Written by Chia-Shuo Tang.
Image credit: The Beira Central Hospital whose roof was destroyed during Cyclone Ida by World Bank Photo Collection/ Flickr, license: CC BY-NC-ND 2.0.
This article is a story about Taiwan’s multi-million US dollars health aid in an African country and its aftermath. It involves two hospitals, some doctors, several aid agencies, and a global pandemic intersecting at the dawn of the 21st century. In addition, this story is about how a Taiwanese hospital turned a bilateral medical aid mission into a non-governmental endeavour after severing diplomatic ties between the two countries.
This story has been retold so many times, with many versions different from each other. As a young Taiwanese anthropologist, this story intrigued me, resulting in a tortuous ethnographic journey to Africa and an ambitious dream to find traces of ‘Taiwanese health diplomacy.’ However, along the trajectory of my fieldwork, I began questioning the fundamental meaning of those categories I unconsciously deployed. Can abstract terms like ‘Taiwan,’ ‘health,’ and ‘diplomacy’ help effectively set boundaries for a story in a world where people and places are more interconnected than ever? In particular, I am talking about how we use ‘Taiwan’ as a prefix in world health and development.
Health for Whom?
I want to start with a core narrative shared among the Taiwanese health aid story(ies) I encountered. In mid-1990, Taiwan donated a 16 million US dollar hospital and stationed a medical team in an African country that once was Taiwan’s few remaining diplomatic allies.  Since the 60s, Taiwan has been in a battle with China in the international fora for foreign recognition. First, it was fighting for the seat saved for the only “China” in the United Nations and later fighting for Taiwan’s own sovereign claims of being a legit state. Therefore, amidst the diplomatic battle, foreign aid had been mobilized by Taiwan to buy ideological support from lower-income microstates, including the African country in the story.
When Taiwan’s deputy foreign affairs minister visited a local African hospital, he was not shy to admit the conditionality behind his hospitality. He said: “The project is a milestone of Taiwan’s keenness to assist developing countries who are friendly to our campaign to lobby the UN to recognize Taiwan as an independent state.”
In other words, such a project was a clear exhibition of political clientelism in Taiwan’s foreign aid policy. Other similar policies could also be found among its (ex-)allies in Central America and Pacific Islands: Taiwan, as a patron, offered monetary or technical resources in exchange for loyal acts from these weaker client states. Under such political clientelism, improving world health was more of an instrument than a pursued goal for the Taiwan government. Therefore, when the African country decided to end its diplomatic ties with Taiwan in the late 2000s and embrace China as the newly rising economic power, the Taipei government immediately terminated the health aid project and dissembled the medical team.
From a Medical Team to an International NGO
Despite the Taipei government’s firm ‘no sovereign recognition, no aid’ stance, Taiwanese doctors in the aforementioned medical team still wished to continue their humanitarian works in the absence of state resources. To achieve this goal, these Taiwanese doctors soon established an international NGO after the end of bilateral aid, and they later joined other global actors, implementing health intervention programs. Moreover, many Taiwanese news media outlets reported these Doctor’s motives (and the NGO) as part of the country’s national pride.
These reports often praised the doctors’ autism and their great contribution to helping the African countries combat HIV/AIDS. One frequently mentioned example was a specialized HIV clinic established by the medical team in a Taiwan-donated hospital. Even when the doctors were forced to retreat due to the cut-off of diplomatic relations, they gave the HIV clinic’s local staff several months of salary out of the doctors’ own pocket. Furthermore, these doctors promised a soon return, which was realized in the form of the NGO. These behaviours were proof of the Taiwanese’s selfless love and persistent commitment, even when a country’s statehood is disavowed.
But what is ‘Taiwanese health aid’ in this story(ies)? The awkwardly juxtaposed political calculation and charity in the above narrative clearly show different views on health aid between the Taiwanese government and civil society actors. According to the medical team members I interviewed, aiding African countries with HIV medicines was rejected by the Taiwan Ministry of Foreign Affairs at the beginning. The Ministry argued that addressing a disease with more than a 10% national prevalence rate would be a financial black hole. It was not until the global health HIV policy shifted toward offering Africa universal access to treatment that the Taiwan Ministry of Foreign Affairs finally agreed to the doctors’ proposal of establishing an HIV clinic for managing the flood in international medical resources.
Nevertheless, the medical team’s budget from the Taipei government was still limited due to Africa’s declining importance in Taiwan’s foreign policy. From the 90s, the attractiveness of Taiwanese aid became unmatched with the growing Chinese economic influence over Africa, resulting in the few remaining ally countries also switching sides. Under such circumstance, Taiwanese official supports in Africa were reduced. Therefore, the doctors’ decided to create their own NGO after the official medical team was disbanded while trying to find resources elsewhere in the global health apparatus. Nowadays, their NGO mainly receives funding from large the United States’ HIV donors, such as the President’s Emergency Plan for AIDS Relief (PEPFAR). In other words, instead of being part of the clientelist Taiwanese foreign aid apparatus, adopting global health buzzwords such as ‘pandemic preparedness’ and ‘universal health coverage’ to write up grant application proposals has become the NGO’s new skillset.
Health from Where and by What?
Can such a story of Taiwanese health aid be perceived as a process of becoming ‘global’? Also, not quite. I was once told by one of the Taiwanese advisors of the NGO that Taiwan was a complete outsider in the global health world because it was comprised mostly of Europeans, Americans, and their ‘Third World’ counterparts. This marginality resulted in the Taiwanese doctors’ unique stance on health intervention in developing countries. While most global health programs viewed disease and illness in Africa as a ‘public health’ problem, the Taiwanese doctors attempted to replicate their practitioner experience and standards in Taiwan, which centred on providing each individual’s best care. Therefore, while the main target amidst the HIV crisis was simplifying treatment and testing procedures (for the rationing of scarce medical resources), the medical team implemented a sophisticated electronic medical record system in their HIV clinic to better follow-up patients.
Such difference reflected how Taiwanese doctors were used to Taiwan’s well-funded national health insurance system, which guarantees uninterrupted medical service accessibility, and a highly digitized Taiwanese hospital environment where information technology specialists were ample. In addition, almost all larger hospitals in Taiwan did in-house development for their health information systems in their clinical settings. Therefore, when the Taiwanese medical team doctors attempted to deliver their international health aid to the African country, it was not surprising that they emphasized electronic medical records.
Suppose it was neither the quest for sovereign recognition nor the Western-dominated global health agenda that defined the ‘Taiwanese-ness’ of the doctors’ practice in Africa. Should we simply say that being Taiwanese denotes the doctors’ ethnical and geographical character? A quick answer is no.
Although all doctors in the medical team were from the same Taiwanese hospital, their motivation for persistent health aid (despite their changing circumstances) actually had a transnational trace. Being a Christian hospital located in Southern Taiwan, it was born out of European missionaries’ medical practices and funding from a mission Alliance. Due to such historical background, the leading doctors from the hospital were mostly Christian, and they took overseas missionary work as their duty. Therefore, when the Taiwanese foreign aid agency recruited doctors to lead the medical team in Africa, these Christian doctors volunteered without hesitation, wishing to follow the missionary medicine path that the founders of their hospitals had chosen. Furthermore, the doctors belonging to the same European missionary network also allowed the medical team to transit their health aid endeavour into an international NGO after the severance of diplomatic ties. In other words, the European connection played a role alongside the trajectory of Taiwanese health aid in the African country.
This story(ies) makes us question the multiplicity of the meaning of ‘Taiwanese health aid.’ It is simultaneously the health and beyond health, local and beyond local, global, and not-so-global. As an anthropologist, defamiliarization is the first step to opening up my perception Such a step is the premise of truly becoming a vehicle capable of viewing the world from the interlocutors’ perspective. Unfortunately, such defamiliarization also means that we anthropologists are doomed to weave and spin morally ambiguous story(ies). However, it is also exactly at those moments when we should temporarily put categorical terms into a bracket. Under such conditions, we can foreground the unexpected connections between things, spaces, and places and inscribe the terms we once used with new possibilities.
 Readers should be noted that due to my ethical obligation as an anthropologist, I cannot specify the African country where the story takes place. This decision is to prevent potential harm to my interlocutors. I also believe anonymization fits the purpose of this article better, which is less about what actually happened but more about how a story becomes story(ies): a juxtaposition of different ways of weaving together the same set of things, so that we can gain some reflective insights about how our preconceptions works and hence more or less transcend it.
Chia-Shuo Tang holds dual identities of being an NGO worker and an anthropologist. He is a project coordinator at Open Culture Foundation and a Ph.D. candidate in the Health, Care, and the Body program group at Amsterdam Institute for Social Science Research, University of Amsterdam (AISSR). Chia-Shuo Tang’s interest lies at the intersection of quantification, information technology, and global governance, especially in the context of North-South dynamics in transnational aid or development projects.
This article is published as part of a special issue on Health Justice in Diversity.