Challenges and opportunities for Taiwan’s global health diplomacy

Health versus politics: Taiwan as an essential partner in global health security

International health cooperation has been one among many areas from which Taiwan has been excluded since 1972 when the United Nations seated the People’s Republic of China (PRC) as the government representing China. Eventually, this resulted in the end of Taiwan’s participation in all organizations in the UN system, including health organizations. However, as cross-border health risks began to grow in an increasingly globalized world, medical professionals and related associations in Taiwan launched campaigns for health cooperation to be separated from the political question of Taiwan’s international status. Beginning in 1997, the Foundation of Medical Professionals Alliance in Taiwan (FMPAT) led efforts for admission as an observer in the World Health Assembly (WHA), the plenary body of the World Health Organization (WHO). The FMPAT argued on humanitarian and scientific grounds, contending that continued exclusion of Taiwan not only weakened its domestic capacity to fight disease, but also undermined the international community’s ability to respond effectively to global health risks. Serious outbreaks of hand, foot and mouth enterovirus in 1998 (causing 78 deaths in Taiwan), and severe acute respiratory syndrome (SARs) in 2003 (81 deaths) provided vivid evidence of this argument. During the latter outbreak, official WHO notifications were delayed and direct technical assistance was blocked.[1] Taiwan’s ambiguous international status also hindered global assistance during the 1999 Jiji earthquake,[2] while Taiwanese aid offers to other countries, such as Iraq and Afghanistan in 2004,[3] have often been declined or gone unanswered. After Taiwan submitted its instrument of accession to the WHO Framework Convention on Tobacco Control in 2005 it was never unacknowledged by the UN Secretary General.

Despite consistent lobbying, supported by the United States, Canada and European countries, the political impasse on WHO observership persisted until 2009 when the Taiwan Department of Health was finally invited to send a delegation to the WHA. The breakthrough came as the H1N1 influenza virus was circling the globe. While relatively few deaths resulted from the pandemic, fears of a future outbreak involving the highly pathogenic H5N1 virus, coinciding with a warming of cross-Strait relations, likely prompted a change of heart. WHO member states, including the PRC, recognized that Taiwan’s closer integration into systems of global disease surveillance, reporting and response would benefit all countries. As well as attending each WHA since 2009 as an “observer by invitation”, the “Department of Health, Chinese Taipei” was permitted to accede to the International Health Regulations (IHR), a framework under WHO that responds to public health emergencies of international concern. Through this accession, Taiwan was able to directly contact WHO and receive information on outbreaks and other health events.[4]

Beyond WHO, Taiwan has had some, albeit limited, official participation in other multilateral health cooperation efforts. For example, Taiwan made financial contributions to the Global Fund to Fight AIDS, Malaria and Tuberculosis, and to a UNAIDS project in Chad, although the latter was channeled through a French humanitarian organization.[5] In 2014, Taiwan donated to the Pan American Development Foundation and Pan American Health Organization for regional preparations for a possible Ebola outbreak.[6] Under the designation “Taipei, China”, Taiwan has also contributed at least US$1.7 billion of capital subscriptions as a member of the Asian Development Bank, and US$110 million to special projects since 1966, including water treatment and infrastructure projects that impact public health.[7]

Given the limited opportunities at the international level, Taiwan has relied on regional and bilateral initiatives. For example, taking advantage of its membership in the Asia Pacific Economic Cooperation forum (APEC) under the name “Chinese Taipei,” Taiwan was among the three highest participants in 26 health-related APEC projects between 2003 and 2009, along with the United States and Canada. Taiwan also transitioned during this period, from participant to active player, by proposing three projects concerning regional cooperation to control dengue fever outbreaks and partaking in surveillance, treatment, laboratory diagnosis and vaccine development of enteroviruses.[8] At the bilateral level, Taiwan has drawn on its own experiences of disasters, health emergencies and disease prevention to offer assistance to countries such as Malawi, Swaziland and Sao Tome and Principe to combat HIV/AIDS, malaria and dengue fever, improve food safety, and strengthen primary health care.  Taiwan has also sent aid for natural disasters both to countries with diplomatic ties, such as Paraguay following flooding in December 2015,[9] and countries without official relations, such as Fiji following Cyclone Winston in February 2016.[10]Development projects, including medical missions, are managed directly by the International Cooperation and Development Fund (TaiwanICDF), Taiwan’s development assistance organization. Taiwan’s medical teams, comprising medical staff from private hospitals, have served on both long- and short-term medical missions in over 24 countries.[11] Taiwan has also built health facilities, trained health workers and donated medical devices and medicines to low-income countries.[12]

Given Taiwan’s continued limbo status within the governmental global health community, the Ministry of Foreign Affairs has relied heavily on NGOs as informal channels of engagement with foreign counterparts.[13] NGOs have been active participants through medical professionals associations and religious organizations. For instance, local chapters of international NGOs, such as World Vision (Taiwan), the Make a Wish Foundation (Taiwan), Red Cross Society of the Republic of China (Taiwan), along with local organizations such as the Formosa Budding Hope Association and Buddhist Compassion Relief Tzu Chi Foundation, have contributed actively to emergency relief and rescue operations, medical missions, training, and medical supplies and equipment donations.[14] NGOs are also platforms to convene meetings of global health experts, such as a Workshop on Ebola Prevention and Response in 2014, organized by Taiwan’s Health Corps.[15] The Ministry of Science and Technology also offers funding to support participation in the European Commission’s Horizon 20/20 program by Taiwanese researchers.[16]

Scope for leveraging “international space” through global health diplomacy

While the foremost rationale behind Taiwan’s efforts to participate more fully in global health initiatives has been to protect and promote health, foreign policy aims have also been an important consideration. For Taipei, health cooperation has been seen as a relatively uncontroversial and pragmatic issue area to engage in international relations and reduce its diplomatic isolation. Securing “meaningful participation” in international health cooperation offers the potential to improve Taiwan’s political standing, in general, and even leverage international space in other policy areas.[17]With the door remaining firmly shut on official relations with most governments and representation in the UN, pragmatic participation in UN agencies such as WHO offers rare opportunities for quasi-diplomatic and informal relations.[18]The political value of global health diplomacy can be seen in the creation of Taiwan International Health Action in 2006 as a coordinating mechanism for the Department of Health, Ministry of Foreign Affairs and civil society.

The potential for global health diplomacy to advance ambitions for “two Chinas” and de jure independence has not been lost on Beijing. This is apparent in Beijing’s close management of Taiwan’s participation in WHO since 2009. As set out in a 2005 Memorandum of Understanding (MOU) between WHO and the PRC, approval by Beijing is required for any participation by Taiwan in the organization’s activities. Thus, WHA observer status is permitted on an annual basis, usually a few weeks beforehand. With WHO communications with Taiwan flowing through Beijing, approval of invitations often are time-consuming, arrive late, and provide inadequate opportunity to prepare. Instead of official delegations, Taiwanese nationals have been permitted to participate in selected WHO activities as individual experts. Even then, many requests to participate in technical meetings and training workshops, other than the IHR, have gone unanswered. As a 2013 report by the U.S. Department of State to Congress stated, “the improvement in cross-Strait relations, coupled with WHA observer status, has not resulted in greater technical involvement by Taiwan experts and officials in relevant meetings.”[19] Beijing has also taken a firm stance on WHO nomenclature, instructing staff in a leaked 2010 memo, “do not use Taiwan. This area is considered, within the United Nations system, as a province of China, under the jurisdiction of the Chinese government in Beijing.” Thus, alongside the International Organization for Standardization (ISO) and UN Terminology Bulletin – Country Names, the term “Taiwan, Province of China” has been used in WHO correspondence, as well as for identifying Taiwan’s ports on the IHR Authorized Ports list. Overall, Beijing’s close management of the WHO-Taiwan relationship has prioritized preventing the notion of “two Chinas” or “one China, one Taiwan” from proliferating in the international community.

Implications for U.S.-Taiwan relations

Since 1994 the United States has been among the countries consistently supporting Taiwan’s expanded participation in “international organizations where statehood is not a requirement for membership”, and “meaningful participation in international organizations where its membership is not possible.” The congressional bills H.R. 2019 and S. 2092, signed into law in June 2004, recognize that “direct and unobstructed participation in international health cooperation forums” is mutually beneficial. They stated that, “as the pace of globalization quickens and the spread of infectious disease accelerates, it is crucial that all people, including the people of Taiwan, be given the opportunity to participate in international health organizations such as the WHO.”[20] The Zika virus outbreak, which, as of April 2016, has affected 66 countries since 2007 including Taiwan, has once again raised concerns about the need for inclusive international health cooperation to address cross-border disease threats.[21]

Beijing’s efforts to tightly control and restrict Taiwanese participation in international health cooperation have been regularly criticized by the U.S. State Department, which in a 2013 report stated, “The sporadic and intermittent nature of Taiwan’s participation in the WHO inherently limits Taiwan’s ability to deal with future public health emergencies, due to a lack of timely information and accessible resources.”[22] In response to WHO’s use of nomenclature towards Taiwan, former U.S. Secretary of Health and Human Services Kathleen Sibelius commented, “We have made it very clear to the WHO… that no organization of the UN has a right to unilaterally determine the position of Taiwan… It needs to be a resolution that includes China and Taiwan in a discussion.”[23] Overall, Taiwan’s limited engagement in WHO has been deemed by the United States to be “unsatisfactory” and that negotiated agreement, rather than Beijing-led restrictions, should be supported.[24]

The prospects for any further relaxation of existing limitations on WHO participation seem dim following the election of the Democratic Progressive Party (DPP) in January 2016. President-elect Tsai Ing-wen and the DPP-majority in the Legislative Yuan will need to delicately navigate between showing too much deference towards the Mainland and provoking Beijing’s withdrawal of Taiwan’s hard-won observer status. Indeed, global health diplomacy may become a casualty of a downward spiral in political and economic relations, resulting in Taiwan becoming more isolated once again from the global health community. This would happen at a time when current outbreaks, such as MERS (Middle East Respiratory Syndrome) and the Zika virus, illustrate the need to move towards greater cooperation.

To prevent a backward step, U.S.-Taiwan health cooperation will be critical. The United States can continue to provide a channel through which Taiwan aid can flow unhindered by political opposition during global public health emergencies. For example, following U.S. Secretary of State John Kerry’s appeal for international assistance to West Africa during the Ebola outbreak, Taiwan donated 100,000 sets of personal protective equipment, along with US$1 million in cash, to meet the most urgent needs of stricken patients in Liberia, Sierra Leone, and Guinea. In 2015, Taiwan launched the Ebola Prevention Training Centre with the United States, staffed by U.S.-trained Taiwanese experts.[25]Prior to this, U.S.-Taiwan collaboration led to establishment of the Humanitarian Cooperation Fund to provide emergency relief.[26]The unwillingness of many countries to accept Taiwan aid, and the relative size of Taiwan’s economy, mean it will be unlikely that Taiwan will rival the largest regional aid donors, Japan and the PRC. Nevertheless, there are opportunities for U.S.-Taiwan relations to promote targeted aid efforts. For example, post-Ebola building of IHR core capacities in low-income countries could be supported by Taiwan as part of a U.S.-led effort. The Global Cooperation and Training Framework MOU, signed by Taiwan and the United States in June 2015, offers a new platform for global health diplomacy. Signed in the wake of the Ebola and MERS outbreaks, the MOU focuses on “training individuals from outside their territories” in “areas of mutual interest” including global health.[27]This initiative can build on a Taiwanese training center to help equip health workers in the Asia-Pacific region with the tools needed to contain an outbreak of Ebola or other infectious diseases.

The United States also provides an influential voice behind widening Taiwan’s participation beyond the WHA and IHR. American calls for “meaningful participation” in five entities “critical for public health in Taiwan and around the world”—Stop TB Partnership, Global Influenza Surveillance and Response System, WHO Western Pacific Regional Office and annual Regional Committee meeting, International Food Safety Authorities Network (INFOSAN), and Pandemic Influenza Preparedness (PIP) Framework[28]—may gain traction if emphasis remains focused on shared benefits. Despite the political cooling of cross-Strait relations, the Mainland and Taiwan recognize the trend towards closer economic integration. Regional and multilateral trade and investment agreements, such as the Trans-Pacific Partnership, will increase flows of goods, services and capital. Health emergencies, such as disease outbreaks and food safety concerns, would be highly disruptive to this flourishing economic activity. The U.S. government could facilitate efforts to find creative workarounds to legal status and language that would enable Taiwan to be a functioning partner for global health security. Overall, while U.S. administrations have varied in their degree of support for Taiwan’s participation in international organizations, the continued occurrence of major cross-border health threats will serve as a reminder of the mutual benefit to China and Taiwan, and indeed all countries, of an inclusive system of international health cooperation.[29]

Conclusion

Global health diplomacy has provided Taiwan a valuable opportunity to extend engagement in international relations, enabled by the relatively technical nature of, and shared benefits derived from, collective action. In pursuing this opportunity, Taiwan has maintained a delicate balancing act, between using health cooperation to gain international space, and not provoking Beijing into revoking hard-won gains. Taipei and Beijing both agree on the practical need for all populations to be part of global systems of disease surveillance, response and prevention. They disagree, however, on how much this should translate into participation in international health cooperation. So far, Beijing has allowed only a minimalist approach to, and maintained tight control over, Taiwan’s official relations with WHO. This stance is likely to remain as we enter a more precarious period for cross-Strait relations. However there is a risk that, if a future public health event of international concern results in major loss of Taiwanese lives, Mainland intransigence could be partly blamed for such an outcome. This would only worsen public opinion towards Beijing, undermining what scholar Vincent Wang describes as the Mainland’s “stated objective of peaceful unification with Taiwan by winning over the hearts of the Taiwan people.”[30]

[1] Hsueh, Po-Ren, Ping-Ing Lee, Allen Wen-Hsiang Chiu and Muh-Yong Yen, “Pandemic (H1N1) 2009 Vaccination and Class Suspensions after Outbreaks, Taipei City, Taiwan,” Emerging Infectious Diseases, vol. 16 (2010): pp. 1309-1312.

[2] Glaser, Bonnie S., “Taiwan’s Quest for Greater Participation in the International Community,” Center for Strategic and International Studies, November 2013 (www.csis.org/files/publication/131121_Glaser_TaiwansQuest_WEB.pdf).

[3] Lee, Deng-Ker, “Taiwan and the United Nations,” Taiwan New Century Think Tank, vol. 28 (2004): 12-23. [Original article in Chinese].

[4]Herington, Jonathan and Kelley Lee, “The limits of global health diplomacy:  Taiwan’s observer status at the World Health Assembly,” Globalization and Health, vol. 10 (2014): p. 71.

[5] Guilloux, Alain, Taiwan, Humanitarianism and Global Governance. (London: Routledge, 2009).

[6] International Cooperation and Development Report 2014. Ministry of Foreign Affairs, Republic of China (Taiwan), 2015 (http://www.mofa.gov.tw/Upload/RelFile/17/262/8a4267f8-9d77-44f3-8dfc-f2ecdc0f38dc.pdf).

[7] Asian Development Bank, “Asian Development Bank and Taipei, China: Fact Sheet,” April 2015 (http://www.adb.org/publications/taipei-china-fact-sheet).

[8] Chien, Hui-Yi, Yu-Chen Hsu, Ling-Yen Pan, Chin-Shui Shih, “An Analysis of Topics of APEC Health Projects and Participation of APEC Member Economies in the Projects during the Post-SARS Period,” Taiwan Epidemiological Bulletin, vol. 28 (2012):  pp. 87-98.

[9] “Taiwan makes disaster relief contributions to Paraguay following flooding,” Central News Agency (Taiwan), December 30, 2015, http://www.cna.com.tw/news/aopl/201512300065-1.aspx, [Original article in Chinese].

[10] “Taiwan makes disaster relief contributions to Fiji”, Central News Agency (Taiwan), February 26, 2016, http://www.cna.com.tw/news/aopl/201602250276-1.aspx, [Original article in Chinese].

[11] “From Taiwan with Love: Overseas Medical Missions

,” Trending Taiwan, January 12, 2016, (https://www.youtube.com/watch?v=LX0ytRyINlY&index=5&list=PLYPG1nurmhopxFfWp0qOeqJ9TGsrFt-N5).

[12]Rollet, Vincent, “Taiwan’s health diplomacy:  time to move forward,” BMJ, vol. 342 (2011):  pp. d3154 (http://dx.doi.org/10.1136/bmj.d3154).

[13] Chong, Jing-you, “Global governance and civil society: perspectives on Taiwan’s nongovernmental organizations’ participation in the international community,” Taiwanese Journal of Political Science, vol. 18 (2003): 23-53 (http://www.taiwanngo.tw/files/11-1000-95.php?Lang=zh-tw) [Original article in Chinese].

[14] “Healthcare NGOs” Ministry of Foreign Affairs, NGO Affairs Committee, (http://www.taiwanngo.tw/files/40-1000-27-1.php?Lang=zh-tw).

[15] Ministry of Foreign Affairs, International Cooperation and Development report 2014.

[16]“Taiwan – Information for Participant Portal,” Horizon 20/20, European Union,  (http://ec.europa.eu/research/participants/data/ref/h2020/other/hi/h2020_localsupp_taiwan_en.pdf).

[17] Lee, “Taiwan and the United Nations.”

[18]Glaser, “Taiwan’s Quest for Greater Participation in the International Community.”

[19] “U.S. Support for Taiwan’s Participation as an Observer at the 67^th World Health Assembly and in the Work of the World Health Organization,” U.S. Department of State, Report to Congress on Public Law 108-235, 2014.

[20] “Public Law 108–235,” 108th Congress, June 14, 2004 (http://uscode.house.gov/statutes/pl/108/235.pdf).

[21]“Zika Virus, Microencephaly and Guillain-Barré Syndrome, Situation Report,” World Health Organization, Situation Report, Geneva, April 14, 2016 (http://apps.who.int/iris/bitstream/10665/205189/1/zikasitrep_14Apr2016_eng.pdf). 

[22] As quoted in the “Taiwan’s Participation in International Organizations,” Formosa Foundation, Background Briefing (http://formosafoundation.org/ambassador-program/documents/issues/TW-International-Participation.pdf). 

[23] Ibid.  

[24] “U.S. Support for Taiwan’s Participation as an Observer at the 67^th World Health Assembly.”

[25] “ROC government launches first class at new Ebola Prevention Training Centre”, Ministry of Foreign Affairs, Republic of China (Taiwan), Press Release, No. 046, March 18, 2015 (http://www.mofa.gov.tw/en/News_Content.aspx?n=539A9A50A5F8AF9E&s=55AAE3188F7230CC).

[26] “International Cooperation and Development Report 2011,” Ministry of Foreign Affairs, Republic of China (Taiwan), 2012 (http://www.mofa.gov.tw/Upload/RelFile/17/262/9652c596-1cea-4268-ae5c-7832ece3c1a2.pdf) [Original report in Chinese].

[27] “Memorandum of Understanding between the Taipei Economic and Cultural Representative Office in the United States (TECRO) and the American Institute in Taiwan (AIT) on the Creation of a TECRO-AIT Global Cooperation and Training Framework (GCTF)”, June 2015.

[28] “U.S. Support for Taiwan’s Participation as an Observer at the 67^th World Health Assembly.”

[29] Ju, Jiao-lin, “An analysis of strategies for Taiwan’s participation in the World Health Organization and the role of the US: 1997-2009,” Journal of European and American Studies, vol. 40 (2010): 431-517. [Original article in Chinese].

[30] Wang, Vincent Wei-cheng,”Taiwan’s participation in International Organizations,’ in China’s Rise, Taiwan’s Dilemmas and International Peace, edited by Edward Friedman. (London: Routledge, 2006).