To explore new avenues of potential U.S.-China cooperation and address a looming domestic healthcare crisis, including a projected shortage of nearly 190,000 new registered nurses annually through 2032, the Monitor spoke with Dr. Kate Zhou. In this conversation, we discuss how integrating Chinese cultural competency with U.S. standard nursing can improve outcomes for diverse senior populations, the strict compliance strategies required to navigate complex immigration frameworks, and how subnational partnerships can build resilient, people-to-people exchanges despite heightened geopolitical tensions.
Dr. Kate Zhou has been teaching American Politics, Asian Politics, and Chinese Development for over 31 years at the University of Hawaii, establishing herself as an expert in her field. She is also the founder of Education Advancement Fund International, which received the prestigious 2006 Templeton Freedom Award for its Small Loan Initiative for Rural Women in Xiangxi, China. This pioneering program empowers disadvantaged women through education, vocational training, and small-business loans.
Elijah Shoaf: So this initiative, the IMNTIP, seeks to address Hawaii’s nursing shortage by integrating US standard nursing skills with traditional Chinese medicine and Taoist wellness concepts. So how does such a hybrid approach to healthcare training improve the outcomes for Hawaii’s culturally diverse and particularly Asian Pacific senior populations compared to the traditional Western nursing models?
Kate Zhou: Let me begin by being precise about what I mean by ‘hybrid’, because the word can be misread. When I use that term, it means the American standard of nursing, full stop. The participant must complete a Hawaii state-approved nursing aide course through a partner school, like a community college or a local Hawaiian nurse training center. We’re training on American precepts to help solve the American shortage problems.
With that said, we do need help from people from the Asia-Pacific. Given today’s political environment, it’s very important this collaboration involves the Philippines. We know there is a lot of conflict between the Philippines and China, and between the U.S. and China. Right now, even if Chinese students are qualified to get training, they will often struggle to get a visa to come to the United States. But Chinese nursing concepts really can help. That’s why we collaborate with the Filipinos. In both China and the United States, 80% of nurses and nurse aides are from the Philippines—please keep that number in your mind.
That’s why the training must meet American standards. Participants first get an associate degree in nursing, then they take the registered nurse exam—the NCLEX. Once you pass the American NCLEX exam, you can work anywhere in the world: Japan, Europe, and many other places. It’s important to note that nothing in the program allows a trainee to diagnose, prescribe, or perform any traditional Chinese medicine procedures on the patient. We are very deliberate about that.
The traditional Chinese medical background is not a competing clinical system with the American system. It provides a depth of cultural competency that Western nursing education rarely touches, because it comes from lived experience rather than a one-week diversity module. We chose Hawaii for this pilot program because it includes a large population of Chinese, Japanese, Korean, Filipino, and other Pacific Islanders. Many of them speak very limited English, especially late in life when a second language tends to fall away. They hold specific ideas about food, heat, cold, family obligations, and the end of life. These cultural beliefs shape whether they follow an American standard care plan, how they report pain, and whether they trust the person at their bedside.
Our program produces a caretaker who understands both cultures. For example, if you have an 80-year-old Cantonese-speaking grandmother who refuses to drink ice water, what do you do? Our trainees are prepared to address those kinds of concerns, or to understand how a family expects to be present for important end-of-life decisions. A culturally competent caretaker gets better patient adherence and prevents avoidable crises. This is the added value of combining Filipino and Chinese cultural understanding with nurse training. The outcomes improve in communication, trust, and the daily work of long-term care that never shows up in a hospital chart but ultimately determines the quality of a senior’s late life.
The telehealth component follows the same logic. The Palolo Chinese Home in Hawaii, for instance, serves elders scattered across the islands who have very few providers. They are really in a crisis. Having a bilingual trainee who can help a senior in Kauai, the Big Island, or Maui use a video consultation system addresses a real access gap. These are professionals trained in the Hawaiian system who understand American healthcare issues but also possess the language and cultural abilities to bridge those gaps.
Ultimately, our claim is modest but important. We are not replacing Western nursing; we are supplementing it with people who can reach patients that the current U.S. workforce cannot, especially low-income populations.
Elijah Shoaf: This program aims to bridge US standard nursing education with Traditional Chinese Medicine (TCM) and Taoist wellness concepts. From the perspective of public diplomacy and soft power, how does integrating TCM into American eldercare, while concurrently training Chinese nurses to Western standards, help reshape mutual perceptions and build trust between American and Chinese societies?
Kate Zhou: As a political scientist, I’m cautious about the phrase “soft power” because it usually describes what a government project does. What we are doing is closer to the opposite. This is a people-to-people exchange built around shared, unglamorous problems. Both societies are aging fast. Neither has enough trained caretakers. When the subject is grandmothers rather than geopolitics, the conversation between Chinese and American partners becomes surprisingly practical.
The exchange runs in both directions, and that symmetry matters. On the American side, care home families in Hawaii encounter young Chinese professionals not as an abstraction in a news story, but as a real person helping them out, bathing their mother, and talking with them.
On the Chinese side, nursing colleges in Harbin, Hong Kong, or Wuhan—where I come from—are getting a structured window into how American long-term care actually works. They see its regulatory rigor, its emphasis on patient autonomy and privacy, and its licensing standards. Chinese professionals can learn these American concepts and take them home. Whether the trainees go home or stay to build careers here, they carry a realistic picture of the other society rather than a caricature.
Trust between countries is built exactly this way: one credible relationship at a time. I consider this true public diplomacy. I don’t think any other program can match this. Doing something apolitical but helpful is the best public diplomacy.
I want to be clear about the limits of that claim, too, because this program is not an instrument of any government. It receives no funding or direction from Chinese state bodies. Its partners on the Chinese side are educational institutions. Everything it does in Hawaii happens under U.S. law, U.S. licensing standards, and the academic authority of an American college. Any public diplomacy benefit is a byproduct of doing honest work well, not the goal of pursuing a government’s agenda. I’m an American citizen, and I want to emphasize that.
I would also note that Hawaii is a natural place for this pilot program to start. It has a century and a half of Chinese-American history and institutions like the Palolo Chinese Home that were founded by that community, a population that has never treated Asia as foreign. If any state can model a form of U.S.-China cooperation grounded in service rather than rivalry, Hawaii is the one.
Elijah Shoaf: So, the pilot program’s launch highlights the necessity of navigating evolving and complex U.S. immigration frameworks, such as F1 student visas, and the legal differences between an educational practicum and actual labor. Given this, and the increased scrutiny on U.S.-China educational exchanges in recent years, what strategies is your program employing to mitigate the risks that could impede Chinese trainees from participating?
Kate Zhou: Excellent question. My answer to scrutiny is to be the most compliant program in the field and to be transparent about it. The paradigm is built around a series of gates that must be closed before we recruit a single student.
The most important one is written confirmation from a partner school’s international office and from U.S. immigration counsel on the questions that actually get programs into trouble: What academic status are participants enrolled under? Who issues the I-20? Is the practicum strictly observational or something else? For example, our partners such as local training programs must have the proper authority in Hawaii. We also have to clarify how living support affects labor classifications, and we must get those answers in writing.
We cannot collect significant non-refundable money tied to a U.S. internship or U.S. work, and we do not market the program that way. We want to be honest with the U.S. government that, in the long run, we are providing a nursing internship because there is a severe need for it. Some trainees may prefer to go back to China, while others may stay—there is a special visa for nurses in the United States. I’ve been working on this, and the State Department is actually very reasonable.
The second strategy is structural. The partner school retains full academic authority. Our program does not guarantee admission, credits, visas, licenses, or employment, and every student contract explicitly says so. Practicum sites must confirm in writing that students are not counted toward minimum staffing and do not substitute for regular employees, because they are not allowed to work. Students can often work on campus, but right now, we are seeking federal allowances for them to do nursing internships in low-income community care homes.
We also maintain four separate money streams: school tuition, project fees, third-party living costs, and restricted donations. This ensures no one can possibly characterize the program as a labor pipeline dressed up as education. That financial separation is also what allows a school, a care home, or a foundation to sign off only for the piece they actually control.
Third, we start small on purpose: 20 to 30 participants over an 18-month phase. We require a formal go/no-go decision by the governing body and a complete audit before anyone talks about scaling up. We are also diversified on the sending side, with conversations in Harbin, Hong Kong, and Wuhan. Recently, someone in Changsha contacted me from a school established by the Yale University School of Medicine, and they are very interested in sending their medical professionals. We may also open up to South Asian partners in the future so that the program’s viability does not depend on the political weather in a single jurisdiction.
If a regulatory gate cannot be closed, the plan calls for a halt or a redesign, not a workaround. That discipline is what lets this program survive scrutiny rather than attract it.
I should also add that we take the current political environment seriously rather than wishing it away. Visa policies for Chinese students can be unpredictable. A program like ours has to assume that some qualified candidates will not receive a visa through no fault of their own. That is why participants who are not yet ready, or who cannot obtain status, remain in a preparatory school in their home country or go to the Philippines first. The training on the Chinese side has value on its own terms. We would rather delay a cohort than put a single student in a position where they have to pay for something the U.S. government has not approved.
Elijah Shoaf: As we discussed, there are significant domestic vulnerabilities in the U.S. nursing market, with an estimated shortage of 193,000 new registered nurses annually. Policymakers rightly view this as an issue of national resilience, especially as the population continues to age. How can advocates like yourself successfully frame this Sino-U.S. training pipeline not as a strategic risk, but as a pragmatic, mutually beneficial solution to a critical American healthcare issue?
Kate Zhou: The first move is to insist on the facts of the shortage itself. Projections show that the United States needs close to 190,000 new registered nurses a year through 2032, and we are producing far fewer. Hawaii’s shortage is worse than the mainland because of geography with our small islands and rural districts. A large proportion of elders cannot travel to Honolulu for care. This is not a hypothetical vulnerability; it’s a family in Molokai with no one to help their father. Any policymaker who takes this resilience seriously has to ask where the caretakers will come from. And the answer is that the American system cannot train them fast enough on its own.
The second move is to describe what the program actually is, because the strategic risk frame rests on the picture of sensitive technology and institutional capture. Nursing training in a Chinese care home is not dual-use research. It involves no laboratories, no proprietary data, which China is famous for stealing, and no defense-relevant knowledge. What it involves is teaching people to take vital signs, assist with daily living, and communicate with a frightened elderly patient. When the content of the exchange is that concrete, national security objections tend to dissolve on contact. That is my experience talking to the State Department.
Third, advocates should lead with American beneficiaries and American governance. Students pay tuition to an American college, train under an American supervisor to American licensing standards, and serve American seniors. The compliance framework is more rigorous than most domestic programs. When that framing is put in front of a legislature, they see Hawaii solving a net Hawaiian problem with a carefully governed partnership, not Beijing soft power.
Finally, resiliency includes redundancy. A workforce pipeline with multiple sending countries and a repeatable, auditable model is exactly what a resilient system looks like. For me, our collaboration with the Philippines is key. Even though there is geopolitical tension, building a partnership between the Philippines, China, and the U.S. works. American trainers can do some training in the Philippines, and Chinese trainees can go to the Philippines to be trained by Hawaiian instructors. This helps avoid the controversy of operating directly in China. Because there are already so many Filipino nurses coming here to work—if you look at any hospital in the U.S., you’ll find that 80% of the nurses and nurse aides are from the Philippines—it makes sense to use that existing pathway. If they can pass the American nursing exams, they can come to the United States and work.
Elijah Shoaf: Organizations like the Educational Advancement Fund International, based in Hawaii, have a long track record of fostering U.S.-China educational exchanges, which are vital for maintaining bilateral communication. Thinking more broadly, what actionable steps can other NGOs, think tanks, or philanthropic foundations take to replicate and scale these types of issue-focused, subnational collaborations despite the challenging political climate between Washington and Beijing?
Kate Zhou: Thank you for asking such a great question. Pick a problem that both sides feel in their own family. Elder care is ideal because it is urgent in both countries, politically unthreatening, and measurable. Climate adaptation, food safety, and disaster response have similar qualities.
In terms of technology, I want to emphasize one thing: China, Japan, and the United States should work together to provide high-quality help for seniors with household chores. While they cannot do things like feeding, bathing, or changing diapers just yet, there are many good companies in China doing a great job with robotics. But they’re not doing as well as the Japanese in terms of caring for seniors. They can work together with American companies, too. That’s a very good area to collaborate on, and people can make money doing it. There are hundreds of small care homes with only three to five patients in Hawaii. Small innovations at that scale can really reduce the shortage.
Working at that subnational level means the authority is real. Our partners are a community college, two care homes, a nursing college in Harbin and Changchun, and a small foundation. None of them needs permission from a national capital to sign an MOU on a training program, and none of them has an incentive to politicize it. Subnational institutional partners also survive changes in national leadership far better than government-to-government agreements. This is why Hawaii is a very good state for this, given its unique history and distance.
If I have one piece of advice for any foundation, it would be to fund the institutional layer: the legal counsel review, the insurance analysis, the term sheet working sessions. That is what turns a good idea into something a college president can safely put a signature on.
I’m a professor at the University of Hawaii. We used to have a lot of partnerships with China, but a lot of problems have recently occurred. So, we have to build compliance from the very beginning, rather than getting bogged down in security issues later. The single most effective response to political suspicion is a program whose paperwork is better than its critics expect: written scope for every activity, separate accounting for every dollar, no promises about visas or jobs, and an extended review at the end of each cohort. Think tanks can help here, like you guys at the Carter Center, by documenting those governance models so that the next organization doesn’t have to invent them.
In the current climate, I would go further: Keep the program free of any government funding, involvement, or branding. Be prepared to disclose every partner and every dollar. Assume that everything you write will one day be read by congressional staff. A program designed to that standard has nothing to fear from government scrutiny.
Finally, start with a pilot program that is small enough to be honest—about 30 participants, one care home, one school, over 18 months. Publish what worked and what didn’t. Scale is a consequence of credibility, and credibility in this climate comes from doing a modest thing extremely well and letting the results speak for both countries.