As new coronavirus variants emerge across the world, governments are announcing further lockdowns and travel restrictions. After more than 430,000 deaths in the United States, states continue to struggle with post-holiday infection rates and overwhelmed hospitals. And hospitals continue to report shortages of critical medical supplies — including personal protective equipment.

In 2020, China — the world’s largest exporter of medical equipment — was a key source for face masks, ventilators and other equipment. China also donated an estimated $12 million in medical supplies to the United States in March and April, the first two months of the global pandemic. Did close political ties with China facilitate access to critical medical supplies? Our study provides insights from provincial-level exports and donations.

Countries criticized China’s ‘mask diplomacy’

In March, a Chinese media campaign showcasing shipments of medical equipment to other countries came under swift criticism as “mask diplomacy.” In the United States, Sen. Marco Rubio (R-Fla.) denounced Chinese donations of protective equipment as “part of a broader global strategy to portray China as a leader on the response to the COVID-19 pandemic they caused.”

Josep Borrell, the European Union’s top diplomat, pointed out that a battle for geopolitical influence was at the heart of China’s “politics of generosity.” Others criticized the images of Serbia’s president kissing the Chinese flag as a team of Chinese doctors arrived with a planeload of donated medical supplies — a move many saw as a calculated effort by Beijing to win hearts and minds abroad.

But did Chinese medical supplies really follow political ties? In the current debate of China’s mask diplomacy, critics portray the country as a single actor. This view may be too simplistic. Using official monthly trade data from the China’s General Administration of Customs, we analyzed commercial exports and aid donations of medical goods at the level of China’s provinces. More precisely, we used provincial-level trade data on face masks and other critical medical supplies during the early phase of the pandemic, in March and April, to study the role of economic and political ties in China’s export decisions. Our results show that both political and economic ties mattered for a country’s capacity to source critical medical equipment from China.

Chinese provinces played an important role in trade and aid during the pandemic

Many of China’s provinces were active in exporting and donating medical equipment during the early days of the global pandemic, in March and April. Much of the commercial exports came from southeast China, while the lion’s share of aid donations went through the capital, Beijing. As the figure below shows, the picture for donations to the United States is slightly different. Zhejiang province was the most important source of donations, while provinces and autonomous regions in China’s hinterland did not provide aid.

But we also found that the sourcing of medical equipment became more spatially dispersed during the pandemic, mirroring reports that both private and state-owned enterprises joined the production and donation of these critical goods. For instance, Chinese automotive components supplier Wanxiang Group, based in Zhejiang province, donated 1.1 million face masks to 12 U.S. states. Among the recipients was Indiana — a sister state to Zhejiang for more than 30 years.

Sister relationships may pay off in times of crisis

Our statistical results suggest that ties between Chinese provinces and their counterparts around the globe, such as U.S. states, helped secure commercial exports and donations of medical equipment. First, Chinese provinces seem to have reciprocated donations from countries that provided assistance during the Wuhan outbreak in January and February — when Beijing reportedly requested that the E.U. and other donors be discreet about the donations.

Second, we found that sister-state relationships played an important role. Having sister ties with a Chinese province — such as between New York state and Jiangsu province, depicted in the map below — more than doubled the monetary amount of medical donations from that province. For example, last February, Maryland donated 20,000 pieces of personal protective equipment to its Chinese sister-state — Anhui province. In April, Anhui reciprocated with a donation of 140,000 surgical masks.

Economic ties also helped

We also find that economic ties mattered for the volume of medical equipment sourced from Chinese provinces during the first wave in March and April 2020. Countries with firms that had invested in specific Chinese provinces in the past were able to source significantly more medical equipment from these provinces during the pandemic. Here’s an example: Minnesota-based 3M imported 10 million N95 face masks from its Chinese plant during the pandemic’s peak.

We also find that economic and political ties work as substitutes for each other. Even if countries had not established close political links to China’s provinces, they could use well-established business links with Chinese companies and obtain comparable access to critical goods.

During the early phase of the pandemic in March and April, global supply constraints created severe price hikes, revealing that many countries were dependent on China’s mask diplomacy. Since then, 3M and other U.S. producers massively expanded production of personal protective equipment, and new suppliers gained approval. But U.S. hospitals struggle to maintain recommended stockpiles of N95 masks — and many health workers are under emergency guidelines to reuse masks as coronavirus cases continue to surge.

The recent waves of infection highlight the fact that access to medical equipment remains a concern for the U.S. coronavirus effort. The Centers for Disease Control and Prevention has accepted Chinese quality standards to facilitate import procedures of personal protective equipment. As the winter 2021 wave of the virus sweeps the United States, one big question is whether political and economic ties with China’s provinces will continue to facilitate access to critical medical supplies.

Andreas Fuchs is professor of development economics, director of the Center for Modern East Asian Studies at the University of Göttingen, and head of the Kiel Institute China Initiative.

Lennart Kaplan is a postdoctoral researcher at the University of Göttingen and associated researcher at the German Development Institute in Bonn.

Krisztina Kis-Katos is professor of international economic policy at the University of Göttingen.

Sebastian S. Schmidt is a research associate and PhD candidate in development economics at the University of Göttingen and a research affiliate of the Kiel Institute for the World Economy.

Felix Turbanisch is a research associate and PhD candidate in development economics at the University of Göttingen.