America Must Not Allow China to Go Viral in Africa
The United States should meet the People’s Republic of China’s growing influence in Africa by scaling an existing comparative advantage that will demonstrably promote well-being, prosperity, and goodwill: strategic health diplomacy.
AFRICA IS rising and shaking up the global balance of power. The continent’s fifty-four countries are growing in wealth and population faster than ever before, prompting a race among global superpowers to invest, build goodwill, and in some cases, acquire strategic assets.
In this domain, the People’s Republic of China (PRC) is making unparalleled and unorthodox inroads into the continent. Since 2003, the country has deployed a thirty-fold increase in investments in Africa and begun to distribute almost eight times as much annual development financing. In the PRC’s pursuit of its Belt and Road Initiative (BRI)—an estimated $6 trillion global infrastructure project engaging seventy countries that account for 30 percent of the world’s gross domestic product (GDP)—new partnerships are being established that pave the way for long-term influence on the continent.
While there is considerable demand for infrastructure investment in Africa, the PRC’s investment practices are not exactly selfless. In order to receive BRI loans, governments are expected to offer collateral in the form of strategic assets such as oil, airports, or land rights. National governments are then free to disburse the BRI funds practically without oversight. If the funds are squandered, countries find themselves in what has been referred to as a “carefully laid debt trap.” In May 2019, for his part, U.S. secretary of state Mike Pompeo went so far as to pointedly characterize the BRI as “corrupt infrastructure deals in exchange for political influence.”
These developments highlight the extraordinary level of investment and pace of change in Africa today, and the urgency with which the United States must reconsider its own security-related, financial, and diplomatic investments in Africa. The dueling efforts of global actors to engage in Africa, both through aid and trade, will influence the political, strategic, and economic landscape beyond the confines of the African continent.
Since the United States does not intend to match the level of foreign direct investment offered by the PRC, new diplomatic and economic strategies are imperative. As such, in addition to replacing the Overseas Private Investment Corporation (OPIC) with a more robust International Development Finance Corporation (DFC), the United States should meet the PRC’s growing influence in Africa by scaling an existing comparative advantage that will demonstrably promote well-being, prosperity, and goodwill: strategic health diplomacy.
ACCORDING TO the PRC, BRI loans are meant to “support Africa’s capacity-building for internally-driven development” in sectors such as infrastructure, trade, and public health. The outputs of BRI loans, such as high-speed trains and ports, are highly-publicized and considered “positive” by almost three-quarters of African beneficiaries. In turn, the PRC derives increased financial, diplomatic, and military benefits in a rapidly-developing continent.
BRI investments are widely appealing to African governments; funds are distributed without external monitoring or accountability other than loan repayment, leaving governments to determine exactly where and how they are spent. This model contrasts starkly with traditional models of development assistance, such as those funded by the United States, which generally prioritize transparency and require detailed project documentation, social and environmental safeguards, procurement and implementation oversight, and monitoring and evaluation. Many leaders have capitalized on this freedom by directing China’s funds to priority healthcare initiatives and potential trade opportunities. Others have used the funds uneconomically by increasing their debt burden rather than their economic growth. And some may have even used funds to facilitate state-sponsored violence and support international terrorist groups.
The PRC has much to gain from its engagements in Africa. Financially, it is positioning itself to capitalize on rapidly-emerging markets. Investments in health and education are expected to increase the size of sub-Saharan economies by 90 percent by 2050, and the continent will host more than 1.52 billion consumers in the next ten years. The PRC’s favorability in public opinion also strengthens its diplomatic ties to major African countries and its influence over their major economic sectors. Finally, given the continent’s proximity to both Europe and the Middle East, the BRI enables strategic military investments that may affect American trade relationships and counterterrorist efforts.
Many African countries have prospered from BRI investments, but others are at risk of falling into “debt traps.” For example, international attention has been drawn to the possibility that Kenya—with an amount of debt to the PRC equaling 60 percent of its GDP—will have to hand over its largest port as it defaults on its loan for an ambitious railway project. Although Kenyan president Uhuru Kenyatta has vehemently denied these “rumors,” twenty state agencies were suddenly removed from the port in June 2019, and a Sino-Kenyan contract leaked in early 2019 mandates that no deals be made public “without prior written permission of the lender.” Adding insult to injury, the contract also states that the country has no immunity to its terms even “on the grounds of sovereignty.”
Other nations rapidly building up BRI debt that could create similar difficulties. In 2015, these investments accounted for one-third of new debt taken on by African governments. In Ethiopia alone, PRC investments have constituted 30 percent of the country’s new public external debt and 90 percent of its new bilateral debt since 2015. Egypt and Djibouti, the latter of which hosts the PRC’s first overseas military base, also face high risks of debt distress due to BRI financing. If these countries default on their immense loans and their collateral assets are seized, said assets will be owned or controlled by the Chinese until the governments honor their financial obligations.
Therefore, one must ask: who truly benefits from the PRC’s investments in Africa? Indeed, even beyond Chinese influence, how might these investments and governance practices affect U.S. interests?
THE PRC’s multifaceted investments in Africa pose a variety of threats. The direct and indirect consequences of unmonitored loans, emerging military infrastructure, and increased political instability are likely to compromise the safety and prosperity of the United States and its allies, and in some cases, already have.
The most tangible threats to American interests lie in Djibouti, a small country in the Horn of Africa that owes half of its public debt to the PRC and is critical to a variety of American military and intelligence operations. It hosts Camp Lemonnier, the United States’ largest and only permanent military base in Africa—and, as of 2017, the PRC’s first overseas military base as well. Located just six miles from Lemonnier, the outpost is not only designed to accommodate thousands of people and is suspected to be monitoring American troops, but also believed to have used laser weapons to temporarily blind nearby U.S. pilots in 2018.
American officials were reportedly “blindsided” by Djibouti’s agreement to lease the land to the PRC. Unlike two years prior, when Russia was denied permission to build a base in Djibouti because the United States was notified and strongly protested the idea, the African country gave the United States no warning of its arrangement with the Chinese and thus no opportunity to intervene. It is therefore reasonable to assume that the PRC used the leverage provided by its billion-dollar investment in Djiboutian infrastructure to prevent such intercession and secure the lease.
Another major concern for the U.S. military is Chinese influence over Djibouti’s Doraleh Container Terminal (dct), considered to be “the primary access point for American, French, Italian and Japanese bases” there. When President Ismaïl Omar Guelleh was unable to repay his country’s BRI loans in 2017, he allegedly illegally transferred ownership of the dct to the PRC as partial repayment. This enables China to more easily strengthen and expand their new base, and, should they choose, influence the entry of ships owned by the United States or its allies.
More broadly, BRI investments in Africa are correlated with rising state-sponsored and civil violence, and, potentially as a consequence, international terrorism. A 2015 report by the University of Sussex found that “political violence by [a] state increases with receipt of Chinese aid, compared to ‘traditional’ aid flows” like those funded by the United States. It notes that the African states that receive the greatest “fungible aid”—the defining characteristic of BRI loans—are most likely to witness conflict.
Conflicts in African countries not only devastate their own populations, but are also likely to harm people elsewhere through spikes in internationally-sponsored terrorism. Domestic instability fueled by guerrilla warfare or civil war is a magnet for such international terrorism. Several African-based terrorist groups have begun to cooperate with international counterparts such as ISIS and Al Qaeda, and some have already been tied to the 137 terrorist attacks in Burkina Faso alone in 2018. This is a number greater than that of all its domestic terrorist events between 2009 and 2015. In December 2018, the Trump administration announced that “countering the threat from Radical Islamic Terrorism and violent conflict” would be one of the administration’s top three priorities in strengthening its relations with Africa—a public acknowledgement of the pressing threats to national security posed by increasing violence on the continent.
THROUGH INVESTMENTS on the continent, China is successfully filling the vacuum created by American diplomatic disengagement. According to Reuben Brigety, a former U.S. ambassador to the African Union, “there is a general feeling among African political elites” that the United States’ inconsistent relations with them implies that it is “ceding its position as a preferred partner to other countries and organizations, especially China and the eu.”
The availability of BRI loans has allowed African governments to choose between international assistance models for the first time, and they are increasingly accepting that offered by the PRC. Among other observers, the Atlantic Council was right to conclude the result is to “undoubtedly reduce US influence.”
As for U.S. standing, two years after the current administration came into office, it announced its “Prosper Africa” plan. Despite its goals of strengthening Africa’s middle class and increasing their “access to financing,” it is explicitly designed to “put the interests of the American people first” and “make certain that ALL [sic] aid to the region [...] advances these U.S. interests.” The president made international headlines in early 2018 for repeatedly referring to African nations at large as “shithole countries” and describing Nigerian households as “huts.” As of this writing, he has left official travel to the continent to his wife and daughter. Opportunities to sustain and expand political ties have not been seized, which has arguably already manifested in the United States’ exclusion from the decision to allow the PRC to build a military base in Djibouti.
THE UNITED States is significantly lagging behind the PRC in its trade posture with sub-Saharan countries. Between 2006 and 2016, American exports to the region rose by 7 percent, while those of the Chinese increased by 233 percent—a jump more than four times the global average. Similarly, during that period, the PRC imported an additional 53 percent worth of products from sub-Saharan countries while American levels decreased by 66 percent. Since that time, U.S. trade levels with the continent have continued to fall each year despite the existence of the African Growth and Opportunity Act, which is considered to be the “most liberal” preferential trade agreement of the United States with any territory.
Furthermore, due to the second-order effects of U.S. tariffs against China, the African Development Bank estimates that the GDPs of resource-intensive sub-Saharan countries could fall by 2.5 percent by 2021. The International Monetary Fund also adjusted its 2019 growth projections for the entire continent from 3.3 to 3.1 percent due to these trade tensions, alongside the effects of Brexit and slowing Chinese growth. Ambassadors representing the PRC have already capitalized on the opportunity to “sow anti-U.S. sentiment” by condemning the impact of U.S. tariffs on African economies—a view then echoed by the former president of Zambia and the current leaders of Cape Verde, Ghana, Nigeria, and South Africa.
Thankfully, the United States has recently sought to position itself as a better partner for African countries in the financial realm. In October 2018, Congress passed the Better Utilization of Investments Leading to Development (BUILD) Act, which explicitly intends “to provide countries a robust alternative to state-directed investments by authoritarian governments and [U.S.] strategic competitors” like the PRC. It has been lauded as “the biggest step forward in US development policy” since 2004.
The act consolidates two existing development finance entities—the Overseas Private Investment Corporation and the Development Credit Authority—to create a new agency called the U.S. International Development Finance Corporation, or DFC, which will offer more numerous targeted loans and legal guarantees for American private sector investments in developing countries. As an “OPIC on steroids,” the DFC will be able to distribute more than twice as much funding as its predecessor; allow equity investments; and provide insurance in the case of war, expropriation, or political turmoil.
The BUILD Act is a step in the right direction for the United States. Among its requirements for potential beneficiaries, ventures must support the “build[ing] and strengthen[ing of] civic institutions,” “broad-based economic growth,” and poverty reduction. DFC-backed businesses are also prohibited from engaging with nations that “support terrorism or violate human rights.” Together, these provisions improve prospects for global security and financial growth—and hopefully public opinion of the United States in developing countries.
Critically, the BUILD Act will also enable and sustain investments that are distinct from those of the PRC. For example, the BRI does not support small- and medium-sized businesses, and an estimated 90 percent of its projects are Chinese-owned and operated. These structural gaps threaten to exacerbate wealth inequality—a noteworthy consideration given that ten of the nineteen “most unequal countries” are in sub-Saharan Africa. By expanding on pre-existing OPIC programs and their legal parameters, the DFC is poised to offer an attractive alternative. Congress revised U.S. law so that, in replacing OPIC, the DFC should issue loans to businesses that “directly serve the needs of small-scale farmers, small rural entrepreneurs, and rural [associations],” as well as “partner with [...] local institutions in sub-Saharan Africa, including private sector actors” to build sustainable energy infrastructure.
In turn, many Americans are positioned to benefit. The BUILD Act states that at least half of DFC funds must be distributed to small-scale American businesses, explicitly including women-, minority-, and veteran-owned agencies. The DFC is also designed to distribute financial risks among private sector organizations and recipient countries to better protect the interests of American taxpayers.
YET SOMETHING as promising as the BUILD Act is not enough. To bolster U.S. standing and interests on the African continent, we recommend that the administration capitalize on two decades of goodwill earned through foreign aid by more proactively pursuing “strategic health diplomacy.” Reports from the Bipartisan Policy Center (BPC) have established that “when national governments do good abroad by actively working to improve public health, they may also further their own foreign policy agenda.” In short, investments in public health have proven to be an asset for reputational influence. Strategic health diplomacy offers the United States a unique opportunity to non-confrontationally counter some Chinese influence on the continent, as well as position itself as a key supporter of Africa’s rise.
There are multiple direct advantages to pursuing strategic health diplomacy, including mitigating cross-border epidemics and garnering positive international humanitarian standing. Two of the United States’ most widespread and successful health partnerships—the President’s Emergency Plan for AIDS Relief (PEPFAR), and the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund), to which it is a primary contributor—have been shown to advance such interests as “…socioeconomic development; public opinion toward the United States; governance, stability and civil society engagement; and diplomatic engagement with the United States” among target countries. These results illustrate the considerable benefits consequential to American interests both at home and abroad at a time when the PRC is increasing its investments in developing nations.
This is all the more apparent in Africa: twenty-one of the world’s thirty “highly fragile” states are in the continent. Rising levels of destabilizing Chinese investment, as well as the repercussions of extreme debt distress, increasing corruption, and potential state collapse, pose substantial threats to international security. However, ongoing strategic health diplomacy has already proven to be a powerful counterforce in fragile states.
State instability and the prevalence of epidemic diseases like HIV/AIDS can feed off each other. High incidences of HIV/AIDS compromise both the quality of health services in affected regions and the apparent effectiveness of local governments, potentially contributing to civil unrest and undermining the health of militaries. The coincidence of fragile governance and epidemic infectious diseases creates a vicious cycle: as a disease undercuts a government’s stability, that nation’s ability to prevent and treat it will be compromised, leading to increased infection and mortality rates.
PEPFAR investments, on the other hand, are directly correlated with stronger governance and civil engagement, leading to overall state stability. A 2018 BPC report documented that since the program’s inception in 2003, countries receiving the highest per capita amounts of U.S. aid directed toward health have witnessed “a large and immediate decline in the level of state fragility” based on World Bank indicators such as political stability, government effectiveness, and rule of law. Sub-Saharan African countries receiving PEPFAR assistance were particularly affected in this respect, having witnessed a 40 percent drop in rates of “political instability and violent activity” since 2004. This robustly statistically significant correlation is likely the result of strategic health diplomacy’s other proven benefits to population health and socioeconomic growth.
Global Fund investments, which also target tuberculosis and malaria, and spur burden-sharing by other donors and aid recipients, have had similarly notable effects on improving civic participation and government accountability. A 2019 study published in the Annals of Global Health found a “significant, beneficial effect” of Global Fund assistance in terms of implementing countries’ “political freedoms, government accountability, quality of public services and independence of state institutions, rule of law, and controls on corruption.” These results are at least partly attributable to its unique model of development assistance, which distributes public and private donors’ contributions to a closely-monitored group of representatives of the public and private sectors, faith-based and non-governmental organizations, as well as individuals themselves living with the diseases. Different from some traditional inter-governmental organizations, the multi-stakeholder model fosters collaboration and accountability.
Another positive outcome of supporting the health and well-being of people in Africa is the greater ability to prevent, treat, and mitigate various other cross-border epidemics. In May 2019, the White House released its first-ever “Global Health Security Strategy,” which formalizes the United States’ “national security interest” in and commitment to fighting infectious diseases. It acknowledges that PEPFAR and other U.S. global health programs have had “direct and indirect outcomes” that enabled a variety of nations to be “poised to contribute to global health security” in their prevention and containment of epidemics. Should such a global health strategy be carried out effectively, especially given the coronavirus (COVID-19) pandemic, countless lives around the world will be saved from these fatal diseases as well as shielded from the resultant civil, political, and economic instability.
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.
Mark P. Lagon is Chief Policy Officer at Friends of the Global Fight Against AIDS, Tuberculosis and Malaria, Senior Fellow at the Trinity Forum, and Adjunct Professor at Georgetown University’s Master of Science in Foreign Service Program.
Rachel Sadoff is a former policy intern at Friends of the Global Fight Against AIDS, Tuberculosis and Malaria, and a junior at Harvard College specializing in public health and history.
Image: Reuters.