Strategic Health Diplomacy in the Indo-Pacific: A Comparative Analysis of US and Chinese Efforts in Latin America and the Caribbean Published Oct. 5, 2023 By Col Brian Neese, USAF Journal of Indo-Pacific Affairs -- Click here for PDF version. Abstract This article analyzes the healthcare diplomacy rivalry between the United States and China in Latin America. Since the 1980s, the US Southern Command has employed medical outreach programs to counter Soviet influence and improve regional stability. Initiatives like New Horizons/Beyond the Horizons missions and embedded health engagement teams have demonstrated the US commitment. China, meanwhile, has made significant inroads with COVID-19 aid, investments, and medical teams embedded in partner-nation hospitals, notably in Barbados. The article underscores the need for the United States to bolster global health engagements with dedicated funding, leverage military residency training, and expand public affairs campaigns to maintain its leadership in healthcare diplomacy. Failing to do so risks ceding influence to China and jeopardizing regional stability. *** Beginning in the 1980s, USSOUTHCOM actively deployed engineering and medical teams in Central America.1 The US military, while countering Soviet communist influence, recognized an opportunity to enhance regional stability and dominate security cooperation. Providing medical and surgical expertise to rural communities, alongside substantial donations of medical supplies, granted the US government access, influence, and positive publicity that furthered its regional security interests. Today, USSOUTHCOM has refined its healthcare engagement strategy. The medical element at Joint Task Force Bravo in Honduras continues delivering routine medical and surgical care. Annual deployments of US Navy hospital ships consistently capture attention and convey a robust humanitarian message. Additionally, the US Air Force employs embedded health engagement teams (EHET), integrating joint military teams directly into partner-nation hospitals and clinics for extended periods, yielding positive impacts on local healthcare capacity and readiness training—a win for all stakeholders. The US military is not alone in utilizing healthcare for security cooperation. The People’s Republic of China actively participates in this domain, notably in the Caribbean, with embedded engagements at a national-level Barbados hospital, significant investments in Suriname’s healthcare infrastructure, and the deployment of its hospital ship. These developments underscore the significance of healthcare diplomacy in our strategic competition with China. US Military–Global Health Engagement From the outset, medical outreach programs provided healthcare services across Central America, eventually adopting the name New Horizons/Beyond the Horizons. These humanitarian missions organized health fair-style events in rural communities, offering outpatient medical, optometry, and dental care. For instance, during a three-week period in the spring of 2018, USSOUTHCOM's New Horizons mission in central Panama attended to 7,500 patients and distributed 1,400 eyeglasses. Army veterinarians administered treatment to 1,185 animals, primarily performing spaying and neutering procedures. Concurrently, ophthalmology and ear, nose, and throat (ENT) surgeons were embedded in a local hospital, restoring sight and hearing to 315 patients.2 Despite the dissemination of anti-US propaganda leading up to these missions, a dedicated public affairs team countered these narratives through 50 radio and television interviews and the publication of 22 articles, which were widely covered by Panamanian and international media outlets. These narratives resonated with local citizens, host-nation political and ministerial leaders, as well as US military commanders, highlighting the universal appreciation for efforts to provide medical and surgical care, treat diseases, distribute eyeglasses, and address dental issues. Recently, the region has witnessed the emergence of a less glamorous yet potentially more sustainable and impactful approach to global health engagement (GHE): the deployment of EHETs. Under this operational concept, small teams of military medical professionals seamlessly integrate into a host nation’s healthcare system, encompassing a wide range of disciplines and specialties aligned with the desired outcomes of key stakeholders such as the host-nation ministry of health, the US Embassy country team, and US military medical planners. This GHE model aims to deliver patient care within the framework of the country's own healthcare system, benefiting its human resource capacity and ultimately enhancing patient outcomes. In early 2023, Air Forces Southern (AFSOUTH), the air component of USSOUTHCOM, executed the Lesser Antilles Medical Assistance Team (LAMAT) operation with this concept in mind. A general surgery and dental team seamlessly integrated themselves into the healthcare systems of Suriname, Guyana, and St. Lucia. At an operational cost of USD 1.4 million, 29 military medical professionals delivered USD 2.9 million in healthcare services to more than 1,100 patients. These professionals engaged in daily activities shoulder-to-shoulder with host-nation surgeons, doctors, nurses, and dentists. The surgical teams, in particular, collaborated on complex cases that neither team could have handled independently. Together, they provided treatment, alleviated human suffering, and improved the healthcare system, benefiting both the host nations and the United States.3 The most renowned medical outreach mission in the USSOUTHCOM region is the USNS Comfort hospital ship. Originally a supertanker, it was converted in 1987, replacing oil tanks with surgical suites to support various US military operations (including Desert Shield, Desert Storm, and Operation Iraqi Freedom) and international and domestic humanitarian assistance/disaster response (HADR) missions (such as Haiti’s massive 2010 earthquake and Hurricanes Katrina and Rita).4 In 2007, the ship gained iconic status when it commenced port calls throughout the SOUTHCOM region under a HADR campaign known as Continuing Promise. Without uttering a word, the USNS Comfort hospital ship boldly signaled the presence of medical aid and humanitarian assistance, courtesy of the United States military. As recently as 2022, during Continuing Promise's twelfth iteration, the USNS Comfort made port calls to five countries in Latin America. These visits included nearly 300 surgical procedures and the dispensing of over 34,000 prescription medications by healthcare providers and pharmacists.5 These medical engagements not only saved lives but also provided substantial opportunities for diplomatic engagement, contributing to the development of social capital among leaders at all levels of the security cooperation landscape. People’s Republic of China Health Engagement Efforts The US security cooperation community has observed with a mixture of curiosity, interest, and concern the entry of the Chinese government into the realm of health diplomacy in Latin America. Throughout the COVID-19 pandemic, Chinese officials donated equipment, personal protective gear, and extended loans for Chinese-made vaccines.6 This foothold has opened significant foreign investment opportunities. For instance, the Chinese pharmaceutical giant, Sinovac, committed to constructing a USD 100-million vaccine plant in Bogotá.7 The intent to incorporate healthcare-related capabilities into China’s Belt and Road Initiative is evident, with China even referring to it as part of the “Health Silk Road.” This strategic move may serve to rebuild reputational trust that has been tarnished by debt-trap dynamics resulting from large-scale infrastructure projects.8 COVID-19 initiatives marked the latest step in China's foray into healthcare infrastructure. In early 2020, China donated USD 28 million to the government of Suriname to establish the Wanica Regional Hospital, addressing a pressing need for the underserved population on the outskirts of Paramaribo.9 During the donation ceremony, the Chinese Ambassador asserted it was the “largest donation ever made to the Surinamese government by China” and the most significant project between the two nations since establishing diplomatic relations nearly half a century ago.10 While China has not yet dispatched large groups of medical professionals to provide care in rural communities, it has initiated the deployment of teams of doctors and surgeons to embed themselves in partner-nation hospitals. Anecdotal accounts from deployed US military personnel consistently report a Chinese presence in emergency rooms, internal medicine wards, and surgical operating theaters in hospitals across Central and South America, as well as the Caribbean. A noteworthy and publicly documented example of embedded Chinese medical teams can be found at Queen Elizabeth Hospital (QEH) in Barbados. Commencing in 2016 through a memorandum of understanding signed by the Chongqing Health Commission, multidisciplinary medical and surgical teams began rotating for extended periods at QEH.11 While not a military medical team, the diplomatic and security cooperation objectives align. This relationship has even facilitated reciprocal visits for Barbadian physicians to Chongqing Medical University.12 Published news articles about these visiting Chinese medical teams convey positive sentiments. The Barbados government acknowledges their contribution in clearing surgical backlogs and suggests improved competencies among their staff. Moreover, their presence facilitates ongoing medical equipment donations, including ophthalmological cameras, anesthesia machines, and ventilators.13 Nevertheless, it remains unclear to what extent these teams have integrated into the QEH system, or if integration is even their primary goal. As of the latest information available, there have been at least five rotations of Chinese teams at QEH.14 In 2011, a watershed moment occurred in Chinese healthcare power projection. The citizens of Latin America looked out on a blue-ocean horizon and saw a hospital ship bearing the familiar red cross. However, this ship did not sail under a US flag. These Latin American countries welcomed instead, for the first time in the region’s history, a Chinese military ship called the Peace Ark.15 Although such hospital ship deployments by China in the region have been infrequent, they served as a prescient reminder of the significance of health diplomacy and as a wake-up call for USSOUTHCOM to continue leveraging its historical advantages in this sphere. Conclusion: Strategic Competition through Health Engagement What should we make of the efforts by both the US and China in the SOUTHCOM region? US military medical teams have consistently executed these highly popular missions for many decades. These GHE activities leverage deep cultural and linguistic ties shared throughout the Americas and the Caribbean. They facilitate the development of enduring professional and personal relationships, promote a shared understanding of health and medicine in the region, and foster a sense of unity against common disease threats. However, the costs remain high, leading to persistent questions about their utility and benefits. There is no dedicated funding mechanism earmarked specifically for these GHE activities. Consequently, all resource requests operate on a zero-sum basis, forcing leaders at various levels of the Departments of State and Defense, and even within Congress, to make choices between supporting GHE activities and allocating resources to other priorities. Furthermore, GHE activities are not a panacea for diplomatic challenges. Even though military medics have delivered millions of dollars in healthcare over the years, some countries in the hemisphere have withdrawn their diplomatic support and recognition of Taiwan. In the ongoing strategic competition with China, this represents just one aspect of the diplomatic landscape. Nonetheless, it underscores the complexity of diplomatic challenges in the region, where military GHE activities are just one element in a larger strategic game. As China continues to construct hospitals and vaccine production facilities in South America and integrate medical teams into Caribbean healthcare systems, the Chinese government and military are gradually undermining a key area of US influence. USSOUTHCOM Commander, General Laura Richardson, has observed that China is positioning itself in the “red zone” of US influence, skillfully wielding soft power across the Western hemisphere. To counter this assertive action, I propose three actions for the US government and military: Adequately fund and integrate military GHEs into strategic plans. Congress should establish a dedicated GHE funding authority within the National Defense Authorization Act. Ringfencing these funds would enable combatant commanders to establish a more regular and enduring medical security cooperation presence. GHE planners could then develop cohesive plans for deploying medical capacity predictably, ultimately leading to genuine healthcare capacity enhancement. This predictability would also facilitate better interagency integration. Leverage military residency training requirements to advance security cooperation objectives. In November 2022, SOUTHCOM (and its subordinate unit, Joint Task Force Bravo) signed a memorandum of understanding with the Defense Health Agency’s San Antonio Market to deploy emergency medicine faculty and residents to Central America. Multiple rotations have since occurred, establishing a sustained presence in at least one Honduran hospital. Accumulating data on this experience shows promising initial results. Combatant commands should allocate resources and promote the expansion of such models in the coming fiscal years. Expand public affairs campaigns associated with GHEs. Medical events generate positive public sentiment toward the US military presence in the region, making these stories a valuable social capital investment. Military and diplomatic leaders can then draw on this social capital during combat-related training activities vulnerable to misinformation campaigns. We must aggressively share these stories through innovative means, beyond social media and published articles. This entails embedding public affairs teams in more medical engagements, producing video documentaries and other novel media products, and even involving US and foreign news correspondents in our medical teams, thus broadening the reach of our information operations. Failure to maintain US leadership in healthcare diplomacy would needlessly squander a 50-year head start in regional medical security cooperation. Ensuring proper funding for an expanded GHE presence, coupled with diversified media channels, will enable the United States to sustain or even enhance its lead in this competitive arena. We must continue to wield the powerful lever of goodwill to fortify regional stability, foster partnerships, and bolster America’s positive influence in the region. ♦ Col Brian Neese, USAF Colonel Neese is the Command Surgeon, Twelfth Air Force/Air Forces Southern. He received a doctorate in medicine from the Medical School for International Health in 2005, a master’s degree in public health from Harvard University, a master’s degree in national resource strategy from The Eisenhower School at National Defense University, and a bachelor’s degree in Spanish from Louisiana State University. Notes 1 Jeffrey McGovern, historian, Twelfth Air Force/Air Forces Southern, interview by the author, 25 August 2023. 2 Darren E. Ewing, “New Horizons Exercise: After Action Report” (Panamá: 346th Air Expeditionary Group, Twelfth Air Force/Air Forces Southern, 2018). 3 Gentry Mobley, “Lesser Antilles Medical Assistance Team (LAMAT): After Action Report (Suriname, Guyana, and St. Lucia: 774th Air Expeditionary Squadron, Twelfth Air Force/Air Forces Southern, 2023). 4 US Navy’s Military Sealift Command, “USNS Comfort History: Medical Treatment Facility Comfort History,” US Navy (website), 2023, https://www.msc.usff.navy.mil/. 5 Deven Fernandez, “USNS Comfort Completes 12th Iteration of Continuing Promise 2022,” US Southern Command (website), 21 December 2022, https://www.southcom.mil/. 6 Diana Roy, “China’s Growing Influence in Latin America,” Council on Foreign Relations, 15 June 2023, https://www.cfr.org/. 7 R. Evan Ellis, “Colombia's Relationship with the PRC,” CSIS, 10 November 2022, https://csis-website-prod.s3.amazonaws.com/. 8 Nader Habibi and Hans Yue Zhu, “The Health Silk Road as a New Direction in China's Belt and Road Strategy in Africa,” GDS Working Paper Series (working paper, General Development Studies, Center for Global Development & Sustainability, The Heller School at Brandeis University, 16 February 2021), https://heller.brandeis.edu/. 9 “Regional Hospital Wanica Enters First Phase,” (Google translation from the original Dutch), StarNieuws, 8 February 2020, https://www.starnieuws.com/. 10 “Regional Hospital Wanica Enters First Phase,” StarNieuws. 11 Joy Springer, “Third Medical Team from China Arrives,” Barbados Government Information Service, 31 July 2018, https://gisbarbados.gov.bb/. 12 Advo Magazine. Undated. “Chinese Medical Care Safeguards Barbadians’ Well-Being,” Advo Magazine, 25 June 2023, https://advomag.com/. 13 Anesta Henry, “China Donates Critical Eye Care Equipment to QEH,” Barbados Today, 8 June 2023, https://barbadostoday.bb/; and Anesta Henry, “China Donates More Equipment to Help in COVID Fight,” Barbados Today, 8 June 2021, https://barbadostoday.bb/. 14 Alexander T. Wald, Regional China Officer for the Caribbean, interview with the author, US Embassy in Barbados, 1 October 2021. 15 Wilder Alejandro Sanchez, “The Significance of U.S. and Chinese Hospital Ship Deployments to Latin America,” The Southern Tide (blog) 16 January 2018, https://cimsec.org/.