The People’s Republic of China has engaged in “health diplomacy” almost since its founding in 1949. Over the course of the 1950s and ’60s, a still-impoverished China sent a total of 6,500 trained medical personnel on assistance missions to over 40 countries and funded the construction of more than 20 medical institutions around the world.

Back then, China’s willingness to spend on foreign aid was driven by a need to find and foster friends amid the tense atmosphere of the Cold War. Guided by the principle of “the poor helping the poor” and an idealistic commitment to national liberation and self-reliance, China dispatched medical teams to African countries and helped fortify the medical infrastructure of fellow communist states like Mongolia. In the words of the country’s premier and lead diplomat, Zhou Enlai: “We would provide sincere help to any independent country. Our assistance is to make (that) country able to stand up.”

These principles also influenced China’s attitudes toward aid offers from developed countries. National leaders’ desire for self-reliance made them reluctant to accept outside help, with the early exception of technical assistance from the Soviet Union. Even after China joined the World Health Organization in the early 1970s, it continued to rebuff WHO offers of aid out of a desire to show its independence — as well as generosity to other nations in need.

This high-minded approach to international aid changed drastically with the advent of the “reform and opening-up” period in 1978. Outgoing health assistance was reframed not as a political issue, but as an opportunity for mutually beneficial technical cooperation. The number of medical teams China sent overseas dropped between the late ’70s and ’90s, as the country began requiring recipient countries to bear some of the costs associated with relief work.

Meanwhile, China was becoming more open to the idea of receiving assistance, including health aid, from outside its borders. Traditional providers of development assistance, including the World Bank, United Nations, and advanced economies, grew increasingly involved in the design and development of China’s health and disease control systems. They provided the country with loans, funding for medical facilities, and free technical training and medical supplies.

This aid proved hugely beneficial, not least in helping the country bring its hepatitis B epidemic under control. One 1992 study estimated almost 10% of Chinese had been infected with hepatitis B, in part because the country was unable to produce or purchase the vaccine in sufficient quantities.

Pharmaceutical company Merck originally planned to market its hepatitis B vaccine in China, but soon concluded the price was far higher than the average Chinese family could afford. Instead, it transferred the associated technologies for just $7 million — which it then spent on building a manufacturing plant in the country and carrying out training. By 2014, the prevalence of hepatitis B among Chinese children under the age of 5 had dropped to 0.32%.

The next watershed moment in the development of China’s public health and international development strategies was the 2003 SARS epidemic. That coronavirus-caused disease killed almost 350 people on the Chinese mainland and had a profound impact on both the national economy and society.

Among other revelations, severe acute respiratory syndrome woke China up to the reality of how public health crises could affect its international image. The country soon began reemphasizing health cooperation in its international development agenda, this time with a greater focus on working through multilateral institutions like the WHO.

Taking advantage of a booming economy over the next few years, the Chinese government scaled up aid for developing countries. For example, in 2009, China committed to providing medical equipment, supplies, and trained medics to dozens of hospitals and anti-malaria institutions in Africa. And after the 2014 Ebola outbreak, China not only actively offered emergency humanitarian assistance, but also participated in the development and construction of the African Centers for Disease Control and Prevention — the health agency of the African Union.

In short, Chinese attitudes toward international health cooperation have varied over the years, according to both its own material conditions and its relations with the outside world. But the recent trend has been toward integration with the international system for mutual benefits.

The global fight against COVID-19 has done little to alter this stance. China has focused on fulfilling its obligations as a responsible member of the international community, including by offering health assistance to other nations struggling to bring the disease under control. At present, China has provided aid to over 140 countries, sent several medical teams overseas, and made two donations totaling $50 million to the WHO.

Some international critics have tarred this aid as a cynical means of boosting the country’s geopolitical standing or an attempt to cover up for earlier policy failings. Others have cast suspicion on efforts made by charitable groups and associations early in the pandemic to buy and ship needed protective gear to Chinese hospitals.

A look at the history of Chinese development aid suggests the country’s actions are merely a continuation of past trends. And in fact, much of its recent outgoing aid mirrors the significant help China received from countries and international organizations in the early stages of its own outbreak. As the virus has spread, the country has emphasized it would not forget those who had extended a helping hand in its hour of need.

Of course, not everything has gone smoothly. The quality of Chinese-produced protective materials and diagnostic kits have come under intense scrutiny abroad, with some countries criticizing it for exporting substandard products.

It’s true that, as overseas demand soared, a number of manufacturers took advantage of differences in international quality standards or turned to unqualified certification firms to get their exports approved. This pursuit of short-term profits by a few individual firms has dealt a blow to the reputation of Chinese manufacturers everywhere. In response, the Chinese government issued a notice March 31 requiring exported materials not just to meet the requirements of a given importing country or region, but also obtain certification according to Chinese standards.

The COVID-19 pandemic is in many ways unprecedented, and everyone is still searching for effective solutions. Complicating matters, countries that might once have led the global response have instead abdicated their responsibilities. In the resulting vacuum, China’s every action has been put under the microscope in ways the country may not have been prepared for: European media outlets have blasted China for over-hyping its foreign aid, and even sending medical teams to African countries has been characterized by local media as somehow belittling the professional competence of the continent’s doctors.

Rather than allow itself to be frustrated by what it perceives as unfair criticisms, China needs to understand and sympathize with dissenting voices in the course of upholding its international responsibilities. And a more low-key approach to publicity might be in order. Historically, China itself has associated receiving aid with weakness, so it should come as no surprise that other countries might feel the same way. Besides, even if China’s earlier success in controlling the coronavirus was facilitated by aid and supplies from abroad, it ultimately came down to its own hard work and sacrifices made by millions of Chinese. The same is true of Italy, South Korea, Germany, and all the other countries that have “flattened the curve,” thanks to the work of their policymakers and residents.

There is still a long way to go to before anything like victory against the coronavirus can be declared, and international cooperation will remain vital to global health initiatives for the foreseeable future. China is working hard to show its sincerity and commitment to international cooperation, but assuaging other countries’ doubts will take empathy, understanding, and effective communication.

Translator: David Ball; editors: Lu Hua and Kilian O’Donnell.

(Header image: A worker unloads medical supplies donated by the Chinese government in Ljubljana, Slovenia, May 1, 2020. Peng Lijun/Xinhua)