Disjunctures and flows in the global “scapes”:  The case of Indian medical students in China

Disjunctures and flows in the global “scapes”:  The case of Indian medical students in China

Bin Wu^a , Pengtao Yu^b & Xiaomin Jiao^b

^aSchool of Education, RMIT University Melbourne, Australia; ^bSchool of International Education, Zhengzhou University, China

Abstract

Traditionally, international students have gravitated towards Western countries, but South-to-South exchanges have grown substantially in recent years, with China emerging as a key destination for students from non-Western regions. This paper explores this shift by examining the experiences of Indian medical students, as well as Chinese professional staff and faculty, at a Chinese university, drawing insights from interview data. The study is guided by Appadurai’s theory of global cultural flows, which encompasses five ‘scapes’—ethnoscapes, mediascapes, technoscapes, financescapes, and ideoscapes. The findings highlight the fluidity and complexity of these global landscapes. While the ‘scapes’ appear disjointed and dynamic, they are simultaneously interconnected and intertwined, shaping and sustaining imagined communities and global networks.

Keywords

Appadurai; globalisation; China; India; internationalisation of higher education; MBBS

Introduction

In recent years, the flow of international students to Western countries has been joined by a rise in South-to-South exchanges (Kondakci, 2011; T.I.M.E. Association, 2021), with China becoming a significant host from non-Western nations for international students. As of 2019, China, with almost half a million (492,185) international students, had the third highest number of international students, just behind the US (1,095,299) and the UK (496, 570) (Project Atlas, 2019). Recently, there have been investigations into whether International Higher Education (IHE) in China constitutes a form of Westernisation, as Western standards are frequently used to measure and validate the process (Guo et al., 2022). There are calls for a Chinese definition of internationalisation (Liu, 2021). In a systematic literature review, Xu (2023) contents that the IHE in China is ‘never entirely Westernisation’ because ‘the urges for valuing Chinese cultures and treating Chinese higher education as equal contributors to world civilisations persist in the academic discourse on ICHE.’ (p.378). In this paper, we offer an alternative understanding. We will argue that Westernisation and indigenisation are paradoxically disjointed and interconnected, rather than standing as two strictly opposing poles.

IHE is ‘an ambiguous, complex and dynamic concept that requires contextualisation’ (Xu, 2023, p. 365). ‘Internationalization is seen as something higher education institutions do while globalization is something that is happening to them’ (Mitchell & Nielsen, 2012, p.1). These definitions establish the scope of IHE research while remaining open-ended enough to accommodate diverse dimensions and characteristics. Informed by Appadurai’s (1996) framework of the five ‘scapes’—ethnoscapes, mediascapes, technoscapes, finanscapes, and ideoscapes, this paper examines how different factors and trends disjoint and interconnect in IHE. Existing empirical research on Chinese IHE tends to focus on a singular perspective at a time, for example, Chinese academics (Wang et al., 2020) and professional staff members (Liu, 2021), international academics (Cai et al., 2022), domestic (Ma & Yue, 2015) or international students in China (Ding, 2016). The current study investigates how different perspectives diverge and intersect. The data are drawn from interviews with Indian students studying the MBBS (Bachelor of Medicine, Bachelor of Surgery) and Chinese teaching and professional staffers at a Chinese university, CC University, in central China. In the remainder of this paper, we will begin by discussing the various layers of the IHE context. Following this, we will present Appadurai’s (1996) theory of cultural flows as the study’s theoretical framework. We will then introduce the research project, followed by a detailed presentation of the findings and discussion. Our argument is that global cultural movements are dynamic and fluid, yet shaped and coordinated by various forces.

Literature Review

Globalisation is necessary for capitalism’s ongoing expansion and profit generation beyond national borders. ‘[T]he process of expansion of foreign direct investments involves a constant flow of profits from the South to the North, that is, from the Periphery to the Center of the imperial power of multinational capital’ (Ernesto, 2014, p. 18). Knowledge is a sociocultural commodity traded in the global marketplace, with universities playing a pivotal role in these exchanges. Current neoliberal globalisation promotes transnational corporate interests through both material and ideological dominance, echoing patterns of colonisation and imperialism (Mignolo, 2021). Global power structures can be understood within a four-tiered framework of international higher education (IHE). The inner circle consists of Anglophone countries that are home to some of the world’s most expensive and prestigious universities. Adjacent to this centre are other developed countries with education and economic systems comparable to those of English-speaking nations. The third ring includes ‘economically developing and non-Anglophone countries’ that both send and receive international students. Occupying the fourth ring are countries that are ‘predominately sending’ people to study overseas (Kondakci, 2011, p. 588). China and India both belong to the third ring. The globalisation process, revolving around the West-centric hegemonic axis, is uneven and unequal (Altbach, 2015). Countries and regions in the Global South are not helpless victims. Instead, they strategically capitalise on the Washington consensus to improve their situations (Hameed & Mathur, 2020; Robinson, 2005).

In Asia, IHE means catching up with the West (Mok, 2007). China’s internationalisation of higher education is a state-coordinated program actively pursuing West-centric rankings and standards to produce ‘quality’ and ‘world-class’ universities whilst increasing soft power by promoting Chinese culture and language (Dervin et al., 2018). The Chinese government has implemented several measures to boost its university world rankings. The 211 and 985 projects commenced in the 1990s. ‘The 211 Project targeted increasing research and management at the top 100 or so higher institutions’ and the 985 Project ‘encouraged universities to establish collaborative relationships with top foreign universities – mostly located in Western countries.’ The project ‘designated a handful of universities to become world class and compete with top institutions’ internationally (Kim et al., 2018, p. 96). In 2017 the ‘double first-class’ University initiative—building first-class universities and disciplinary areas—was launched, and 4.7% of Chinese universities made it to the ‘Double First-class’ list. They are assessed every five years (Liu, 2018). Unlike the 985 and 211 schemes that favour traditional universities, the Double First-class University initiative encourages ongoing competition, and the outcomes directly link to university funding, staff career advancement and salaries (Kim et al., 2018).

Meanwhile, the number of international students in China jumped from 100,000 in 2004 to 397,635 in 2015. It reached almost half a million (492, 185) in 2018. The three most popular subjects for international students in 2018 were the Chinese language (37.7%), Science and Technology (14.9%) and Western Medicine (11.2%). India was the fourth largest country of origin, with over 23,000 students in 2018. Among them, 21,000 studied Western medicine—Bachelor of Medicine, Bachelor of Surgery (MBBS) in English medium instruction (EMI) (Ministry of Education China, 2019). This trend began 20 years ago in South India because admissions into public medical schools are highly competitive, and tuitions for private schools are beyond reach for many (Sharma, 2020). The roots of this flow can be traced back to the region’s colonial history.

Medicine, Knowledge and Power

Knowledge and technology were instrumental in establishing Western colonial power (Hodge, 2011) with Western medicine being a significant part of this process (Hortan, 2019). Natives trained in Western medicine were awarded prestigious status in Colonial India (Islam, 2017). Today, gaining admission to a medical school in India is highly competitive. Approximately 1,000,000 students each year compete for 70,000 seats in public medical colleges (Jha, 2018). Tight control of the number of doctors preserves the rarity of the profession and, subsequently, its elite standing. Despite facing a shortage of medical professionals, India remains ‘the world’s largest exporter of doctors,’ with the majority moving to the UK and the USA (MacAskill et al., 2015, para.7). As a former British colony, India’s medical credentials are recognised and transferrable within countries of the Commonwealth, particularly those with close historical ties to the British Empire.

Like India, Western medicine was introduced to China in the 19th Century by European missionaries (Islam, 2017). Unlike India, Western medicine in China did not achieve the elite status as that in colonial India. In Mao’s time, accessible health care for rural areas and anti-elitism were high on the political agenda (Wei, 2013). In post-Mao reforms, the focus shifted from equal access to marketisation. With the privatisation of healthcare, patients faced soaring medical costs while hospitals were pressured to generate revenues. These reforms eroded trust between patients and doctors, leading to a surge of medical violence in some cities (Zhou et al., 2017). Previous surveys indicated that job dissatisfaction among medical staff was low. High workload, low pay, and patient aggression were among the primary reasons for discontent (Wu et al., 2014). Physicians’ salaries vary. Overall, doctors’ median income in China is relatively lower compared to average wages than that of their counterparts in Western societies (Zhang & Liu, 2018).

The healthcare situation in China and India shares common concerns but the internationalisation in both countries is geared towards the West rather than collaborations with each other. Despite sharing similar challenges, such as developing ‘comprehensive healthcare systems in the context of rapid but uneven economic growth and rapidly changing burdens of disease’, there were no formal avenues for collaboration between Chinese and Indian scholars on their shared concerns. ‘With a few exceptions… most collaborative efforts involve Western institutions separately to China and India, rather than lateral connections between the two’ (Holdaway et al., 2015, pp.268-273). For many non-Western countries, internationalisation is often driven by the pursuit of credentials and prestige, with less emphasis placed on building genuine partnerships to address critical issues.

Opportunities and dilemmas in the post-colonial globe

Globally, university credentials and prestige are tied to alignment with Western norms. As a result, the internationalisation of higher education in China involves adhering to Western standards and criteria (Wang et al., 2020). On the one hand, conforming to the West-centric order no doubt increases homogenisation. On the other hand, indigeneity and heterogenisation are also revived (see Xu, 2023). Nationalism, for example, does not diminish in globalisation. Nationalism entailing ‘a sense of belonging’ or ‘feelings of consciousness to develop one’s group identity’ (Islam, 2017) has been crucial for both India in state governance and mass mobilisation in gaining independence from the British. The anti-colonial movement amassed various counter-hegemonic forces—demanding equality in gender, caste, and class, to achieve its final success. After gaining independence, India is anxious to catch up with the colonisers to ‘be treated as a worthy member state of the international community’ (p.14). Meanwhile, the colonial power is framed as ‘the Other’ to unify the state under a new national identity, and the ‘India’s civilisational heritage is construed as a hegemonic discourse in itself’ (Bajpai &Parashar, 2021, p. 216). Post-colonial states encounter a paradox: they resist external dominance on the global stage while governing their own populations through forms of hegemonic power (Bajpai & Parashar, 2021). The family, too, plays a part in the process. The family ‘is an institution and a typical symbol of the collectivist culture of India from ancient times’ (Hameed & Mathur, 2020, p. 90). Traditional family values continue to resonate with many young Indians. However, families in post-colonial India are not immune to political divisions and tensions, with fault lines of race, religion, class, and gender influencing both the rhetoric and practices surrounding family and marriage (Natrajan, 2022).

Likewise, the family and clan were at the core of one’s identity and belonging in traditional China. Like India, foreign invasions in the 19th and 20th centuries awoke and strengthened China’s national identity (Modongal, 2016). Nationalism has become pivotal for China’s national development. ‘Nationalism has enabled post-colonial societies to invent a self image through which they could act to liberate themselves from imperialist oppression’ (Anderson, 1983, p.15). In the economic reform era, the Chinese government downplayed political rhetoric and appropriated the Chinese traditional values (Wu & Devine, 2018) while promoting nationalism to legitimate its power (Huang, 2015, p. 408). The Chinese government sees IHE as a channel to expand its soft power by exporting Chinese traditional culture (Yang, 2007). For example, the expansion of Confucius Institutes abroad has faced scrutiny for promoting China’s cultural and political influence under the guise of language and cultural education (Hartig, 2012; Paradise, 2009). Nonetheless, this practice is not unique to China. Western universities have long established branch campuses overseas, with several of these institutions operating within China itself (Altbach & Knight, 2007). These international campuses, much like Confucius Institutes, are seen as a form of cultural diplomacy, serving not only educational purposes but also enhancing the soft power of their home countries (Nye, 2004). Such global educational expansions, whether by Western or Chinese institutions, illustrate the growing importance of higher education in shaping global landscapes. The current study is situated in the context as afore discussed. Following Appadurai’s (1996) theoretical framework of global cultural flows, we scrutinise IHE against such a backdrop through the experiences of Indian students, Chinese faculty, and professional staff in a Chinese university.

Theoretical framework: the five ‘scapes’

While global exchanges and movements have long existed, modern globalisation is distinguished by its unprecedented intensity and scale. This new reality calls for fresh theoretical approaches. Appadurai (1996, pp. 32-33) elucidates that the ‘new global cultural economy has to be seen as a complex, overlapping, disjunctive order that cannot any longer be understood in terms of existing center-periphery models (even those that might account for multiple centers and peripheries)’. Therefore, he proposes a framework addressing ‘the relationship among five dimensions of global cultural flows’: (a) ethnoscapes, refer to ‘the landscapes of persons who constitute the shifting world in which we live’ (p.33), (b) mediascapes, are concerned with how information is generated and disseminated through various outlets such as ‘newspapers, magazines, television stations, and film-production studios’ (p. 35), (c) technoscapes, pertain to technologies, imagined ‘both low and high, both mechanical and informational’ (p. 34). (d) financescapes, entail flows and exchanges of finances—capital, stock, demands and supplies of the markets, (e) ideoscapes are similar to mediascapes in that both disseminate information and ideas and are ‘concatenations of images.’ However, the key difference is that ideoscapes focus on political ideologies and counter-ideologies, particularly those ‘of movements explicitly oriented toward capturing state power or a part of it’ (p. 36).

Using the suffix- scape is to capture the dynamic and fluid nature of the cultural flow and that they constantly evolve and change from different points of reference. The framework is characterised by two features: disjuncture and imagination. Appadurai (1996, p. 33) maintains that the ‘complexity of the current global economy has to do with certain fundamental disjunctures between economy, culture, and politics that we have only begun to theorize’. As discussed earlier, the context of IHE and medicine in both China and India are full of disjunctures. For example, India exports large numbers of doctors to the UK and the US despite its domestic shortage of health professionals. China and India are eager to collaborate with the West rather than with each other despite sharing similar concerns in healthcare. Another feature is imagination. Appadurai (1996) argues that ‘the image, the imagined, the imaginary—these are all terms that direct us to something critical and new in global cultural processes: the imagination as a social practice’ (p. 31). For example, the Western benchmarks are projected to be universal, and this imaginary becomes a social practice—Western universities are perceived as of top quality. Hence, they attract international students and yield financial benefits. This image is embraced and, to varying degrees, emulated by academics in China (Wang et al., 2020). We will flesh out these features of disjunctures and imaged world/community in the data analysis later in this paper.

In a critical reading of Appadurai’s works, Heyman and Campbell (2009) maintain that the framework of cultural flows breaks away from a static understanding of globalisation and geography and points to a dynamic and complex nature of cultural flows and interactions. However, they also point out that Appadurai has overemphasised the disjunctures—’seeing complete disjuncture and implicitly causal equality among all the different flows’. Instead, they continue to say, ‘[d]isjuncture and breakdown of bounded social and cultural units are contingent outcomes of processes that may also reinforce social and spatial entities, boundaries, and so forth’ (p.144). Heyman and Campbell (2009, p. 136) explain, ‘past mobilities lead into the present, it obscures how the shift from past to present involves reworking of older patterned flows into new set of flows.’ Indeed, while emphasising disjunctures, Appadurai’s (1996) also underscores ‘flows’—the connections of the past, present and future. Appadurai’s (1996) concept of ‘imagined worlds’ or ‘imagined communities’ highlights that globalised visions are both coordinated and disjointed. While shared media, technology, and economic systems connect people globally and create a sense of common experience, individuals interpret these influences through their own cultural and personal lenses. This leads to fragmented and sometimes conflicting visions of reality. As a result, imagined worlds are simultaneously interconnected and fragmented, reflecting the complexity of globalisation. These disjunctures and flows occur across both temporal and spatial dimensions. For example, as discussed, the elite status of doctors in India has its roots in the colonial past, which contributes to the ongoing migration of Indian doctors to the UK and US, even in the face of a domestic shortage. This imbalance reinforces the colonial hierarchy, highlighting the continued power of former imperial centres to attract top medical talent from their ex-colonies, transcending both time and space.

Appadurai’s (1996) framework has been applied in a range of study areas, including IHE (e.g. Geerlings & Lundberg, 2018; Jokila, 2015: Marginson, 2008; Woo & Wang, 2024). A question often raised in empirical research is whether researchers should expand the current five scapes by adding more. Appadurai was not against the idea of adding more. But he cautioned that ‘the danger is you lose sight of the basic tension’ (Rantanen, 2006, p.14). In this paper, rather than creating new scapes, we adhere to the five scapes with adaptation and modification suitable for the specific data and contexts. In this paper, the ideoscapes refer to state political rhetorics as well as cultural and social ideologies. In China, political and cultural ideologies are intertwined in governance (Wu & Devine, 2018). The technoscapes include informational and material entities, such as knowledge, techniques, skills, resources and facilities. The mediascapes contain mechanisms for disseminating information, such as word of mouth, chatrooms, email correspondence and other personal and professional channels and networks, both digital and in-person.

The Study

The study was part of a larger project on international students at CC University in central China. In 2019, 84% of the international students in CC University came from Asia, 14% from Africa, and the remaining from Europe, North and South America. Up until 2020, the most popular subject for international students at CC University was the EMI (English-medium instruction) MBBS program, with over 80% of students choosing this major. Of these, more than 60% were from India. The data were drawn from one-to-one interviews with 12 Indian international students in English medium MBBS and 10 Chinese professional staffers and academics. All names used in this paper are pseudonymous, and personal details have been modified to ensure confidentiality.

Ethics approval was obtained from an Australian university ethics committee prior to the commencement of data collection. The first author, bilingual in Chinese and English, recruited participants, obtained written consent, and conducted the interviews between 2018 and early 2020, each lasting 45 to 60 minutes. In an interview setting, participants are situated within a social context where they are inclined to follow social norms and expectations. Goffman (1959) suggests that individuals in social interactions often engage in ‘impression management,’ tailoring their behaviour to present themselves in a favourable light. As Rapley (2001) observes, while interviewees may modify certain details to preserve a positive self-image, their responses are generally more reflective of the truth than outright fabrications.

The Chinese participants, including professional staffers and academics, spoke Mandarin, while the Indian students used English. Interview questions were semi-constructed. The first author de-identified, transcribed, and translated the Mandarin interview data. The other two authors, both native Mandarin speakers fluent in English, reviewed the translation for accuracy. The first author then identified themes from the verbatim interview data, which the other two authors subsequently checked for consistency and clarity. Major themes were first coded as a first step to conceptualising data. Internal variations and commonalities were identified attached to the themes, and then connections between them were made to develop and recontextualise the data (Attride-Stirling, 2001). The initial coding focused on common themes that emerged from the interviews and were categorised. The aim was to preserve the data in its entirety as much as possible within the context. The next step is to break down the data further into components that are more analytical—major patterns and trends from these narratives will be analysed using Appadurai’s (1996) framework of cultural flows and will be presented in the Discussion. The second level of analysis focuses on Appadurai’s (1996) concepts of five scapes, disjunctures and imaged words/communities, and how these elements are interconnected and coordinated.

The Narratives

A common theme from the interviews with both Indian youth and Chinese staff is their motivation to improve or better their circumstances. In the context of Appadurai’s concept of ‘imagined worlds’ and ‘five scapes’, the motivations expressed by both Indian students and Chinese staff reflect their engagement with overlapping global and local influences, or scapes. These imagined worlds are shaped by the aspirations and goals they envision for themselves, influenced by individual and collective experiences.

For the Indian students, their imagined world includes personal improvement driven by familial obligations and support. This reflects Appadurai’s ethnoscapes (movement of people) and ideoscapes (flow of ideas like duty and family support), where they navigate between their cultural values and global opportunities. Their aspirations to ‘alleviate or better their situations’ are shaped by their sense of belonging within both their family structures and the broader global educational sphere. Indian students strive to improve their financial situation and that of their families, reflecting financescapes as they pursue economic opportunities through education. They access crucial information via various media platforms—technoscapes—which helps them navigate global opportunities and career paths.

Similarly, the Chinese professional staff and faculty see themselves as connected to their imagined world, navigating the movement of people and talent within the education system through ethnoscapes. Mediascapes expose them to global education trends and media narratives. Their focus on quality improvement, aligned with state and university initiatives, demonstrates how their imagined world is shaped by financescapes (economic aspirations) and technoscapes (advancement through technology and institutional progress). They view their individual progress as intertwined with the broader goals of the state and university, reflecting a collective vision of improvement tied to national development. In ideoscapes, they echo state-promoted ideologies of progress and national pride.

Both groups, while propelled by individual desires to improve, also rely heavily on social support structures—be it familial ties or institutional backing. These perspectives show how their imagined worlds are coordinated through shared aspirations of self-betterment and advancement, yet disjointed in how those aspirations are shaped by their cultural and social environments.

Indian students’ narratives: upward social mobility

All overseas medical graduates must pass the Foreign Medical Graduate Exam (FMGE) to practise medicine in India. About eighty-four (84) per cent of foreign-educated doctors failed to pass the exam (Rawat, 2019). Even if they successfully pass FMGE, doctors with overseas qualifications could face discrimination and exclusion in India (Jha, 2018). None of our informers, however, paid much attention to this grim reality. We will return to this point later. For now, our question is why these young people chose to study medicine in China.

All the Indian participants chose to study in China after being unable to secure a place in a public university for their preferred medical major. They selected CC University based on word of mouth, having heard about it from friends already studying there. The participants mentioned that pursuing a medical career was not just a personal interest but also a familial obligation. Deepit explained, ‘I wanted to be a doctor because I want to help people. A doctor is a respectful profession. …I am a girl…I am the only child; I need to do my best for my parents’ (Deepit interview)

Families serve as a source of motivation. Fajar explained that he chose to study medicine as a way to honour his parents, who had worked hard to support him:

My father is a farmer. My mother is a homemaker. They always have high expectations for my elder brother and me. My brother is now a software engineer. My parents have worked hard for us. Even now, despite their age, they still toil and soil to support me (Fajar interview).

Some were inspired by other family members. Aja said:

My cousin is a doctor. He helps people, everyone respects him, and he is rich. I thought I could be a doctor. … (but) I didn’t get into a medical school in India because I didn’t do well in exams…. We had a lot of information from different agencies. My dad made the decision for me to come to China. It was a good decision…My dad is an engineer. He is a smart guy (Aja interview).

For Harij, who was in his final year, his inspiration was a historical figure. He recalled, ‘I wanted to be a doctor since I was six or seven because of the story of Ida Scudder. She was an American who helped Indians’ (Harij interview).

The young Indians believed that CC University provided quality programmes at an affordable price. Several interviewees agreed that the scale of the affiliated hospitals was one of the reasons contributing to their decision. At the time of the interview, CC University had ten affiliated hospitals with more than 27,000 hospital beds and total daily outpatient visits of more than 50,000.

For the participants, EMI was another reason for choosing the course. This was because English is the lingua franca, a ‘global language’, as they explained, and medical exams in India and the US are in English. However, the Indian students noticed a disjuncture that the lecturers who had to teach in English were not native speakers. A few of our Indian participants complained about the teachers’ English skills. For example, Aja described that only a few lecturers who returned from the US spoke ‘very good’ English and believed that CC University should hire more academics from overseas or returning from overseas (Aja interview). Other students looked beyond linguistic techniques in a narrow sense. Bhuvan said that the teaching strategies were more important (Bhuvan interview). Another student, Gulika, said that communication was bi-directional. She said hard working students would always get the most out of it. Besides, there were different styles of delivery depending on the subjects, not just teaching styles (Gulika interview). Deepit said some students felt that classroom teaching should be fun. But she reasoned that studying could not always be about fun: ‘sometimes, it is fun, sometimes, it is not. It is part of the deal’ (Deepit interview). Harij alluded to the socio-emotional aspect of learning, suggesting there should be culturally responsive counselling on campus. He learned about counselling services while he was in the US studying a short course (Harij interview). Fajar, a student representative, suggested that the University could offer motivational seminars to encourage people to see the value of being a doctor, not just academic learning (Fajar interview).

For some senior students, the primary concern was the FMGE. Aja explained that a few years ago, some senior students initially lobbied the University to hire academics from the US or India, but to no avail. Subsequently, they pooled their money to bring a well-known doctor from India to give a talk on FMGE preparation. Eventually, the University invited Indian agencies to campus to deliver regular tutorials for exam preparation (Aja interview).

The Indian youth believed that they would pass the exams if they worked hard. Gulika commented on the FMGE, ‘it depends on the individual student. If you work hard, you can pass. I will work hard, and it shouldn’t be a problem’ (Gulika interview). Other students echoed this sentiment. Ekraj, a first-year student, said, ‘With my hard work, I will pass the FMGE. If I don’t, I will try the USMILE’ (Ekraj interview). The United States Medical Licensing Exam (USMLE) is a three-step, four-exam process. The first step is an eight-hour exam of multiple-choice questions on basic concepts and knowledge. These young people chose to talk about positive stories, not the disappointing, cold, hard statistics. Fajar, a fifth-year student, said he had already passed the first step of the USMLE. He planned to seek medical residency in the US and later study for a master’s degree there. Fajar mentioned that Chinese medical qualifications might face discrimination in India, as reported by local Indian news. But the US would offer a fair game and his qualification from China would be accepted there (Fajar interview). Anecdotes of CC University alumni successfully passing medical exams in India, or the US were circulated, whilst failure stories were ignored. The exams thence became surmountable.

Although India and the US were popular destinations after graduation, there were other choices, such as the United Arab Emirates (UAE) and East Asia. While expressing their confidence in passing the exams, participants criticised the exam-focused education in India and China. Deepit questioned the examination systems in both India and China, stating, ‘The entrance exams reveal a person’s academic abilities but not their personality.’ (Deepit interview). Most of the participants said the entrance exams in India are not fair. However, none of them disputed the validity of FEMMG or USMLF.

Most of these young Indians dreamed of practising medicine in India or the US, while also questioning the territorial divisions in a global world. Ekraj planned to pursue a master’s degree in the US, specialising in pathology. Nonetheless, he reiterated that doctors should have no borders, ‘in an ideal world, I can study in any place…my goal is to become a pathologist’ (Ekraj interview). Likewise, Deepit said, ‘I don’t know where I am going to be, but I want to be a doctor. Being a doctor can serve people from all over the world’ (Deepit interview). She then went on to question the meaning of being a doctor in India (Deepit interview):

People believe they will have a good return in the future because doctors in India are wealthy. I don’t think becoming a doctor should be about making money. It should be about earning good deeds as a doctor.

Some students went on to reconsider some of their traditional cultural values. Two of our participants crossed the fault lines of caste and religion. Aja was dating someone from a lower caste, and Deepit, a Hindu, was seeing a Muslim Pakistani, which would have been difficult, if not impossible, were they in India. The participants expressed gratitude to their families and wanted to make their parents proud, while knowingly contesting familial authority, albeit covertly. To sum up, a central thread from the Indian students’ interviews is a conviction that their disadvantaged situation could be improved through individual endeavours and familial support.

Chinese participants’ narratives: ‘quality’ and self-improvement

Like the Indian students’ narratives, The Chinese interviewees expressed hope for improvement through individual and collective efforts. When China’s economic reforms began in the late 1970s, coastal regions were prioritised for development. Now, inland cities are experiencing economic catch-up. CC University emerged as a rising star, achieving Double First-Class University status in 2017. The University ushered in its 6-year EMI MBBS programme almost two decades ago with only a handful of international students at the beginning. As Lin, a professor of Medicine, recalled, ‘The first intake, we had six students. We built up close relationships and provided great support for them to succeed…. the number slowly increased after a few years and continued to grow’ (Lin interview). Even though international enrolment had increased more than a hundredfold, the staff noted that the number of international students remains only a fraction of the domestic student population. The Chinese participants concurred that having international students was not for financial purposes. It was to have a global outlook, a criterion for university rankings. Ms Hong, a student support manager, said: ‘International students only take up a tiny part of the University enrolment. We do not have international students for financial profit, unlike those Western countries’ (Hong interview).

All international students were under the administration of the school for international students. The school was responsible for offering Chinese lessons, administrative support, and pastoral care—the school coordinated with other schools/faculties for different study areas. Hong explained that the rationale for placing all foreign students in one school was to ensure the best support— ‘for example, providing specialist support such as renewing visas…some mature students came here with the family, and we need to organise special accommodation for them’ (Hong interview).

As more universities began offering MBBS courses, China tightened regulations in recent years. Yao, an associate professor of Chinese language, explained, ‘Universities now need special accreditation to offer English-medium MBBS instruction for foreign students.’ CC University is one of the accredited institutions permitted to teach MBBS. Yao added that the new regulations ensure the overall quality of the courses. In addition, accredited universities are required to provide a compulsory introductory course on Chinese culture and language for all foreign students (Yao interview). Hao, a professor of Chinese, commented on the change of international education. She said that in the past, having international students was primarily about introducing China and Chinese culture to the world: ‘Before the 1980s, most foreigners came to China to learn the Chinese language and culture. Now they came for all different subjects, and this is an opportunity to show the world the real China’. Hao said that traditionally, international students in China were always in separate classes from domestic students. Now, in some subjects taught in Chinese, international and local students work together. She concluded that China is still ‘learning to adapt to the new situation of internationalisation’ (Hao interview).

Using English in teaching can be challenging for teachers. Lin said that ‘we are not native English speakers and most of our teachers don’t have overseas experience’. Although the staff believed an English medium MBBS programme was crucial for the University’s internationalisation and keeping up with world-class standards, not everyone was enthusiastic about it:

Not all staff wanted to teach the English MBBS programme. First, we are used to the lecture style because we have big numbers of domestic students and big classes. Chinese students are used to lectures. Teachers now need to be more interactive when teaching international students. On top of it, teachers must speak English. It doubles or triples the time (Lin interview).

Lin continued:

Medical doctors (in China) are not paid as much as their counterparts in the West or India. Clinical professors are extremely busy because of the enormous volume of patients. They don’t have additional pay or extra time for teaching the English programme (Lin interview).

This situation echoes a study (Xu et al., 2021) on EMI in China. The authors conclude teaching EMI is viewed as a prestige for academic, professional, personal fulfilment, not for financial gains. In the current study, Lin said that the English-medium instruction programme was an opportunity for academics to ‘better’ themselves. He said that some academics looked at it as an opportunity to improve their English and motivate them to seek new teaching strategies. But he added, another issue with English-medium instruction programmes in China was international students’ Chinese proficiency. When medical students are on a clinical internship during the final two years of the course, their Chinese language is more important because they need to communicate with Chinese patients. In Anglophone countries, international students are required to meet certain English proficiency before being admitted to universities. However, ‘not many foreigners have mastered Chinese before coming to China. We are now gradually raising the bar on students’ Chinese proficiency’ (Lin interview).

Unlike EMI programmes that are relatively new, teaching Chinese as a foreign language has a long tradition in the university. Bai, an Associate Professor of Chinese language, said that the school has resources and expertise accumulated over the years. Teaching is interactive as opposed to traditional lectures. Bai explained: ‘we keep our classes small; we are well connected with students. We always have positive student feedback’. Bai said that ‘despite all the great achievements, like other subject areas, we also participated in the university-wide open class competition so we can continually improve ourselves’ (Bai interview).

The staff applauded the government’s new regulations and policies of ‘quality improvement’. They believed that improving the quality would boost the University’s reputation and attract high calibre students. Mr Peng, a recruitment manager, had been in the university for more than a decade. He started in the administrative role in the school and moved to recruitment a few years ago. The importance of ‘quality’ was a priority in Peng’s job. Peng explained that one way to achieve quality was for the recruitment team to work closely with the agencies. His recruitment team provided training to the agents in India. The university accepted students only from accredited agencies to ensure ‘quality’, not ‘quantity’ (Peng interview). A consensus among the Chinese participants is that their school of international students is a small one in the university but is in a critical position to heighten the University international presence and boost rankings. CC University in an inland city, not in the traditional elite circle, was walking abreast with the top universities in China. Similar to the Indian students’ narratives, the Chinese professional staff and faculty believed that with individual and collective efforts, they would progress and improve.

Discussion: Scapes — disjointed, enmeshed, and imagined

The five scapes and their movements are noticeable in the findings. The scapes are interconnected yet disjointed and fluid while simultaneously coordinated. The ideoscapes ‘are composed of elements of the Enlightenment worldview…The master narrative of the Enlightenment (and its many variants in Britain, France, and the United States) was constructed with a certain internal logic and presupposed a certain relationship’ (Appadurai, 1996, p. 36). This ‘internal logic’ of IHE in Asia repeats itself in the catch-up (with the West) mentality (Mok, 2007). The mediascapes and technoscapes reflect this logic—Western universities or universities that adopt Western standards are believed to have high quality with advanced technologies, resources, and facilities (e.g. The Economic Times, 2023; Wang et al., 2020). These perceived prestigious universities have higher tuition fees and offer credentials deemed more valuable and, subsequently, better employment opportunities. In tandem, the financescapes have seen money and other material and symbolic gains flow from the periphery towards the centre in the West (T.I.M.E. Association., 2021). India’s medical system, shaped by its colonial roots and closely aligned with the British system, offers high salaries, status, and opportunities to work in the UK and the US. Relatedly, in the ethnoscapes, Indian students and Chinese staff measured themselves against the West-centric standards and indicators as universal yardsticks associated with a sense of prestige, upward social mobility, and material benefit.

Such flows, however, are not linear or smooth. The rise of China’s international students (Ministry of Education China, 2019; T.I.M.E Association, 2021) is an example of a counter current. This disruption resulting from disjunctures may reshape or reinforce existing dominant flows (Heyman & Campbell, 2019). With China’s economic development, the technoscapes have evolved. In the current study, the Indian students cited CC University’s large-scale affiliated hospitals, advanced equipment, and resources as evidence of its quality education. This shift in technoscapes represents a disjuncture in global movements, as China lies outside the central circles of Western universities. Even so, internationalisation is more than resources or facilities. It is also ideological and discursive. CC University, like other non-Anglophone universities (Gundsambuu, 2019; Rowland and Murray, 2020; Tamtam et al., 2012), offered EMI courses to elevate its international profile. This measure, however, often misfires or mismatches among its policies, intentions, and practices (Xu et al., 2021). In our study, EMI was problematic for some teaching staff and Indian students. The styles of teaching were also up for debate. Teaching and learning in traditional China emphasised discipline, earnest effort, and character building (Wu, 2011; 2019). Hence, the lecture is traditionally a good fit for such a purpose, particularly with large classes. New developments in education have challenged this traditional mode of delivery. There are many explanations. To name a few, they include 1) the influence of modern Western psychology of constructionism (knowledge as construction); 2) teaching moves away from content dissemination to knowledge inquiry; and 3) the marketisation of education as consumption that emphasises enjoyment and student experience. These disjunctures between the past and present elicited various reactions from Indian students and Chinese faculty. Again, this finding shows the disjoints and interconnections of different scapes—dominant ideologies co-exist with counterideologies and their variations.

In the mediascapes, we see from the findings that information about studying a MBBS course was spread favourably among friends, families, agencies, and internet chatrooms. Further, anecdotes about successfully passing the medical exams in the US or India were shared, but unsuccessful stories were ignored. These mediascapes insulate an imagined world (Appadurai, 1996), offering an alternative path to the Indian students’ medical career aspirations. For the Chinese participants, the growth of international students in CC University provided a sense of achievement. It boosted the hope for the University’s better ranking in the future, availing themselves of the Double World-Class system. Although these changes in the scapes increase international students within Asia and potentially disrupt the dominant current gravitating towards the centre of the Anglophone countries and their allies, they also reinforce the existing order. For example, CC University offered a detour—for most of the Indian students, the ultimate goal was to move back to India or the US, at least for the majority of them. The Chinese academics promoted Chinese culture and language while actively pursuing ‘quality’ comparable to Western standards and ideologies.

Disjunctures are present within the scapes. In the ethnoscapes, the Indian students rejected India’s college admission system which had denied them opportunities for a medical career and upward social mobility. Some Indians questioned the legitimacy of the medical entrance exams and went further to challenge the elite status of India’s medical systems, asserting that medicine should be the public good. Meanwhile, these young Indians strenuously pursued medical exams of FEMG or USMLE. The Indian students were confident they could succeed if they worked hard and declared they did so for their families, not just personal gains. Being cited as a crucial source of support, to some, the family also symbolises power and control over its members. Two of our Indian participants dating someone from a lower caste and a different religion challenged the familial authority, at least symbolically.

Similar contradictions are noted in the Chinese participants’ narratives. EMI was considered an opportunity to improve their English skills. It was simultaneously a burden on the staff workload. The practice became absurd when international medical students who may not be proficient in Chinese would have to communicate with patients on their internships. While Western norms were held as universal touchstones, staff claimed a moral high ground by reiterating that the international student enterprise in China was not for financial benefits, unlike the West (e.g. Mittelmeier and Lomer, 2021). China has been accused of using IHE as a channel to increase its ‘soft power’ (Dervin et al., 2018; Yang, 2007). This IHE is crucial in expanding the state’s soft power (Bhardwaj & Kumar, 2023). Western countries, such as the UK (Lomer, 2017) and Canada (Trilokekar, 2010), have been the key players. In the UK, the assumption is ‘that international students change their political attitudes and identify with the host country as a result of positive experiences. Later, they are supposed to return home and reach positions of influence, which they exert in favour of the UK’ (Lomer, 2017, p. 581). In recent years, China and India have joined the league (Bhardwaj & Kumar, 2023). Nonetheless, the approaches differ. While soft power generates financial gains directly for Western countries, Chinese universities rely on the hardware—hospital facilities, EMI in the current study as seen in the current study and forsaking monetary benefits to attract international students and establish a positive international image.

The Chinese academics stressed the importance of teaching the Chinese language and culture. These statements were in sync with the Chinese government’s rhetoric, aligned with the ideoscapes that promote nationalism in domestic governance and enhance Chinese culture as soft power (Dervin et al., 2018). The narrative presents ‘counterideologies of movements’ (Appadurai, 1996, p.36), resisting a West-centric master narrative. The conviction of ‘valuing Chinese cultures and treating Chinese higher education’ as equal players in IHE has been a persistent academic discourse in China (Xu, 2023, p.15). The current study suggests that this discourse, for the participants, is not merely rhetoric or propaganda. The Chinese staff cited genuine practical concerns that medical students need to understand the Chinese language and culture during an internship. Even though they embraced Western standards and values that would result in material gains, the Chinese faculties applauded the Chinese government for raising the ‘quality’ that benefited the University. The state-coordinated approach to IHE in China has seen China’s ‘stellar’ progress in international rankings (Kim et al., 2018, p. 95). The staff’s careers and promotions are connected to their university’s achievements and the state’s broader social situation in a global world.

The Indian students moved to China for medical credentials while most of them contemplating a future either back in India or moving to the US. The ethnoscapes were anchored in and connected to various imagined communities. The Indian students and Chinese participants have differing desires and orientations in relation to the West-centric power, belonging to two different ‘imagined’ worlds (Appadurai, 1996). For the Indian students, their connection to family was central, as they relied on their families for emotional and financial support, which formed a key part of their identity. They also bonded with fellow Indian students over shared interests and goals. Together, they worked to support each other in preparing for the FMGE exam and lobbied the University for favourable social and academic conditions.

In contrast, the career advancement and job prospects of Chinese staff were tied to their university and the state. Some Chinese academics viewed the presence of international students as an opportunity to introduce Chinese culture and language to the world. For the Indian students, however, although some expressed an appreciation for China and its culture, their primary focus was on obtaining medical credentials to secure upward social mobility for themselves and their families. The relationships and interactions between international students and their host countries reflect broader perceptions and connections between nations (Jokila, 2015). Across the five scapes, disjunctures and ruptures unfold as existing borders and territories are reinforced, and imagined worlds take shape.

Conclusion

This paper conceptualises IHE in China as situated within dynamic global landscapes that transcend social, cultural, historical, and economic arenas. To explore this, we adopt Appadurai’s (1996) global cultural flows as the theoretical framework, focusing on the interactions and disjunctures of the five scapes– ethnoscapes, mediascapes, technoscapes, financescapes, and ideoscapes. The purpose of this paper is two-fold. Empirically, we provide insights into the perspectives and experiences of the Indian medical students and Chinese professional staffers and faculty at CC university before and around the onset of the global COVID pandemic. Theoretically, we demonstrate how Appadurai’s (1996) global cultural flows enable a nuanced understanding of IHE in China. Our study reaffirms and extends Appadurai’s (1996) framework. In the case of Indian MBBS students in China, the five scapes are disjointed yet interconnected, coordinated by various global forces. The disjunctures create new opportunities and challenges, simultaneously disrupting and reinforcing existing power relationships while shaping imagined communities. Through the lens of the five scapes, we capture the dynamic and complex currents within the IHE landscape, showing that the study of IHE in China should move beyond a simplistic, dichotomous understanding of Westernisation as an either-or scenario.

Disclosure statement

The authors declare they have no conflicts of interest.

Notes on contributors

Bin Wu is a Senior Lecturer at the School of Education, RMIT University. Her research focuses on various aspects of education, encompassing educational theories, philosophies, and history. She is particularly interested in issues related to gender, diversity, and social justice within educational contexts, as well as teacher education, curriculum development, and policymaking in higher education.

Pengtao Yu is a lecturer at Zhengzhou University, China, with substantial experience in teaching Mandarin to international students, as well as in administration. She has many years of study and work experience in the UK and Malaysia, during which she has devoted herself to researching internationalization, understanding the experiences of international students, and Mandarin teaching and learning.

Xiaomin Jiao is an Associate Professor, the Dean of the School of International Education at Zhengzhou University in China. He completed his doctorate degree at AUT University in New Zealand. His research focuses on teachers’ and students’ accounts of their everyday experience of teaching and learning in higher education.

ORCID

Bin Wu https://orcid.org/0000-0001-6164-8722

References

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