Vaccines have had a place in diplomacy since the Cold War era. The country that can manufacture and distribute lifesaving injections to others less fortunate sees a return on its investment in the form of soft power: prestige, goodwill, perhaps a degree of indebtedness, even awe. Today the country moving fastest toward consolidating these gains may be China, under President Xi Jinping, who proclaimed last May that Chinese-made vaccines against COVID-19 would become a “global public good.” Since that time, top officials have promised many developing countries priority access to Chinese vaccines, and the Chinese Foreign Ministry has announced that the country is providing free vaccines to 69 countries and commercially exporting them to 28 more.
China’s competitors worry that where Beijing’s inoculations go, its influence will follow. But the field of COVID-19 vaccination is still a largely uncharted one and scattered with barriers, whether logistical, scientific, psychological, or geopolitical. China’s path through this labyrinth is neither obvious nor assured. The country faces stiffening competition from Russia and India. Now the United States, too, has entered the global stakes for equitable distribution of safe and effective vaccines. China has yet to prove that it can fulfill the role it has taken on or win the trust of those it has offered to aid.
CHINA'S STAKE
The Chinese government dislikes the term “vaccine diplomacy.” The implication that China would distribute vaccine doses in order to broaden its global political influence is a “sinister” one, according to the official Xinhua News Agency. Rather, the Chinese government contends that “in promoting cooperation in combating the pandemic, China does not seek any geopolitical goals or have any economic interest considerations, and it has never attached any political strings.” Xi has further stressed that by distributing necessary goods in a crisis, China is merely acting as a responsible great power should. In this regard, China may seek to succeed with vaccines where it failed with masks: last spring, quality-control issues and clumsy propaganda tarnished the country’s efforts to supply medical products to the developed world. Now China is looking to showcase its global health leadership to lower- and middle-income countries, where it is distributing vaccines.
But Beijing surely has additional foreign policy objectives in mind. China began its vaccine development projects early last spring, and state media made quite clear that through them, China hoped to demonstrate its technological prowess and the superiority of its authoritarian model of governance. “We are not lagging behind the United States as far as the technology is concerned,” a Chinese virologist told the state-backed Global Times. Another scientist highlighted China’s “system advantages”: “The United States is no match for China in terms of concentrating power to accomplish big things.”
Indeed, unlike in the United States, vaccine development in China was a highly state-driven process. The Chinese government simultaneously pushed several technological approaches, including inactivated vaccines, mRNA vaccines, and adenovirus vector vaccines. It mobilized at least 22 institutes and firms to work on 17 vaccine development projects. And until last summer, China was leading the global race in vaccine development. It developed a vaccine (Ad5-nCoV) as early as February 2020, started Phase 1 clinical trials on March 16, and published results of the trials in late May. General Chen Wei, the face of China’s vaccine development operation, celebrated such achievements as “an embodiment of our country’s S&T progress, an embodiment of China’s great-power image and responsibility, and, even more, a contribution to humankind.”
Behind such lofty goals lie commercial objectives, too. Health-related development assistance has long offered Chinese pharmaceutical companies a low-cost means of expanding their market share in the developing world. In March 2020, President Xi explicitly linked the shipment of medical supplies overseas to the “Health Silk Road,” now an important component of the Belt and Road Initiative. Xiaofeng Liang, a former deputy director of the Chinese Center for Disease Control and Prevention, has publicly called for prioritizing BRI countries for access to Chinese vaccines.
But the opportunity hardly ends there. Prior to the COVID-19 pandemic, few Chinese pharmaceutical companies had received World Health Organization prequalification to supply medical products to international organizations and donor funds. In 2019, China’s share in the value of UN-procured medical products was only 1.9 percent, compared with 21.9 percent for India. Chinese media lamented that of the 155 WHO-prequalified vaccines, only four were from China, compared with 44 from India. Indeed, Indian pharmaceutical firms produced more than 60 percent of the vaccines sold worldwide.
The huge global demand for COVID-19 vaccines and “vaccine nationalism” in wealthy nations have created a great opportunity for China to break into a market that Indian and Western pharmaceutical firms have long dominated. If the vaccine were priced at $10 per dose with a 40 percent net profit margin, even a 15 percent share of the vaccine market in lower- and middle-income countries would generate total sales of $10.8 billion and a profit of $4.32 billion for the Chinese economy. In reality, Chinese vaccines are often priced higher than $10.
"TAKING OVER THE WORLD"
China’s vaccine drive appears in many ways to be paying off. China has completed Phase 3 clinical trials for four vaccines with positive results. Unlike some of their Western counterparts, all of China’s vaccines can be stored at normal refrigerator temperatures, a factor that makes them particularly appealing to the developing world, where refrigeration is often not available. One Chinese vaccine, developed by the company CanSino Biologics, shows the same efficacy as Johnson & Johnson’s (66 percent) and also requires only a single dose.
For these reasons among others, elites in the developing world are embracing Chinese-made vaccines. The leaders of many countries—including Chile, Cambodia, Peru, Serbia, the United Arab Emirates (UAE), Indonesia, Turkey, Zimbabwe, and Seychelles—have either welcomed Chinese vaccine deliveries personally or publicly received the first shot of a Chinese-made vaccine. In mid-February, Peruvian Foreign Minister Elizabeth Astete resigned after being accused of jumping the line to receive a shot from Sinopharm.
By early February, three Chinese vaccine makers (Sinopharm, Sinovac, and CanSino) had received overseas orders for more than 572 million doses, accounting for nearly eight percent of all doses under contract globally. In Indonesia, Sinovac alone will supply 38 percent of the nearly 330 million doses that Jakarta has secured, in a deal that will bring the company a profit of some $1 billion. As of mid-February 2021, China—a latecomer in internationally marketing its vaccines—had shipped more than 46 million doses or their active ingredients overseas.
Whether or not Beijing likes the term, vaccine diplomacy is reaping soft-power dividends for the Chinese government and consolidating its relationship with BRI countries. Algerian Foreign Minister Sabri Boukadoum, for example, recently said that his country was grateful for China’s vaccine assistance and expressed his willingness to promote China’s BRI. And the Chinese public takes pride in Beijing’s vaccines, viewing their uptake as a clear sign of China’s global leadership. A widely circulated social media post claims that “Chinese vaccines are taking over the whole world.” A well-known Chinese scholar proudly wrote of China’s becoming “the arsenal of the world’s pandemic response.” Even French President Emmanuel Macron admitted in early February that China’s vaccine diplomacy is “a little bit humiliating” for Western leaders and countries, as the Western, multilateral approach to vaccine distribution has proven less efficient.
CONCERNS AND COMPETITION
China’s vaccine diplomacy is off to a strong start, but Beijing still faces stiff competition and tough questions from abroad. In particular, potential consumers of the Chinese vaccines have pressing concerns about whether China can deliver on its promises and whether its scientific claims are credible.
China has taken more vaccine orders from low- and middle-income countries than it is currently outfitted to fulfill while simultaneously meeting its domestic need. As of early March, China had committed more than ten times as many doses overseas as it had administered in China (52 million). The country was reportedly still reaching only half of its daily manufacturing capacity (one million) in January. China would need to vaccinate 70 to 80 percent of its population in order to meet the requirements of herd immunity. But according to the Economist Intelligence Unit, it will be able to vaccinate just 60 percent of its populace by the end of 2022 if it continues to produce vaccines at the current speed. Despite government efforts to ramp up vaccine production, capacity constraints are not expected to alleviate significantly until after 2021. Indeed, China aims to vaccinate just 40 percent of its population—560 million people—by the end of July.
This likely shortfall might explain why China has donated vaccines to at least 24 countries but delivered to each only a minuscule number of doses compared with their populations, typically in the range of 20,000 to 300,000. Meanwhile, the delay in shipping Chinese vaccines to countries that have ordered them for purchase, such as Brazil and Turkey, has raised concerns that China may not honor its promises.
Concerns about delivery have dovetailed with complaints that Chinese companies have not been transparent in announcing interim results of Phase 3 clinical trials, leading to public questions about the vaccines’ safety. Except for CanSino’s vaccine, China thus far has barely conducted Phase 3 clinical trials on people over the age of 60 and cannot guarantee its vaccines’ safety in this population. Efficacy is another concern. Sinovac’s vaccine trials in Brazil yielded an efficacy rate just over 50 percent, much lower than that of the Pfizer and Moderna vaccines. Clinical trials elsewhere (such as in the UAE, Turkey, and Indonesia) produced higher efficacy rates, but the results are inconsistent, and disclosures about the Chinese-made vaccines have been slow and spotty. To head off these concerns, China’s state and social media started a misinformation campaign to discredit the Western vaccines. While the campaign boosts domestic support for Chinese vaccines, it does not help burnish China’s global reputation.
In January, the British market research firm YouGov conducted a survey of around 19,000 people in 17 countries and regions. The poll found that Chinese-made vaccines were among the least favored. Public suspicion of Chinese vaccines has spread throughout Southeast Asia, South Asia, and Africa, undercutting China’s soft power. Russia, by contrast, has been more forthcoming in revealing its Phase 3 clinical trial data and has encountered less suspicion as a result. According to the YouGov survey, people in the UAE, the first foreign country to approve a vaccine developed by China, feel more positive about the vaccines developed in Russia or India. Even in Mexico and Indonesia, where China had partnerships to develop its vaccines, people prefer Russian-made vaccines to those developed in China.
China’s vaccine diplomacy, for these and other reasons, does not enjoy a totally open field. Rather, Chinese vaccines must jostle for position among those from India, Russia, and the United States. The Central Asia Barometer Survey released in early February found that 52 percent of Kazakhstanis, 58 percent of Uzbekistanis, and 76 percent of Kyrgyzstanis believed that Russia would be best able to help their countries, compared with 20 percent of Kazakhstanis, 14 percent of Uzbekistanis, and 8 percent of Kyrgyzstanis who said China would be best able to help their countries. Given China’s growing BRI investment in what India considers its sphere of influence, India has particularly strong incentives to counterbalance China’s geopolitical influence by sending desperately needed vaccines to its neighbors, including Nepal (one million doses), Bangladesh (two million), Sri Lanka (500,000), Bhutan (150,000), Maldives (100,000), Myanmar (1.5 million), Afghanistan (500,000), and Seychelles (50,000). The only country in the region that has not received India’s vaccine is its archrival, Pakistan, to which China pledged 1.2 million doses. India’s generosity highlights the limits of China’s vaccine diplomacy in India’s strategic backyard: thus far, China has donated only 500,000 doses to Nepal, 300,000 doses to Sri Lanka, and 300,000 doses to Myanmar. Its vaccine donation to Pakistan, the largest among all BRI countries, covers no more than 0.6 percent of the country’s population.
Recipients of Chinese largess know that Beijing’s vaccine diplomacy is not a one-way street and that vaccines may come at the price of influence down the line. These countries make their own rational calculations in dealing with Beijing. Many seek to diversify their vaccine supply. Some might be happy to see China and its rivals compete with one another to offer vaccines. Seychelles, with a population of 98,000, has received 100,000 doses of vaccines manufactured in either China or India. As a result of “dueling vaccine diplomacy,” the island nation now ranks second in the world in the percentage of population vaccinated. Vietnam, which has territorial disputes with China, was the first to preorder a large batch of vaccine from Russia, even though it was promised priority access to Chinese vaccines. The need to neutralize Beijing’s influence and avoid public criticism for relying on Chinese jabs might explain why two other Southeast Asian countries that have overlapping claims with Beijing in the South China Sea also moved to secure vaccines from additional countries, including India, Russia, and the United States, even after purchasing vaccines from China.
For the very reasons that such diversification makes sense for China’s uneasy neighbors, it frustrates the purpose of Beijing’s vaccine diplomacy. China committed 250 million doses to Southeast Asia—44 percent of the total doses it committed worldwide. It has shipped 18 million doses to Indonesia, accounting for 40 percent of all vaccines and active ingredients shipped overseas. According to a survey of opinion makers, policymakers, and thought leaders in ten Southeast Asian countries, conducted between November 18, 2020, and January 10, 2021, China was ranked the region’s number one provider of assistance in fighting COVID-19. Still, only 16.5 percent of the same respondents considered China a trusted power in the region, compared with 19.8 percent for India and 48.3 percent for the United States. Indeed, between 2020 and 2021, trust in China actually fell, as did the percentage of the region’s elite who saw China as Southeast Asia’s most important strategic player.
REENTER THE UNITED STATES
Under former President Donald Trump, the United States chose not to seek the soft power that might accrue to those who offered vaccine aid. Washington went the nationalist route instead, opting out of the COVID-19 Vaccine Global Access (COVAX) Facility and refusing to commit vaccine aid internationally, even to its allies.
Washington’s abdication served to boost the marginal benefits of China’s vaccine diplomacy. Had quality vaccines from the United States been more available, decision-makers in low- and middle-income countries might have been less willing to overlook the efficacy and transparency issues with Chinese vaccines. Beijing filled a leadership void that Washington left open.
But the United States did not leave that space uncontested for long. The country’s swift development of an effective vaccine using advanced mRNA technology signaled that it remained the world’s top technological and scientific powerhouse. And toward the end of the Trump administration, the United States began to show an interest in global vaccine distribution, approving a $4 billion commitment to Gavi, the Vaccine Alliance in December 2020. Under President Joe Biden, the United States has rolled out a domestic vaccination program that will likely bring the country to herd immunity before China, thus allowing it to assert leadership in pandemic control. And by joining COVAX, the Biden administration further sent a strong message that the United States is back as a global health power. The United States has now reportedly opened discussions with India, Australia, and Japan about providing vaccines to Asia, precisely in order to compete with Beijing’s vaccine diplomacy.
Government leaders in the developing world are eager to see the United States play a more proactive role in global vaccine distribution and administration. By doing so, the United States will inevitably dilute the influence that China has gained by distributing its vaccines. But by far the best outcome of such competition will be for it to give the two countries a reason to work together toward more equitable vaccine access for all.
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