In her recent Foreign Affairs essay, The Taiwan Temptation: Why Beijing Might Resort to Force, Center Fellow Oriana Skylar Mastro argues that Chinese leaders now consider a military campaign to take Taiwan a real possibility and cautions that the United States cannot by itself alter Beijing’s calculus on Taiwan. The essay sparked a heated debate. In the September/October issue of Foreign Affairs, several scholars — Rachel Esplin Odell and Eric Heginbotham, Bonny Lin and David Sacks, and Kharis Templeman — provide counterarguments to Mastro's analysis and she responds to their criticism. Read her complete rebuttal below.

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Rachel Esplin Odell and Eric Heginbotham, Bonny Lin and David Sacks, and Kharis Templeman all argue that China is unlikely to attempt armed unification with Taiwan. Although I appreciate their perspectives, they do not present any new evidence that would make me reconsider my assessment that the risk of Chinese aggression across the Taiwan Strait is real and growing. To the contrary, they repeat many of the increasingly dangerous misperceptions that I sought to dispel in my original article—namely, that China does not have the military capabilities to pull off an amphibious invasion, that the economic costs of an invasion would be sufficient to deter Chinese President Xi Jinping, and that China can afford to wait indefinitely to achieve its most important national goal of unification. My critics assume that insofar as there are risks, they can be dealt with through relatively limited adjustments in U.S. policy and military posture — a position with which I still strongly disagree. 

Let’s take these arguments in order. My critics say that I have exaggerated China’s military capabilities and understated the difficulties of an invasion. But their assessments rely on outdated or largely irrelevant comparisons. Odell and Heginbotham, for instance, note that the United States needed more naval tonnage to capture Okinawa from Japan in 1945 than China has today. But this example is inapposite. Japan’s military was more than six million strong in 1945 and had been fighting for over a decade; Taiwan’s military consists of 88,000 personnel and two million reservists, of whom only 300,000 are required to complete even a five-week refresher training course. Tonnage, moreover, is not a useful metric. Modern navies have moved to lighter, more flexible fleets. Odell and Heginbotham point out that civilian ships were of only limited use in the Falklands War, but the United Kingdom used just 62 of them in that campaign. The People’s Armed Forces Maritime Militia has many thousands of ships and is closer to a naval force than a civilian one. If China were to mobilize all its naval vessels, including its new large amphibious transport ships and civilian ships, it could hypothetically carry hundreds of thousands of troops across the 80-mile-wide Taiwan Strait in a short period of time. Even if the United States had enough warning to optimally position its submarines, it does not have enough munitions to target such a large force. 

For their part, Lin and Sacks argue that to believe China can take Taiwan by force is to fall for a Chinese misinformation campaign. They warn that “analysts should not accept at face value China’s claim that it could easily win a fight against Taiwan.” But no one, not even the cockiest of People’s Liberation Army analysts, argues that a full-scale attack on Taiwan would be easy, only that the PLA could prevail at an acceptable cost. Moreover, my assessment of Chinese military capabilities is not based on Chinese discourse or the results of war games alone. Reams of unbiased and rigorous analysis—from the U.S. Department of Defense’s annual report to Congress on China’s military modernization to Congressional Research Service reports on Chinese naval modernization to hundreds of studies by think tanks and defense-affiliated organizations, such as the RAND Corporation—suggest that the PLA has made unparalleled advances in the past two decades and could take on the United States in certain scenarios. Indeed, Heginbotham himself argued in 2017 that “the balance of power between the United States and China may be approaching a series of tipping points, first in contingencies close to the Chinese coast (e.g., Taiwan).” 

I do not mean to suggest that a Chinese invasion would be a cakewalk. Taiwan could get some shots in, but it does not have the ability to defend itself. Luckily, the United States would, I believe, come to Taiwan’s aid and could still prevail in many scenarios. Taiwan is far from a lost cause. But ten years ago, the United States would have prevailed in any scenario. Because there are now some scenarios in which U.S. strategists think the United States could lose, it is not unfathomable to think that Chinese strategists have come to a similar conclusion. 

My critics also argue that economic considerations will deter Beijing. Should China attempt to use force to assert control over Taiwan, the international response would be severe enough to imperil Xi’s ambitious development goals. But as I argued in my original article, Chinese analysts have good reason to think the international response would be weak enough to tolerate. China could even reap economic benefits from controlling Taiwan, whose manufacturers accounted for more than 60 percent of global revenue from semiconductors last year. The United States is heavily reliant on Taiwanese semiconductors. Should China take Taiwan, it could conceivably deprive the United States of this technology and gain an economic and military advantage. 

But economic costs or benefits, while part of Beijing’s calculus, are unlikely to be the determining factor. Xi’s top priority is protecting China’s sovereignty and territorial integrity—as Beijing defines it. China’s Belt and Road Initiative, its militarization of the South China Sea, and its sanctions against countries that offend it, such as Australia or South Korea, all demonstrate that Chinese leaders are willing to subordinate economic considerations to considerations of power and prestige. In a speech marking the 100th anniversary of the Chinese Communist Party in July, Xi warned against foreign attempts to bully or oppress China, declaring that “anyone who dares try to do that will have their heads bashed bloody against the great wall of steel forged by over 1.4 billion Chinese people.” Those words should be taken seriously. 

Finally, my critics argue that China has no need to attempt to forcibly unify with Taiwan. Lin and Sacks think peaceful unification is working; Templeman believes China can wait indefinitely to resolve the issue. I disagree because I think unification is a top priority for the Chinese Communist Party and Taiwan will not give up its autonomy without a fight. 

A Chinese invasion is by no means imminent or inevitable, but Beijing is now seriously considering initiating a conflict to gain political control over Taiwan, whereas in the past the only scenario in which it would have used force was to prevent Taipei from declaring independence. I agree with Templeman that China is unlikely to invade in the next four years (although I think this is largely because China could benefit from more time to prepare, not because it fears U.S. President Joe Biden’s resolve), but his argument that China can wait indefinitely is logically and empirically flawed. As I argued in my original article, Xi has made numerous statements that suggest he wants to achieve unification during his reign. It would be unwise to dismiss these as mere rhetoric, since he has repeatedly voiced his intention to assert control over other territorial claims before doing exactly that — in the South China Sea, by building military infrastructure and conducting naval drills, and in Hong Kong, by imposing a harsh national security law last year.

Templeman argues that if China believes the United States is in decline, then it has every reason to wait on Taiwan. But in the eyes of Chinese strategists, American decline actually hastens the need for action. Power transition theory, which holds that war becomes more likely as the gap between a rising power and an established great power diminishes, is also studied in Beijing. And although U.S. strategists fret that a rising China, dissatisfied with the U.S.-led international order, will become aggressive and start a conflagration, Chinese strategists fear a different pathway to war. They worry that the United States, unable to accept its inevitable decline, will make a dangerous last-ditch effort to hold on to its unrivaled great-power status. By this logic, a declining United States is more dangerous than a stable, ascendant one. 

Lin and Sacks make a different argument for why Beijing does not need to attempt armed unification. They believe that Chinese leaders remain committed to their long-standing approach of limited coercion coupled with economic incentives showcasing the benefits of unification because that strategy is working. As evidence of Beijing’s progress, Lin and Sacks point to polling that shows the majority of people in Taiwan support the status quo, not independence. But it is an enormous leap from not supporting independence to desiring or conceding to unification. As Lin and Sacks themselves acknowledge, China has employed this strategy of limited coercion and economic inducements for decades, but Taiwan is no closer to being a part of mainland China. In a September 2020 poll conducted by National Chengchi University, only six percent of Taiwanese citizens preferred eventual or immediate unification. So although Lin and Sacks are correct that Beijing will likely continue with its carrot-and-stick approach, it will still need to put boots on the ground to gain full political control of Taiwan. 

My critics also raise concerns about some of the policy implications of my argument. Odell and Heginbotham warn against focusing too much on the credibility of the U.S. military threat when it comes to deterrence, rightly highlighting the equal importance of reassurance. They warn that changes in U.S. policy toward Taiwan could convince Beijing that the United States now supports Taiwanese independence — a misperception that could lead to war. But my argument is for a change in posture, not in policy: the United States should develop the force posture and operational plans to deny China its objective in Taiwan and then credibly reveal these new capabilities. It should not make dangerous policy changes that would risk provoking a Chinese military response. Indeed, I have argued elsewhere that even if a war breaks out over Taiwan and the United States wins, Washington should not demand Taiwan’s independence as one of the terms of peace. 

Templeman raises a separate concern: that highlighting the potential costs of defending Taiwan could bolster the case of those advocating that Washington abandon Taipei. If this were a serious worry, I would be the first to shift my work to more private channels. But those calling for the United States to reconsider its commitment to defend Taiwan are still in the minority, and the Biden administration has been clear that it would come to Taiwan’s aid in the event of an invasion.

Moreover, the reaction of the U.S. Department of Defense to the threat posed by China’s growing military power has been not to back down but to ramp up efforts to counter it. From new doctrines that enhance joint capabilities between the U.S. Air Force and the U.S. Navy to base-resilience initiatives to efforts to improve U.S. early warning systems in the region, the Pentagon is firing on all cylinders to ensure it can deter and, if necessary, defeat China in a wide range of conflict scenarios. U.S. Cyber Command, the U.S. Space Force, and the Department of Defense’s Joint Artificial Intelligence Center were all established partly to counter Chinese advantages in those organizations’ respective domains. If Lin and Sacks are correct that China exaggerates its capabilities to try to convince the United States to give up, Beijing has achieved the opposite.   

In the end, all my critics highlight an important truth: the situation across the Taiwan Strait has been relatively stable for 70 years because of the United States. Washington has managed to convince Beijing that armed unification would fail and that China would pay a hefty price for trying. But China is not the same country it was 70 years ago. Its rapid military modernization, spectacular economic ascent, and growing global influence have changed Beijing’s calculus on many issues. It has taken a more assertive approach to international institutions; built one of the world’s largest, most capable militaries; and extended its economic influence deep and far throughout the world. It would be wishful thinking to assume that China has not also changed its thinking on Taiwan.

Indeed, although my critics argue that China is unlikely to invade, they still recommend that Taiwan improve its defenses and that the United States enhance its military posture in the region — not exactly a vote of confidence in Beijing’s restraint. I had hoped to convince skeptics that China is now seriously considering armed unification, but at least our debate has yielded a consensus that more must be done in Taipei and Washington to enhance deterrence across the Taiwan Strait.

This article was first published in Vox China. Read the full article online.

In this relatively well-insured population, annual health care utilization significantly increases primarily because of more intensive use of outpatient care at retirement. This increase in outpatient care stems from a decline in the patient cost-sharing rate, the reduced time constraints upon retirement, and the interaction of these factors with supply-side incentives such as prescribing antibiotics. There is no evidence of change in inpatient care at retirement.

The economics of medical expenditure growth and its interaction with population aging is of considerable policy importance for countries in all income groups. “Our findings may provide useful evidence as one consideration for policymakers in other cities in China and elsewhere looking to increase insurance benefits and control medical spending for burgeoning elderly populations.

Modeling Health Outcomes Among East Asian Populations

The chronic progression to diabetes-related complications is apt for computer simulation modeling due to the long-term nature of health outcomes and the time lag for interventions to impact patient outcomes. It is problematic, however, to estimate the impacts of health interventions on East Asian populations with diabetes using existing models, which were developed and validated in European and North American populations with different epidemiology and outcomes.

To fill in this gap, Eggleston and her colleagues set out to develop and validate an outcomes model for the progression of diabetes and related complications in Chinese populations. They compared this new model, called the Chinese Hong Kong Integrated Modeling and Evaluation (CHIME), to two widely used existing models developed and validated in the United Kingdom (known as the United Kingdom Prospective Diabetes Study Outcomes Model 2, or UKPDS-OM2) and in the United States/Canada (called Risk Equations for Complications of type 2 Diabetes, or RECODe). Despite the continuum of risk across the spectrum of risk factor values, these two existing models ignore the progression from prediabetes to diabetes.

The CHIME integrates prediabetes and diabetes into a comprehensive model comprising 13 outcomes. These include mortality, micro- and macrovascular complications, and the development of diabetes. The researchers developed the CHIME simulation model using data from a population-based cohort of 97,628 participants in Hong Kong with type 2 diabetes (43.5%) or prediabetes (56.5%) from 2006 to 2017. Known as the Hong Kong Clinical Management System (CMS), this cohort makes one of the largest Chinese electronic health informatics systems with detailed clinical records. 

The next step was to externally validate the CHIME model against individual-level data from the China Health and Retirement Longitudinal Study (CHARLS) cohort (2011-2018), a nationally representative longitudinal cohort of middle-aged and elderly Chinese residents age 45 and older. The researchers validated the CHIME model against six outcomes measures recorded in the CHARLS data and an additional 80 endpoints from nine published trials of diabetes patients using simulated cohorts of 100,000 individuals.

Towards Reducing the Disease Burden of Diabetes

The researchers found that the CHIME model outperformed the widely used UKPDS-OM2 and RECODe models on the data used, meaning that the validation of the CHIME model was more accurate for trials with mainly Asian participants than trials with mostly non-Asian participants. The results indicate that the CHIME model is a validated tool for predicting the progression of diabetes and its outcomes, particularly among Chinese and East Asian populations, for which the existing models have been unsuitable.

With the new model, clinicians and health economists can evaluate population health status for prediabetes and diabetes using routinely recorded data and therapies related to the long-term management of diabetes. In particular, the CHIME outcomes model enables them to assess patients' quality of life and measure cost per quality-adjusted life-years over the long-time horizon of chronic disease conditions. The new model thus supports the economic evaluation of policy guidelines and clinical treatment pathways to tackle diabetes and prediabetes, address micro- and macrovascular complications associated with these conditions, and improve life expectancy.

Working across linguistic and cultural differences, students in the China Scholars Program (CSP) and Stanford e-China (SeC) met and collaborated online as partners, from opposite sides of the world, in November and May. The two programs focus on different themes—U.S.–China relations writ large (CSP) and emerging technologies through the lens of design thinking (SeC)—but found common ground in finding local solutions to environmental sustainability problems.

The students were divided into groups, each including both U.S.- and China-based members. Each student shared a sustainability issue that they observed in their home communities—discovering similar issues around recycling, food waste, and environmental pollution, in particular. The group then selected one problem to focus on and brainstormed a specific solution targeted at a specific user group using the design thinking process. Finally, they shared creative presentations of their process and their proposed solutions with both classes. 

Although these projects have real-life applications—with at least one group intending to go forward with actually prototyping their idea to see how far they can take it—the true challenge of this assignment for the students was to figure out how to collaborate across technological, cultural, and (to a lesser extent) linguistic barriers and solve a common problem together. It was not easy. But many students reported that it was one of the most rewarding and memorable experiences in their program. We hope it will seed the skills they need for cross-cultural collaborative problem-solving in the future.

Following the joint project, students sent reflections to CSP Instructor Tanya Lee and SeC Instructor Carey Moncaster, marveling at how much they had in common, and at the value of their differences. An American student noted, “Working with students from [China] showed me what true cross-cultural collaboration is like. It was cool to see how cultural differences affect the way in which people approach and work on a task and how collaborating with people who work differently than you can produce better results or help you see things in a new way.” Reflecting a similar team-driven sentiment, a Chinese student noted, “There are more similarities than differences that divide us. We really need to promote communication between individuals in two countries instead of knowing the other country from the authorities’ slogans.”

Fall 2020 marked the inaugural session of the Stanford e-China Program, an English-language, online program for high school students across China exploring current technological innovation and human-centered brainstorming strategies. The China Scholars Program completed its seventh and eighth sessions this past year, bringing together students from all over the United States to study the politics, economics, and society of contemporary China. Both programs feature lectures and discussions with Stanford University faculty and are offered twice annually, in fall and spring.

Applications for the Fall 2021 Stanford e-China Program are currently open with a final deadline of September 1, 2021. 

Applications for the Spring 2022 China Scholars Program will open in September, due November 1. (Applications for Fall 2021 have closed.)

This commentary was first published by The Lowy Institute.

Two recent naval exercises demonstrate the potential for Russia-China cooperation in the Indian Ocean, and how the two present a much greater threat to a continued US role and influence in the region than either would individually.

Last year, South Africa hosted a maritime exercise with Russia and China, the first-ever trilateral exercise among the three countries. Exercise Mosi was designed, according to the South African Navy, to “enhance interoperability and maritime security“ and showed the three countries’ willingness to work together to counter security threats at sea, such as terrorism and piracy. There were the obligatory social and cultural activities, and then military maneuvers that focused on a surface gunnery exercise, helicopter cross-deck landings, boarding operations and disaster control exercises.

China and Russia followed this up in December 2019 with another trilateral maritime exercise with Iran in the Gulf of Oman called Exercise Marine Security Belt. The exercises included live-fire drills and an anti-piracy exercise involving Iranian commandos. According to the Iranian naval commander, the exercises’ message was that “Iran cannot be isolated.” A Chinese spokesman stated: “The naval drills aim to deepen exchange and cooperation among the navies of the three countries, and display their strong will and capability to jointly maintain world peace and maritime security”.

Both China and Russia have gradually been increasing their presence in the Indian Ocean. Russia recently announced it would establish a naval facility in Port Sudan on the Red Sea. China opened its first overseas base in Djibouti in 2017, and China’s navy has increased operations in the Indian Ocean region over the past three decades.

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The Covid-19 crisis may have slowed further moves towards cooperation this year. Moscow just hosted the 12th BRICS summit virtually, which doesn’t lend itself to deep military engagement. But the trilateral exercises are notable because they signal Moscow’s and Beijing’s desire to cooperate in the region. And more importantly, they reveal that regional powers such as South Africa and Iran, as well as other countries, welcome the increased role of China and Russia.

Relations between South Africa and the United States were already strained when Pretoria agreed to the trilateral exercises last year. Under the Trump administration, the United States grew critical of South Africa’s UN voting record. Washington also declined to exempt the country from hikes in tariffs on US imports of steel and aluminum. In contrast, China has pledged the most investments of any country in South Africa. Russia has followed in its footsteps in building political, military and trade ties across sub-Saharan Africa.

Iran has even more reason to build relations with China and Russia. Since the US withdrawal from the Iran nuclear deal in 2018, Iran has strengthened its ties to China and Russia, using multi-billion-dollar loans from the two countries to resist US sanctions and deepening defense cooperation and intelligence sharing.

Smaller countries can also find the Russia-China nexus useful. According to a Chinese-language source, Sudan, a long-standing regional partner of China, first proposed hosting a Russian base in 2017 as a counterbalance “against aggressive acts of the United States”.

In other words, China and Russia together may be better equipped to compete with the United States and its allies in the Indian Ocean region for influence, for several reasons.

Moscow may be more willing than Beijing to play the ringleader role in organizing and directing opposition against the United States, but it doesn’t have the economic heft to make such cooperation a winning proposition for Indian Ocean states.

While China has considerable resources, it is more concerned about provoking the United States and potentially worsening already poor relations. China often argues that it is a different type of great power, one that does not engage in hegemonic behavior such as alliance formation. China is also keen to avoid sparking a countervailing coalition against it.

For these reasons, Beijing often tones down its rhetoric about the nature of its relationship with Russia. China claimed the Indian Ocean exercises do “not target any third party”. For Russia, however, overtly undermining the United States is a key component of its strategy and plays well domestically for Putin.

On the other hand, China has the economic resources to wield influence and invest heavily in Indian Ocean countries. In Pakistan alone, Beijing has pledged an estimated $87 billion in funding and completed roughly $20 billion worth of projects. Recently, Beijing and Tehran reportedly agreed to a 25-year deal to expand China’s investment in Iranian banking, telecommunications, ports and railways in exchange for oil.

While China and Russia are nowhere near dominating the Indian Ocean region militarily, their combined influence may promise trouble for the United States and its partners. The two countries will likely work together to inure their partners to international pressure, including over human rights violations. And those partners will receive security benefits (such as military access) and economic benefits (such as preferential economic ties) in return. Although it seems a bit exaggerated, there is some truth to Iranian Admiral Hossein Khanzadi’s declaration that strategic coordination with Russia and China means “the era of American free action in the region is over”.

China and Russia may be slow in enhancing their strategic coordination in the Indian Ocean slowly, but the intent is there. The United States and its allies may still be dominant militarily. But we should be careful not to fall under the illusion that this guarantees influence. With China and Russia presenting themselves as strong alternative powers, the United States and like-minded countries have to work that much harder to promote sustainable economic development, protect international rules and norms, and ensure peace and security in the region.