HUANG Yanzhong, Senior Fellow for Global Health, Council on Foreign Relations; Director of Global Health Studies, Seton Hall University’s School of Diplomacy and International Relations.
FULL VIDEO ON OUR YOUTUBE CHANNEL
On May 6th, 2021 ThinkINchina online event#79 focused on China’s COVID-19 vaccine diplomacy, welcoming as speaker Professor Huang Yanzhong, that first gave the audience a general overview of China’s vaccine diplomacy starting with a brief explanation on the general definitions, for then going deeper into examining global vaccine developments. Professor Huang discussed some of the promises of China’s vaccine diplomacy according to the Chinese government, where China decides to send its vaccines and their commercial implications. Finally, Professor Huang outlined the outcomes and the challenges of implementing such diplomacy.
What does Vaccine diplomacy mean?
According to P. J. Hotez , vaccine diplomacy is the branch of global health diplomacy that relies on the use or delivery of a vaccine. The term was coined two decades ago; nonetheless, the history of vaccine diplomacy dates back to the Cold War era, when the United States and the Soviet Union cooperated to produce and distribute a vaccine for the eradication of infectious diseases like Poliomyelitis . However, according to Professor Huang, China’s vaccine diplomacy has developed in a very different context and under different circumstances.
Even before the spread of the COVID-19 pandemic, China was already undergoing and witnessing a shift in the attitude towards global leadership. Since 2012 China has been on a trajectory of asserting itself within international organizations and displaying capability and drive for more international responsibilities. This global leadership’s ambition was evident during the administration under President Donald Trump, which catalyzed the opportunity for China to rise within the international order that America was otherwise retracting from. China’s “mask diplomacy” (meeting worldwide sudden demands for surgical masks) and the subsequent vaccine diplomacy have demonstrated its ambition to be a global leader and its willingness to play a more pro-active role in the foreign policy front.
China Vaccine Diplomacy – an overview
Vaccine diplomacy in China is a state-driven process. 22 institutions and firms have been working on 17 vaccine development projects, and, until last summer, the global vaccine race was led by China.
China has developed many different types of vaccines: (SinoVac and Sinopharm), adenovirus vector vaccines (Cansino), recombinant protein subunit vaccines (CAS), nucleic acid vaccines (mRNA). Professor Huang pointed out that China’s decision to focus on inactivated vaccines is significant to understand the trajectory of Chinese vaccine diplomacy.
On the domestic level, China launched its emergency program in June 2020: two vaccines, developed by CNBG/Sinopharm and one by Sinovac Biotech, still in Phase 3 trials, have been administrated. More than 4.5 million doses have been given on a voluntary basis to high-risk or priority groups (medical workers and people going overseas to work).
China’s first COVID-19 vaccine was developed by an affiliate of state-backed pharmaceutical giant Sinopharm and on 31 December 2020, it received approval for public use by the National Medical Products Administration. It earlier gained approval for general use in the United Arab Emirates and Bahrain.
In February, China developed a vaccine Ad5-nCoV, then on March 16, it started the Phase 1 trial, and published results of the trial in late May. The Phase 3 clinical trial required a study on an area with a significant number of COVID-19 cases, considering China’s rapid containment of the virus, it was necessary to build partnerships with other countries to carry forward experiments for Phase 3. Subsequently, the UAE and Egypt decided to test Sinopharm; Brazil, Indonesia, and Turkey the Sinovac; Pakistan and Saudi Arabia the CanSino.
According to Professor Huang, this operation can morph those countries into regional hubs, working together to produce vaccines locally and distribute them. The registered efficacy rate of the Chinese vaccine tested abroad are the following: Sinopharm: 79% (Peru), 86% (UAE); Sinovac: 91% (Turkey), 68% (Indonesia), 50% (Brazil), 67% (Chile); Cansino: 66% (one-shot).
Why did COVID-19 Vaccine diplomacy commence?
Vaccine diplomacy was launched following the partial failure of “mask diplomacy”. “Mask diplomacy” started in early March 2020, as the epicenter of the pandemic shifted from China to Europe. China authorities affirmed to have great control over the virus outbreak, thus China decided to send medical aid, equipment, and supplies to European partners. At first, the donations received a great welcome, especially in Italy; however, Western countries displayed concerns over quality control, which significantly affected China’s overall mask campaign. For instance, the Spanish government tested kits from a Chinese company in Shenzhen and the results showed that they were only 30% accurate. In the Netherlands, the government recalled 600,000 masks because the filters were ineffective.
The distribution of vaccines in lower- and middle-income countries may be an attempt to recover from the failure of “mask diplomacy” in the West, and a way to showcase China’s global health leadership in lower- and middle-income countries, according to Professor Huang.
What are the objectives of Chinese Vaccine diplomacy?
Following the Chinese government’s official discourse, China’s vaccine diplomacy has three major objectives:
Moreover, during a speech at the World Health Assembly in May 2020, President Xi Jinping promised that China’s vaccine, once developed, would have been made a “global public good”. However, the President did not give an extensive explanation of the meaning of this goal. The government also promised priority access to vaccines to many developing countries in South East Asia, Middle East, and Sub-Saharan Africa.
In October 2020, China joined COVAX – the WHO-supported vaccine distribution mechanism to ensure equitable access to vaccines for less developed countries – declaring to donate 10 million doses to COVAX.
Behind those promises, however, there are also commercial objectives. China exported 206 million doses abroad, accounting for around 30/40 percent of global exports, thus becoming the largest vaccine exporter in the world. Among the exported doses, 10 million were shipped as donations, while the rest of them have been purchased. At what price? According to the New York Times, Hungary revealed that the cost of vaccine purchased is about 30 euros per dose (36 $) . This is a much higher cost in comparison to AstraZeneca, which is $2.15 per dose.
Where does China send vaccines?
By the end of March 2021, China has committed about 800 million doses to more than 60 countries and started collaborating with 10 countries including Serbia, Malaysia, Egypt, to produce Chinese vaccine locally. The distribution of Chinese vaccines is wide, however, there are different opinions on where China decides to send its vaccines.
First, China is more likely to send vaccines to countries with high mortality rates. This demonstrates that China is, indeed, making vaccines a “global public good”, meaning that the humanitarian factor plays a primary role in vaccine diplomacy. Second, China is donating vaccines to its long-term allies. Pakistan, for example, is the largest receiver of vaccine: 1.5 million donations from China and it has bought more than 1 million doses of Chinese Sinopharm and CanSino Biologics COVID-19 vaccines. Third, China sends vaccines to strategically important regions, such as South East Asia, with the only exception of Vietnam, while the largest purchaser is Indonesia (100 million doses). Considering the number of coronavirus cases, the Southeast Asia region registers a lower number compared to African countries, where poverty and low life conditions exacerbate the situation. Nonetheless is still the greatest receiver of Chinese vaccine donations, while African countries are at second place on a worldwide scale. Southeast Asia has a geopolitical value for China as other relevant actors like the US and the Quad have political and economic interests and influence on the region.
How successful is vaccine diplomacy and what are the challenges?
According to Professor Huang, vaccine diplomacy helps mitigate the global disparities in vaccine access. Secondly, it reaps soft power dividends in low- and middle-income countries like Malaysia and Indonesia as they are developing more positive opinions about China. For instance, in Malaysia the Foreign Minister recently stated that China is like a “big brother”, implying the good relations between the two countries. Thirdly, it facilitates China’s pursuit of the BRI and Health Silk Road projects. The donation of vaccines is a way to find greater consensus for the implementation of BRI infrastructural projects. After receiving vaccine donations, many African countries  have confirmed their support. Finally, it is aiding China’s foreign policy objectives. For instance, after receiving the Chinese vaccine, Hungary blocked an EU statement that criticized China’s new National Security Law in Hong Kong .
Professor Huang concluded his talk by mentioning the main challenges and takeaways of China’s vaccine diplomacy, described as the “three Cs”:
China is now pushing to vaccinate half a billion of its citizens by the end of June; however, capacity constraints are slowing down China’s vaccine production. Moreover, the set domestic target is ambitious: according to the National Health Commission’s officials, Sinovac and Sinopharm have a daily manufacture capacity of 5 million, while China needs to administer 10 million doses daily to reach the goal . The urgent question now is how China will balance its domestic and national needs.
Chinese vaccines are popular in low- and middle-income countries. However, the lack of transparency in announcing interim results of Phase 3 clinical trials is causing several delays in China’s vaccine diplomacy. In Sri Lanka even though the vaccine arrived, the export panel disapproved of the use of the Chinese vaccine due to transparency issue; Singapore had the same dilemma as the formal vaccine campaign did not approve the use of Chinese vaccine.
Another rising question is the relatively low efficacy rate. Domestically, the Director of the China Center for Disease Control, Doctor Gao Fu, in an interview with Global Times affirmed that: “The protection rates of all vaccines in the world are sometimes high, and sometimes low. How to improve their efficacy is a question that needs to be considered by scientists around the world“. In this regard, he suggested adjusting the vaccination process by adopting sequential vaccination with different types of vaccines . Safety and efficacy issues have been questioned also by the WHO  assessment panel regarding the vaccine used on older people (over 60 years old).
Russia and India cannot be considered real competitors anymore. Even though Russia is strongly marketing its vaccine, the number of exports remained very small in comparison to China. India was producing AstraZeneca’s vaccine for COVAX and for other countries with whom it stipulated bilateral accords but now has temporarily stopped exporting vaccines because of the increasing number of domestic cases. The true competitor is the United States, which is set to reach herd immunity by July 4th, being able then to send its own vaccines overseas afterward (like 6 million doses of AstraZeneca vaccines bought but never used).
In conclusion, China’s vaccine diplomacy seems to be paying off: more than 572 million doses have been requested by overseas countries to three Chinese vaccine makers – Sinopharm, Sinovac, and CanSino (8% of all doses under contract globally). Moreover, vaccine diplomacy is consolidating relationships with BRI countries. However, China’s vaccine production now must find a way to cope with both the demands from domestic needs and those of the countries China has signed contracts with. Moreover, questions on the efficacy and safety of China’s vaccines are rising among Chinese partners that have purchased its vaccines.
The United States is the real competitor for China, as America seems to be back as a global health power. The Biden administration is fully committed to reaching herd immunity as soon as possible and distributing more vaccines for low- and middle-income countries. The United States’ more pro-active role will affect China’s influence with the distribution of its vaccines, however as said by Professor Huang, 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.
First, we talked about the penetration of vaccine diplomacy in eastern Europe, in countries like Serbia and Hungary, and its implication considering their recent frictions with Brussels.
According to Professor Huang, the eastern European countries showed their willingness to receive Chinese vaccine: Hungary 15 thousand doses, Serbia 2 million doses, while China sent to Montenegro vaccines in the form of donations. However, most of the countries purchased Chinese vaccines and Serbia signed an agreement with China for the domestic production and distribution in the region. China has made progress in this region concerning vaccine market share and has also achieved some foreign policy objectives. Thus, it seems that vaccine diplomacy has challenged the unit of EU and, maybe, it will be difficult to maintain a consistent unified policy toward China, however, it is still uncertain whether vaccine diplomacy will be successful or not within the region. Professor Huang has also pointed out that national agencies play an important role in the scheme as they first prioritize national interests: eastern European countries are also receiving Pfizer and Russian vaccines, for instance.
The second issue examined focused on waiving Intellectual Property rights on vaccines. First mentioned, several months ago, by South Africa and India, who called for the lifting of protection on all medical products to fight the pandemic, the issue was also recently raised by US President Biden. Where does China stand in this concern?
According to Professor Huang, China historically supported countries asking for patent waivers at the WTO, however in this case things might be different. Moderna and Pfizer vaccines have a higher efficacy rate than the Chinese ones. If they will become open-source information, that everybody can have access to, in the long-term period this might bring more competition for Chinese vaccines and make them less preferred than others.
It is still a dilemma how China would respond to this. Officially, one would expect China to support such an initiative because it is another tool to fight the pandemic. According to our speaker, this initiative will not push a significant increase in vaccines’ global supply, even though it is a reasonable diplomatic proposal. Moreover, nowadays access to raw material is a bigger concern with respect to the waiver of IP rights. On this concern, speculation on production capacity to meet vaccines’ global demand can be advanced. For instance, Sinopharm and Moderna have already announced their goal to reach an annual manufacture capacity of 3 billion doses, which would count for a total amount of 6 billion doses. If they achieve the set target, then the situation will improve in the second half of this year.
Another interesting topic discussed concerned the African countries. They are the second receiver of vaccine donations worldwide, however, the number of deliveries to the region is the lowest. According to Professor Huang, African countries are still a priority, however, looking at the data is evident that China is prioritizing the South East Asia region. The problem is that most of those countries cannot afford to buy vaccines, despite that China’s donation amount remains very small. Professor Huang believes that China in the future should collaborate with those countries possessing manufacturing capacity to produce and distribute vaccines locally. Now Egypt has signed an agreement with China on this concern.
Professor Huang concluded by saying that it is necessary for China to improve vaccine access in the region and this action would be helpful also to improve its international image and get more soft power benefits.
Report written by Susanna Guidi and edited by Natasha Lock.