deterrence—to the extent that it is based on a credible threat to intervene militarily to protect Taiwan—could actually incentivize an attack on U.S. forces once Beijing has decided to act. The more credible the American threat to intervene, the more likely China would be to hit U.S. forces in the region in its opening salvo. But if China thought the United States might stay out of the conflict, it would decline to attack U.S. forces in the region, since doing so would inevitably bring the United States into the war. 

Wishful Thinking

What might dissuade Xi from pursuing armed unification, if not U.S. military might? Most Western analysts believe that Xi’s devotion to his signature plan to achieve the “Chinese dream” of “national rejuvenation,” which requires him to maintain economic growth and improve China’s international standing, will deter him from using military force and risking derailing his agenda. They argue that the economic costs of a military campaign against Taiwan would be too high, that China would be left completely isolated internationally, and that Chinese occupation of the island would tie up Beijing for decades to come. 

But these arguments about the cost of armed unification are based more on American projections and wishful thinking than on fact. A protracted, high-intensity conflict would indeed be costly for China, but Chinese war planners have set out to avoid this scenario; China is unlikely to attack Taiwan unless it is confident that it can achieve a quick victory, ideally before the United States can even respond. 

Even if China found itself in a protracted war with the United States, however, Chinese leaders may believe they have social and economic advantages that would enable them to outlast the Americans. They see the Chinese people as more willing to make sacrifices for the cause of Taiwan than the American people. Some argue, too, that China’s large domestic market makes it less reliant on international trade than many other countries. (The more China economically decouples from the United States and the closer it gets to technological self-sufficiency, the greater this advantage will be.) Chinese leaders could also take comfort in their ability to quickly transition to an industrial wartime footing. The United States has no such ability to rapidly produce military equipment.

International isolation and coordinated punishment of Beijing might seem like a greater threat to Xi’s great Chinese experiment. Eight of China’s top ten trading partners are democracies, and nearly 60 percent of China’s exports go to the United States and its allies. If these countries responded to a Chinese assault on Taiwan by severing trade ties with China, the economic costs could threaten the developmental components of Xi’s rejuvenation plan.

But Chinese leaders have good reason to suspect that international isolation and opprobrium would be relatively mild. When China began to cultivate strategic partnerships in the mid-1990s, it required other countries and organizations, including the European Union, to sign long-term agreements to prioritize these relationships and proactively manage any tensions or disruptions. All these agreements mention trade, investment, economic cooperation, and working together in the United Nations. Most include provisions in support of Beijing’s position on Taiwan. (Since 1996, China has convinced more than a dozen countries to switch their diplomatic recognition to Beijing, leaving Taiwan with only 15 remaining allies.) In other words, many of China’s most important trading partners have already sent a strong signal that they will not let Taiwan derail their relationships with Beijing. 

Whether compelling airlines to take Taiwan off their maps or pressuring Paramount Pictures to remove the Taiwanese flag from the Top Gun hero Maverick’s jacket, China has largely succeeded in convincing many countries that Taiwan is an internal matter that they should stay out of. Australia has been cautious about expanding its military cooperation with the United States and reluctant even to consider joint contingency planning over Taiwan (although the tide seems to be shifting in Canberra). Opinion polls show that most Europeans value their economic ties with China and the United States roughly the same and don’t want to be caught in the middle. Southeast Asia feels similarly, with polls showing that the majority of policymakers and thought leaders from member states of the Association of Southeast Asian Nations believe the best approach to U.S.-Chinese sparring is for the association to “enhance its own resilience and unity to fend off their pressures.” One South Korean official put it more memorably in an interview with The Atlantic, comparing the need to pick sides in the U.S.-Chinese dispute to “asking a child whether you like your dad or your mom.” Such attitudes suggest that the United States would struggle to convince its allies to isolate China. And if the international reaction to Beijing’s crackdowns in Hong Kong and Xinjiang is any indication, the most China can expect after an invasion of Taiwan are some symbolic sanctions and words of criticism. 

The risk that a bloody insurgency in Taiwan will drag on for years and drain Beijing of resources is no more of a deterrent—and the idea that it would be says more about the United States’ scars from Afghanistan and Iraq than about likely scenarios for Taiwan. The PLA’s military textbooks assume the need for a significant campaign to consolidate power after its troops have landed and broken through Taiwan’s coastal defenses, but they do not express much concern about it. This may be because although the PLA has not fought a war since 1979, China has ample experience with internal repression and dedicates more resources to that mission than to its military. The People’s Armed Police boasts at least 1.5 million members, whose primary mission is suppressing opposition. Compared with the military task of invading and seizing Taiwan in the first place, occupying it probably looks like a piece of cake.

For all these reasons, Xi may believe he can regain control of Taiwan without jeopardizing his Chinese dream. It is telling that in the flood of commentary on Taiwan that has come out of China in recent months, few articles have mentioned the costs of war or the potential reaction from the international community. As one retired high-level military officer explained to me recently, China’s main concern isn’t the costs; it’s sovereignty. Chinese leaders will always fight for what is theirs. And if China defeats the United States along the way, it will become the new dominant power in the Asia-Pacific. The prospects are tantalizing. The worst-case scenario, moreover, is that the United States reacts more quickly and effectively than expected, forcing China to declare victory after limited gains and go home. Beijing would live to capture Taiwan another day. 

No Exit

These realities make it very difficult for the United States to alter China’s calculus on Taiwan. Richard Haass and David Sacks of the Council on Foreign Relations have argued in Foreign Affairs that the United States could improve cross-strait deterrence by ending its long-standing policy of “strategic ambiguity”—that is, declining to state specifically whether and how it would come to Taiwan’s defense. But the main problem is not U.S. resolve, since Chinese leaders already assume the United States will intervene. What matters to Xi and other top Chinese leaders is whether they think the PLA can prevail even in the face of U.S. intervention. For that reason, successful deterrence requires convincing China that the United States can prevent it from achieving its military objectives in Taiwan, a difficult undertaking that would come with its own downsides and potential risks. 

One way to convince Beijing would be to develop the capabilities to physically stop it from taking Taiwan—deterrence by denial. This would involve positioning missile launchers and armed drones near Taiwan and more long-range munitions, especially antiship weapons, in places such as Guam, Japan, and the Philippines. These weapons would help repel a Chinese amphibious and air assault in the initial stages of an attack. If Chinese leaders knew their forces could not physically make it across the strait, they would not consider trying unless Taiwan took the truly unacceptable step of declaring independence. 

The United States would also need to invest heavily in intelligence, surveillance, and reconnaissance in the region. The attractiveness of a full-on invasion from China’s perspective lies in the possibility of surprise: the United States may not be able to respond militarily until after Beijing has taken control of the island and the war is over. Leaving aside the operational challenges of such a response, it would be politically difficult for any U.S. president to authorize an attack on China when no shots were being fired at the time. 

An enhanced U.S. military and intelligence presence in the Indo-Pacific would be sufficient to deter most forms of armed unification, but it wouldn’t prevent China from using force altogether. Beijing could still try to use missile strikes to convince Taiwan to bend to its will. To deter all Chinese military aggression, the United States would therefore need to be prepared to destroy China’s missile batteries—which would involve U.S. strikes on the Chinese mainland. Even if U.S. intelligence capabilities improve, the United States would risk mistaking Chinese military exercises for preparations for an invasion—and igniting a war by mistake. China knows this and may conclude the United States would not take the chance. 

The most effective way to deter Chinese leaders from attacking Taiwan is also the most difficult: to convince them that armed unification would cost China its rejuvenation. And the United States cannot do this alone. Washington would need to persuade a large coalition of allies to commit to a coordinated economic, political, and military response to any Chinese aggression. And that, unfortunately, remains a remote possibility, since many countries are unwilling to risk their economic prospects, let alone a major-power war, in order to defend a small democratic island. 

Ultimately, then, there is no quick and easy fix to the escalating tensions across the strait. The only way the United States can ensure Taiwan’s security is to make an invasion impossible for Beijing or to convince Chinese leaders that using force will cause them to be pariahs. For the last 25 years, however, Beijing has sought to prevent Washington from doing either. Unfortunately for Taiwan, only now is the United States waking up to the new reality.