Covid-19 vaccines: a game of power jabs

Vaccines have enabled us to reduce and eliminate infectious diseases, including eradicating smallpox and nearly eradicating polio. Due to an extraordinary global effort, numerous covid-19 vaccines have been created and approved in record time. Vaccines have powerful impacts in improving global population health, but if not fairly and ethically distributed, they can generate international tension; therefore, it is crucial that equitable access to vaccination is ensured.

Vaccine diplomacy has proven its potential in humanitarian settings, particularly in mediating conflicts and even bringing about ceasefires amid vaccination campaigns. The covid-19 pandemic has further highlighted just how political vaccination is and its potential to be used as an “instrument of foreign policy.” Governments advocated for global cooperation and equitable access during the vaccine development process. Unfortunately, today’s world is far from being one in which countries are waiting their turn for doses and sharing them as they are produced.

Amid global distribution and procurement challenges, recent events have seen wealthier countries securing vaccine stocks first (vaccine nationalism)—with some vaccinating as many as one person each second—while the majority of the world’s poorest nations have yet to administer a single dose. In this “game of (power) jabs”, not only are players starting out on unequal footing, but it has become clear that not all are playing by the same rules (let alone the same game). Even among the largest global powers, various strategies emerge: while some are hoarding enough doses to vaccinate their entire populations several times over and to make up for their poor performance thus far, others either appear entangled in the intricacies of complex administration and collective decision-making, or see the present “vaccine race” as an opportunity to promote their domestic and foreign policy agendas.

Wealthier countries did not wait for vaccine availability or approval to sign major procurement agreements with the most advanced pharmaceutical companies, securing enough doses to vaccinate the majority of their populations by summer 2021—and claiming a near monopoly of the global vaccine supply. Not only did this leave countries with less financial support, it also diminished the supply of purchasable vaccines remaining. Fifty years ago, it was difficult for Russia and China to compete with American influence to gain global allies. Today, they can easily enter the vacuum left by the US and its NATO counterparts—whose vaccine production has so far only served themselves—and offer their assistance (in the form of nationally-developed vaccines) on a global scale.

Russia, China, and India have used their existing pharmaceutical infrastructure to take the lead in meeting global supply demands. Many low- and middle-income countries are looking to them for an affordable vaccine supply which cannot be obtained elsewhere. These countries, however, are not offering vaccines to every country that asks. In contrast, they seem to be using their new found power to carefully select clients, who range from long-term allies to nations they wish to influence.

Latin America, for example, presents a significant opportunity for China and Russia, because they have yet to gain influence in the region, but also due to its close geographical proximity to the United States. Brazil, in particular, struck deals with both countries—both China’s Sinovac jab and Russia’s Sputnik V are part of Brazil’s vaccination plan. Working with the African continent, whose supply so far highly relies on COVAX, is another great opportunity for China, which is looking to further expand its existing power in the region. Noticeably, the United Arab Emirates is using Sinopharm’s jab to vaccinate its entire population at the second fastest rate globally, behind only Israel.

Even some European countries are looking to Russia and China for doses, despite their vaccines not being approved in the EU. In response to efficacy demonstrated by the Russian vaccine—Hungary has purchased 40,000 doses. Conversely, China’s Sinovac vaccine is far from being as effective (barely above 50%) and concerns arose around lack of transparency and possible adverse effects, but in a context when the demand far exceeds the supply, countries cannot afford to be picky. A divide could appear between countries which are in a position to afford more effective vaccines and those who simply do not have a choice. This may also have implications for discussions related to vaccine passports, particularly if countries were to only accept specific vaccines for travel. Importantly, the same gap could also soon be seen within countries where private insurance plays a large role, if patients are given the possibility to ask for specific vaccines with higher efficacy rates and fewer side-effects.

Vaccines may prove to be the soft power China has long been looking for. China was ahead of the vaccine race last year, having entered phase 1 of the trials for one of its vaccines as early as February 2020, a rapidity probably due to its highly state-driven effort. By prioritising vaccine nationalism, previously powerful countries may find themselves losing commercial and political influence around the world as rising, lower-income countries feel they can only rely on Russia or China to satisfy their vaccine supply demands. The US seems to be realising that now and is playing catch-up, with the Biden administration recently announcing a partnership with India, Australia, and Japan to supply up to one billion coronavirus vaccines across Asia by the end of 2022. Together with other global powers, they have largely ignored the moral and ethical obligations to share vaccine doses equitably to ensure a coordinated, global vaccine roll-out. This may ultimately threaten the very “democracy” which large democratic countries are fighting to uphold and promote around the world. In a world fraught with frustrations and uncertainties, solidarity in delivering effective vaccines must be a critical step towards rebuilding trust in the international community.

Governments have been using vaccines to advance specific foreign agendas. It has become apparent that global collaboration is still very much a dream. Recent events have shown that when inappropriately applied, vaccine diplomacy may be detrimental to global coordinated “vaccine internationalism” efforts (e.g. COVAX). This undoubtedly raises questions about finding a balance between a more utilitarian perspective and achieving fair distribution. Vaccine resource allocation and decision-making processes should not only follow a framework of accountability for reasonableness, but must also be transparent, public, and revisable in light of new evidence and arguments; such standards should be set by existing international bodies and provisions should be made for their enforcement.

In his latest book, Peter Hotez makes a bold call to promote vaccine diplomacy to prevent diseases as well as promote peace and cooperation among countries. Diplomacy must also be used to convey the concept that we need global immunisation approaches, leaving no country or individual behind, if we are to get the disease under control and prevent the emergence of new variants which may threaten the progress achieved thus far. In fact, if we are to reach the herd immunity levels necessary for defeating this virus. In efforts to “build back better” from covid-19 and “return to normal”, we can—and must—rely on vaccine diplomacy to address this new world order in disease and global health.

Brian Li Han Wong (@brianwong_), Medical Research Council Unit for Lifelong Health and Ageing at UCL, Department of Population Science and Experimental Medicine, UCL Institute of Cardiovascular Science, University College London.

Marine Delgrange (@marinedelgrange), Department of Health Policy, London School of Economics, London, UK; Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK

Jose M Martin-Moreno (@JMMartinMoreno), ASPHER Honours Committee & Department of Preventive Medicine and INCLIVA, University of Valencia, Spain

 Manfred S Green, Professor of Epidemiology and Public Health. School of Public Health, University of Haifa, Israel.

 John Middleton (@doctorblooz), President, Association of Schools of Public Health in the European Region (@ASPHERoffice)

 Competing Interests: none declared

 On behalf of the Association of Schools of Public Health in the European Region (ASPHER) COVID-19 Task Force Vaccination group: Brian Li Han Wong, Giulia Sesa, Ines Siepmann, Jean-Philippe Naboulet, John D Middleton, John Reid, Jose M Martin-Moreno, Katarzyna Czabanowska, Laurent Chambaud, Manfred Green, Mohamud Sheek-Hussein, Nadav Davidovitch, Ranjeet Dhonkal, and Robert Otok.