Towards a Better Vaccine Diplomacy

COVID-19 has reshaped everything, not least global politics. In a world where access to limited vaccine supplies is the only way to end the crisis, so-called “vaccine diplomacy” has emerged as a new channel through which major powers seek to curry favor and shape the international environment to their benefit, doling out vaccines to favored countries according to perceived national interest.

Billions of vaccine doses have now been pledged for international donation, with the bulk coming from the United States and China, as well as the European Union and its members. Although much has been achieved, there is nonetheless little doubt that the global vaccine effort is falling short. Vaccine doses have been donated based on overly narrow geopolitical considerations rather than need or equity. The multilateral COVAX initiative remains underfunded and struggling to fulfill its mission for global vaccine equity. And the technology behind the leading vaccines is not being shared widely enough, despite the obvious need to expand global vaccine supplies.

In an age of escalating great power rivalry, overseas vaccination efforts are too often mistaken for charity and pursuing the national interest conflated with playing for short-term geopolitical gain. If vaccine diplomacy is the new great game, it is being played wrong by all sides, with the risk that no one will be left a winner.

The heart of the problem is the failure to fully recognize that international vaccine equity is a global public good in every major power’s self-interest. Anything less risks prolonging the pandemic and fuelling instability. At present, less than two-thirds of the world’s population have received at least a single vaccine dose. While around 70 percent of people in rich countries have done so, the figure is only about 10 percent in low-income countries. The need for booster shots in response to the Omicron variant will only widen the gap.

This is not only a moral failing but also means COVID-19 still has a pool of billions of unvaccinated people among which to circulate and mutate into more dangerous forms.

The possibility of more dangerous future variants could prove especially dangerous for China, given its reliance on less effective homegrown vaccines and its consequent reliance on a costly zero-COVID strategy.

But Western powers are hardly immune. While the hope may be that widespread immunity, due to vaccination or previous infection, can prevent a renewed health crisis, there is no guarantee that some future variant will not evade this immunity and existing treatments in dangerous ways. Furthermore, even an endemic COVID-19 could still imply a high disease burden and repeated waves of infection capable of putting intense pressure on hospital systems and creating substantial economic disruption.

Moreover, persistent international vaccine inequity carries other important geopolitical consequences for Western powers – weakening key emerging partners in the Indo-Pacific vital to the regional balance of power amid a rising China and undermining the liberal international order that the West seeks to defend.

Asia’s Balance of Power, Disrupted

There is a striking disjunction between the traditional security risks largely centered on the shifting balance of power in the Indo-Pacific, and the fact that for the past two years the world has been far more affected by the non-traditional security threat of pandemic disease.

Quite apart from the human toll exacted by the pandemic, the Lowy Institute’s 2021 Asia Power Index shows that COVID-19 has also driven down the comprehensive power of almost all states in the Indo-Pacific, weakening their capacity to respond to and shape their external environment.

Uneven economic impacts and recoveries from the pandemic will likely continue to alter the regional balance of power well into the rest of this decade. Taiwan, the United States, and Singapore are now predicted to have larger economies in 2030 than originally forecast prior to the pandemic. But emerging powers – including India and much of Southeast Asia – have been badly damaged in comparison to their pre-COVID growth paths. China’s comprehensive power consequently continues to grow in relation to nearly every other emerging regional power in Asia.

This should be concerning to the United States and its partners seeking to build a durable regional balance of power, with Southeast Asia at its center. A robust post-pandemic recovery of developing Asia will be a prerequisite to ensuring a resilient and prosperous region capable of restraining the excesses of China’s growing influence. The ability of governments in this part of the world to procure and administer COVID-19 vaccines is crucial to determining their success. But so too is bringing the pandemic to a heel globally.

The United States Is Still Leading

According to the Think Global Health initiative of the Council on Foreign Relations, leading powers have pledged to donate around 2.7 billion vaccine doses to other nations globally. The United States alone has pledged to provide 1.1 billion doses. China’s initial focus was on exporting its vaccines largely on a commercial basis. But more recently it too has made significant vaccine donation pledges, now totalling 850 million doses, with the bulk destined for Africa. Meanwhile, the EU and its member states have collectively committed to donate half a billion doses. Altogether, the three superpowers account for about 90 percent of the doses that have been pledged for donation in total.

After years of Chinese diplomatic momentum on the world stage and U.S. apathy on transnational challenges under President Donald Trump, Washington turned a corner by the middle of 2021 to begin a more concerted international vaccine push.

For all the handwringing about the U.S. turning its back on the world, it is now the United States that has stepped up the most on international vaccine donations. The U.S. alone accounts for 40 percent of total vaccine doses committed for donation. Its pledge to provide 1.1 billion means it has effectively committed to provide three doses overseas for every person in the United States, far higher than any other donor country. Australia has been the next most generous in per capita terms, committing to donate a little over two doses overseas per Australian at home. Most other countries have made much smaller per capita promises, including China.

The United States has also provided relatively more funding to the COVAX Advanced Market Commitment (AMC) facility, which aims to provide vaccines to 91 developing countries on an equitable basis. Although COVAX remains underfunded, the United States is both the largest single donor and among the more generous on a per capita basis, providing about $10 per American. China, for its part, has largely spurned COVAX, so far only providing the equivalent of about seven U.S. cents per capita.

For geostrategic reasons the Indo-Pacific has also been a key focus for Washington’s vaccine diplomacy. By late last year the United States had delivered more than 90 million COVID-19 doses of its promised vaccine donations to countries in the region – twice as many as China.

Washington also sought to broaden the appeal of the Quadrilateral Security Dialogue (Quad) – alongside its partners Australia, India, and Japan – with an expanded remit on the provision of international public goods, notably the supply of COVID-19 vaccines. In March 2021, leaders of the Quad committed to deliver 1 billion COVID-19 vaccine doses to the Indo-Pacific region by the end 2022. Under the deal, Japan and the United States agreed to finance – for an undisclosed sum – the production of COVID-19 vaccines in India, from drugmakers including U.S. firms Novavax and Johnson & Johnson, which Australia would then distribute across Asia.

China’s Vaccine Diplomacy Falters

Asia has similarly been a key linchpin in Beijing’s vaccine diplomacy, with the region receiving the greatest number of Chinese vaccines to date, albeit largely on a commercial basis.

While the United States and Europe were relatively late to the vaccine diplomacy game, China expedited the export of its vaccines across the developing world. Reports suggest that close to 1.7 billion doses have been sold by China so far throughout Asia, but also Africa, Latin America, and the Middle East – with around 80 percent of those doses already delivered. As a result, Sinovac and Sinopharm are thought to account for about half of the total global supply of vaccines to date.

China’s vaccines held multiple layers of appeal for developing countries. First, supply of Sinovac and Sinopharm was readily available and delivered quickly at a time when leading Western alternatives were scarce due to hoarding and export restrictions in rich countries. Second, the Sinovac and Sinopharm vaccines do not require cold-chain storage as mRNA vaccines do, making them more viable options for developing countries with weaker public health infrastructure. Third, the willingness of China to partner with countries like Indonesia to produce and distribute vaccines, if even at a basic level around packaging, was also alluring.

Yet despite early gains, China has failed to sustain its early mover advantage in vaccine diplomacy.

Many developing countries – including key early beneficiaries in Southeast Asia – turned away from Chinese-made vaccines once leading Western alternatives started becoming available by the middle of 2021. This was at a time when their health systems were coming under intense strain from the Delta variant and doubts began to grow around the efficacy of the Chinese shots.

Thailand, for instance, announced it was changing its vaccine policy in July 2021. Instead of receiving two Sinovac shots, the government announced its citizens would receive a mix of Sinovac and AstraZeneca. Indonesia announced a similar move in July and began administering Moderna booster shots to healthcare workers previously immunized with Sinovac.

The shift underscores the limits of China’s soft power push particularly in Asia, which does not seem to have translated into substantial goodwill in recipient countries.

An expert survey conducted last year by the Lowy Institute as part of the Asia Power Index showed that China’s vaccine efforts were only seen as somewhat constructive among countries in the Indo-Pacific region. By contrast, U.S. efforts were seen as world leading. Smaller powers, such as Japan, Australia, and New Zealand – which have given far more doses per capita in the region than China – were seen more favorably.

One can speculate as to the reasons behind China’s poor performance, but the commercial nature of China’s bilateral vaccine deals, its low per capita generosity, and the fact that its vaccines appear less effective than Western alternatives, especially against the newer variants of the virus, seem the obvious culprits.

Credibility Gap

Leapfrogging China in vaccine diplomacy, however, does not mean that the United States and its partners will emerge from this global health crisis triumphant. China may have proven itself unable to step up in the way required, but the world does not expect as much of China to begin with. The task for the United States and its like-minded partners, by contrast, is to convince the rest of the world that they are the principled global actors they claim to be and that the much-fabled liberal international order for which they stand is worthy of its status.

The billions of doses committed still fall well short of global demand for vaccines, especially once the need for booster shots in response to Omicron and possible future variants are factored in. Moreover, aside from the U.S., many of the biggest donors have made relatively small donation pledges on a per capita basis. Only the United States, Germany, and Australia have promised to donate a full course overseas for every person in their domestic population.

Concerns are also rising around the practice by many rich countries of donating excess doses close to their expiry dates, leaving poor countries little time to get jabs into arms and forcing them to reject or destroy the donated vaccines instead.

Timing is crucial. From both an epidemiological and economic standpoint, jabs in arms today are far more valuable than vaccines delivered tomorrow, let alone years in the future. Yet just a fifth of total doses promised by donors have to date been delivered. Of the 10 largest donors, only the U.S., Australia, Italy, and Japan have delivered more than a quarter of their commitments.

Few flagship initiatives have been so high profile and yet so afflicted by a yawning delivery gap as the Quad Vaccine Partnership. The Quad’s headline commitment in March 2021 was to deliver 1 billion COVID-19 vaccines to the Indo-Pacific by the end of 2022. However, only around 248 million – about a quarter – had been delivered as of February 2022, nearly a year after the pledge was made.

The innovative partnership sought to leverage India’s vast vaccine production capabilities and its role as the backbone of global vaccination supply for low- and middle-income countries. Yet in a cruel irony, the world’s vaccine manufacturing powerhouse was crippled by the Delta variant only weeks after the Quad leaders first met. India effectively blocked exports of vaccines as its own hospitals were overrun with COVID-19 patients in the spring and summer of 2021.

Fortunately, there are signs that global vaccine donors are beginning to accelerate delivery on their promises. Data from Think Global Health suggests that the same number of doses were delivered in the five weeks between the end of October and start of December 2021 as in the first 10 months of the year. Much of this progress was driven by European countries, including Germany, Belgium, Italy, and France, rapidly picking up the pace of deliveries, giving between two to five times more in those five weeks than during the first 10 months of 2021.

Moreover, in February 2022 the Quad foreign ministers’ meeting in Australia agreed to resume and expedite the delivery of COVID-19 vaccines. The first batch of the Indian manufactured vaccines under the Quad group’s initiative is now set to be rolled out in the first half of 2022.

No Winners Without Global Vaccine Equity

Nonetheless, progress will remain fragile as long as potential for dangerous future variants persists.

The Quad Vaccine Partnership highlights a key problem with bilateral vaccine diplomacy: Leading powers are donating strategically rather than equitably. The result has been to skew the distribution of vaccines toward Asia as opposed to other parts of the world where the vaccine gap is much starker, especially Africa.

The Quad’s Vaccine Partnership is clearly a means to counter China’s vaccine diplomacy in the part of the world with the greatest geopolitical significance to its members. But a more enlightened reading of the grouping’s geopolitical interests would urge that the partnership go global in its scope and ambitions. When it comes to bringing a faster end to the pandemic, global vaccine equity is what is needed most. Even success in helping particular countries can be quickly undone by the arrival of more dangerous new variants.

It is no surprise that the area of the world with the lowest vaccination rate, sub-Saharan Africa, also appears to have provided the fertile ground for the Omicron variant to develop. Moreover, not only are vaccination rates in Africa tragically lower than elsewhere, but the region is also lagging well behind other parts of the world in securing an adequate pipeline of doses from any source, be it bilateral donations, COVAX, or their own commercial arrangements. Although there are concerns about vaccine hesitancy and weak absorptive capacity, at this point the evidence does not suggest this is the binding constraint to faster progress, except in a handful of cases. Most countries seem capable of absorbing more vaccine doses if they were made available.

Multilateralism Allowed to Fall Short

Relying on bilateral vaccine diplomacy was always a suboptimal strategy for ensuring the equitable global distribution of vaccines. That is why when the pandemic struck the World Health Organization and its partners were quick to establish the COVAX initiative aimed at distributing vaccines on an equitable basis, particularly to developing countries. Despite numerous challenges, COVAX has made admirable progress – reaching the milestone of 1 billion doses delivered in January 2022.

Nonetheless, COVAX, and the multilateralism it represents, was undermined from the start, first by vaccine nationalism on the part of richer countries and later by a preference for bilaterally directed vaccine diplomacy over the multilateral kind. Rich countries undermined the initiative at an early stage by moving quickly to strike their own bilateral deals with vaccine manufacturers to ensure their domestic supply. COVAX was also severely hampered when India – which was to be a key vaccine supplier to COVAX – imposed an export ban last year as it was engulfed by the Delta wave.

Most fundamentally, COVAX and the broader Access to Covid-19 Tools Accelerator (ACT-A) program of which it is a part, run by the World Health Organization and its partners, was underfunded and remains so, currently facing a funding gap of $20 billion.

Other forms of multilateralism have also underdelivered. The multilateral development banks collectively allocated around $30 billion to support the vaccine rollout in developing countries, with the World Bank committing $20 billion and the Asian Development Bank separately making $9 billion of its own funds available. Other development banks allocated smaller amounts.

Yet, to date, the majority of funds available under these facilities have yet to be committed. Part of the problem has been with the banks themselves, which initially imposed overly stringent controls particularly on which vaccines were eligible under their programs (which have since been relaxed). Like COVAX, the banks’ vaccine efforts have also struggled to compete with rich nation governments in securing relatively scarce vaccine supplies.

More fundamentally however, the multilateral development banks’ vaccine response simply lacked the required ambition from the international community. The vaccine programs should have been made additional to the banks’ existing resources and provided on the most concessional terms, given the scale of the crisis and the global public good nature of the international vaccine rollout. This would have increased the overall level of support to developing countries and promoted take up. Instead, the money for vaccines came out of existing bank resources and, consequently, took the form of a mixture of grants and concessional and non-concessional loans – with populous middle-income countries like Indonesia and Philippines, important to the global vaccine effort, only having access to non-concessional loans.

Sharing the technology behind the miraculous COVID-19 vaccines is another area where multilateralism has fallen short. In October 2020 India and South Africa proposed that the World Trade Organization agree to waive intellectual property rights for COVID-19 related health technologies, including vaccines, with the goal of expanding global supply and access. In May 2021 the Biden administration threw its public support behind the waiver, though some would say the support was only lukewarm. In any case, resistance from European powers means the proposal remains stalled.

The WHO has instead pressed ahead with its own technology transfer efforts, without the support of the major vaccine companies. This year it announced that its newly established mRNA technology hub in South Africa had successfully produced its own vaccine based off publicly available information on the Moderna vaccine. This is a major breakthrough. Nonetheless, the WHO says approval for use of the new vaccine will likely only be achieved in 2024.

Toward a Better Vaccine Diplomacy

Despite significant strides in the right direction, the United States and its partners have a long way to go to make a success of their vaccine diplomacy.

China may have proven itself unable to step up in the manner expected of a superpower and aspiring alternate hegemon. However, the task for the United States and its partners is not simply to outdo China – it is to convince emerging powers in the Indo-Pacific, and the world, that the liberal international order for which they stand is worthy of its name. Western claims to be principled global actors are discredited when governments hoard vaccines, belatedly donate the excess, and allow multilateralism to fall short at a crucial global moment.

Global vaccination efforts have more recently begun to move more forcefully in the right direction. But the race to inoculate the world has only just begun. Further challenges, setbacks, and plot twists no doubt still lie ahead. Vaccine diplomacy, as practiced, leaves much to be desired. The answer, however, is not less vaccine diplomacy but doing more and better to bring the global pandemic to heel.