RECIPIENTS OF foreign assistance are likely to have a positive opinion of their donor, but some aid models are more effective than others in building diplomatic ties and alliances. As the current administration proposes decreasing levels of aid and Congress has sustained recent levels (a modest 1.2 percent of the federal budget), decisions about non-military aid must account for the strategic value of health programs as a U.S. comparative advantage among types of aid.
Meanwhile, the PRC’s infrastructural investments are admired by much of the African public. African public opinion is not universally positive regarding Chinese assistance, as protests in 2018 and 2019 against BRI investments in Zambia and The Gambia reflect. Yet more generally, when people in thirty-six African nations were asked how beneficial Chinese aid was to their country, almost half claimed that it helped “somewhat” or “a lot”—only 8 percent fewer than that of the United States. The most common answer for what people admired most about the PRC’s assistance was “investments in infrastructure and other development projects”—likely due to the fact that Chinese aid manifests in large-scale, rapidly-constructed, and tangible projects that create a significant number of jobs for uneducated workers.
However, effective health diplomacy also inspires great appreciation for donors: throughout the nearly sixteen years of the American presidents’ PEPFAR program, “investments have been strongly associated with improved perceptions of the United States,” not only among the twelve target countries, but around the world. A 2019 study out of Stanford University found that the probability of holding a very favorable opinion of the United States was 19 percentage points higher in the countries and years where U.S. aid for health care was highest compared to the countries receiving the least health aid and in years when funding was lowest.
In the American Journal of Public Health, Aleksandra Jakubowski suggests that strategic health diplomacy is “uniquely positioned” to garner goodwill because of its “visibility, sustainability, and effectiveness,” and the BPC attributes the benefit to the United States deriving from “the demonstration of American values like compassion and ‘generosity and technical virtuosity.’” American ambassadors to African countries have also attested to how cooperation in the fight against HIV/AIDS has been key in “opening doors in difficult relationships” with African governments. PEPFAR has enabled stronger military relationships, cemented relationships with local authorities and civil society players, and facilitated conversations about previously sensitive topics. According to one ambassador to a PEPFAR country, “…it was a seamless transition from our relationship with [local partners] with health issues to our relationship with them on democracy and human rights issues.” Most concretely, PEPFAR helped the Zambian government, among other governments on the continent, feel comfortable giving the U.S. military local access, and welcoming the creation of the U.S. military’s Africa Command. Overall, beneficiaries of American global health programs have more positive opinions of the United States, closer relationships with American diplomats, stronger trade ties to American businesses, and higher GDPs than unaided counterparts. Each of these effects supports key U.S. diplomatic and strategic interests on the rising African continent.
One should observe how the emergence of COVID-19 highlights opportunities and challenges for the United States in Africa vis-à-vis China. The U.S. comparative advantage of PEPFAR led its chief of six years, Deborah Birx, to be tapped as U.S. COVID-19 coordinator. Yet at the time of writing, the United States has not sufficiently gotten its arms around COVID-19 at home. By comparison, China’s initial mishandling of the situation and lack of transparency is what allowed the virus to spread to the point where it became an international pandemic. Lack of transparency in China and multilateral efforts has been a significant problem.
Thereafter, however, China has made strides getting its COVID-19 situation under control, and in March, Chinese philanthropist Jack Ma announced he would distribute over 6.5 million testing kits, face masks, and protective suits across the continent. Coupled with other PRC government initiatives, China will likely use these as positive talking points in Africa. As such, the United States has an asset vis-à-vis China in Africa of health security, but it needs to match its health assistance to Africa with efficacy on COVID-19 at home.
Through U.S. health diplomacy and investment, improved public and elite opinion among African countries is likely to ease U.S. integration into future markets and political alliances and foster connections that could last longer than roads or railways.
AMERICAN HEALTH diplomacy in African countries also provides economic benefits, as healthier populations make for more productive and reliable trade partners.
Economic growth in sub-Saharan countries can be compromised by high prevalence rates of HIV/AIDS. The correlation between HIV/AIDS and low GDP may be attributed to the costs of country-wide health services as well as individual barriers to employment. For example, studies conducted between 2010 and 2017 have indicated that being an HIV-positive person in Africa decreases the likelihood of one’s employment between 13 percent and 38 percent, due to the disease’s symptoms, the time required to access and maintain treatment, and stigma in the eyes of employers. Unemployment, in turn, has been associated with “significant increase[s]” in HIV/AIDS mortality in seventy-four countries, as it hampers patients’ collective ability to afford and access life-saving treatments.
Investing in the public health of African countries is therefore highly likely to increase their wealth. A finding of the BPC report on PEPFAR was that countries with medium-to-high investment in HIV epidemic response had “greater GDP growth and greater changes in worker productivity” between 2004 and 2016 than their counterparts without such levels of aid. Studies have also shown that there are immense returns on investment for fighting epidemics. The Global Fund has determined that each dollar invested in relevant prevention and treatment yields $19 worth in “health gains and economic returns,” and that over 60 percent of these returns in the next four years will have occurred in sub-Saharan Africa.
The United States and others who partner and trade with African countries are poised to benefit. Countries without malaria, for example, have been shown to witness economic growth about five times greater than their malaria-burdened counterparts. The Journal of Virus Eradication also established a model that showed a one percent decrease in HIV/AIDS prevalence would have the same impact on advancing progress toward the United Nations’ Sustainable Development Goals as a 40 percent increase in GDP, serving U.S. interests in economic growth, stability, and security.
Investing in health aid not only contributes to the prosperity and stability of target countries, but also positions the United States to participate in Africa’s rise. Strategic health diplomacy helps create a more dynamic Africa with which the United States can partner and work—as stronger economies, workforces, and consumer markets yield direct economic benefits in the U.S. national interest.
These policy instruments are pertinent to the standings of the United States and China in Africa and other parts of the world. China is investing in developing nations massively, and attaining leverage. On the one hand, it invests in infrastructure without the “strings” of governance or transparency requirements of U.S. and multilateral assistance loans. On the other hand, it gains leverage precisely because its loans do have “strings” of another kind attached. China has the chance to win privileged access to energy and other resources, as well as the power to call in the collateral put up by borrowing nations if they don’t pay their debts.
Given the increasing state fragility, security threats, and economic potential of Africa, an energetic U.S. response subtly aimed at offering an alternative to China has two pillars. The U.S. International Development Finance Corporation is a promising step built with a unique bipartisan consensus in a time of vituperous political polarization. It is designed to present an alternative to the Belt and Road Initiative which China is offering countries bilaterally and even embedding into the development work of the United Nations (where China’s influence is mounting).
Yet however canny it is, the DFC is not enough to counter China’s investment. Sustaining and scaling up U.S. strategic health diplomacy in Africa would be wise. Leadership on health is already a U.S. comparative competence and advantage, a form of foreign assistance that demonstrably produces results, and a signature element of the U.S. humane and efficacious brand in Africa and the world. It advances U.S. economic interests in African and other developing nations, and wins friends for U.S. interests on counter-terrorism and security aims. There would be an immense return on finishing the job of ending the AIDS, tuberculosis, and malaria epidemics in Africa, which the United States has already done so much to advance through PEPFAR, the President’s Malaria Initiative, and the Global Fund.
When combined, renovating U.S. development investment and extending U.S. health leadership are the keys to consequential engagement in Africa. They offer something different from a rising China: transparency, good governance, and actually investing in people. Helping sub-Saharan African nations tackle the health security threats of epidemics (including COVID-19, in addition to AIDS, tuberculosis, malaria, and Ebola), transition to funding their own health systems, and empower their women and men to thrive economically, is strategic. It would be valuable to Africa. And with China on the rise, it would be valuable to America’s standing in Africa and elsewhere around the world.