“Vaccine Diplomacy”? - China’s Global Vaccine Efforts and Controversies

As Canada races ahead in its COVID-19 vaccination programme and tops the world in percentage of population having received at least one dose, it is worth thinking about one of the key players in the global race towards immunity - China. Canada’s vaccination successes have been built on vaccines designed and manufactured in the west - the now familiar names Pfizer, Moderna, and AstraZeneca. China has played almost no role in Canada’s vaccination procurement - apart from an ill-fated partnership with CanSino Biologics. 

In such a situation, the role China has played in the global vaccination effort can be easy to neglect . However the vaccine situation for much of the world is very different. While Pfizer, Moderna, and AstraZeneca have been widely distributed throughout North America and Europe (and were designed by Western companies and are manufactured mostly in Western countries), the rest of the world has been put on the proverbial back burner. Particularly early in the global vaccine rollout, these manufacturers gave priority to Western countries in a form of “vaccine nationalism”. This includes the United States “using wartime measures to force manufacturers to fill massive U.S. government orders first” and effectively preventing exports of vaccines from the United States. This approach has been seen in many vaccine producing countries. 

This reality has forced countries unable to secure western vaccines to turn to other sources such as China.  China’s vaccine efforts, however, have been often described as “vaccine diplomacy.” What do China’s global vaccine efforts look like, and why have observers linked vaccines so closely with China’s diplomatic and geopolitical goals? 

Background

Since becoming the leader of China in 2012, President Xi Jinping has taken an extremely proactive approach to increasing the country’s standing in international circles. China has, under President Xi, become increasingly assertive on both regional and global issues. Broadly, Xi’s plan has mainly been predicated on a two pronged approach to foreign policy. On one hand is the aggressive and pointed “Wolf Warrior Diplomacy” towards perceived rivals; this contrasts with China’s second, softer approach using investment, trade and other economic means to gain influence and promote expanded ties with other countries. The so-called “Wolf Warrior Diplomacy” approach includes taking aggressive diplomatic stances on key issues and confronting critics directly, while the latter approach includes elements such as the Belt and Road Initiative (BRI). Now,in 2021, the COVID-19 pandemic and the resulting opportunity for vaccine diplomacy has given President Xi a new avenue to increase Chinese influence on the international stage.

With wide distribution of China-made Covid vaccines China would become a country that other nations, especially those in the developing world, could rely on for support in times of crisis and need. This would be similar to the role the United States has been playing since the mid 20th century. Many countries are not able to produce the vaccines necessary to fight COVID-19 domestically, and are instead forced to purchase them from foreign entities primirary in the Western world. Most of these countries, in Africa and South-East Asia, are located in the Global South. These are places where China had already been investing heavily through the BRI and building influence.Thus, the development and distribution of vaccines as a means of improving relations is not necessarily a new development. Instead of building roads, ports, pipelines and other forms of infrastructure in these countries, China is using vaccines as a means of improving relations and building influence.

In addition, however, China might also be looking to repair the damage that has been done. The lack of transparency and inefficiency in managing the initial outbreak of the corona virus from Wuhan has damaged the global reputation of China in the opinion of some observers, which is a major wrench in the plans of President Xi when it comes to foreign relations. This gives China another motivating factor behind its emphasis on vaccine diplomacy, as many countries feel that China is in some respects responsible for not containing the spread of COVID-19 inside China, and not warning the rest of the world in time about the potential for danger. Vaccine diplomacy gives China a powerful avenue to repair some of the damage done to its international reputation, as well as gain influence in countries unable to produce their own vaccines.

China’s Vaccine Offerings

Figure 1: A vial of BBIBP-CorV, manufactured by Sinopharm. (Source: Wikimedia Commons, CC BY 2.0)

The backbone of China’s vaccine diplomacy efforts are, of course, the vaccines themselves. China was at the forefront of the global scramble to be the first to develop a COVID-19 vaccine, being responsible for half of the 10 vaccine candidates that had entered clinical trials during the summer of 2020. As of June 4, 2021, China has 20 vaccine candidates in clinical stages, eight of which are in phase 3. Given that a comprehensive overview of China’s vaccines and vaccine candidates is beyond the scope of this article, we will focus on three leading vaccines most significant to China’s vaccine diplomacy efforts. 

Figure 1: A table of the basic features of the three most prominent vaccines of Chinese origin. Data sourced from the New York Times and McGill University’s Vaccine Tracker.

Of these, the Sinopharm (Beijing) and Sinovac vaccines have been at the forefront of China’s vaccine diplomacy. Sinopharm’s jab has obtained approval (full or emergency) in 53 nations, while Sinovac’s vaccine has received full or emergency approval in 29 countries. The WHO approved the Sinopharm (Beijing) and Sinovac vaccines on May 7, 2021 and June 1, 2021, respectively. 

China’s Initial Vaccine Efforts

The selling point: speed, numbers, and logistics 

Figure 2: Coronavac (i.e. the Sinovac vaccine) is used at a vaccination centre in Uruguay in March 2021. Source: Jimmy Baikovicius, CC BY-SA 2.0

For a vaccine diplomacy effort to be successful, China had to offer some advantage or benefit to their vaccines in comparison with the West. The strength of China’s vaccine diplomacy efforts has been built on three key pillars: the speed in which China rolled out vaccines to countries with few other options, the scale (in the number of vaccines shipped by China around the world), and simpler logistics compared with Western vaccines. 

The greatest soft power coup for China was the speed in which their vaccines arrived on the shores of many nations - particularly low-income nations in the Global South. As wealthy nations bought up much of the supply of the West’s cutting edge mRNA vaccines, China focused its efforts on low and middle income countries.Throughout the bulk of late 2020 and early 2021, China was one of the few sources of a vaccine for much of the world. 

The speed with which China’s vaccine diplomacy efforts took off was backed by the considerable number of doses committed to foreign sales and donations by both the Chinese government and the vaccine manufacturers themselves. Throughout the first few months of 2021, it was reported that China had prioritized exports over a then sluggish domestic rollout. An examination of Bridge Consulting’s Chinese vaccine tracker reveals that China has delivered an impressive 302 million vaccines worldwide as of June 2021. 

Finally, both the Sinopharm and Sinovac vaccines require only standard refrigeration (at 2-8°C as compared to extreme sub-zero temperatures required for Pfizer and Moderna)  ; this is  an advantage for many low and middle-income countries in the Global South, as many face poor logistical systems and a hot climate. 

Early Challenges: Distrust, Opaque Science, and Efficacy Issues

Despite the strengths of China’s vaccine diplomacy efforts - speed, numbers, and easier logistics - the country still ran into numerous difficulties and considerable distrust that plagued early vaccine diplomacy efforts. Even as Chinese vaccines arrived, many countries and populations were reluctant to use them. In one notable case, shipments of Sinovac sat unused for months in Singaporean warehouses as authorities hesitated to approve it. In another case, vaccination centres in the Philippines offering Pfizer shots were overwhelmed, while clinics with Sinovac vaccines sat empty. This distrust can be summed up along three fronts -  existing pre-pandemic distrust in a Chinese designed vaccine, skepticism due to China’s opaque scientific processes with respect to the vaccines’ development, and concern over low efficacy (applicable in particular to Sinopharm and Sinovac). 

Before China’s vaccine program had even gotten off the ground, there were many who already distrusted it. From a series of vaccine safety and quality scandals to doubts about China’s scientific practices and capabilities, faith in a Chinese vaccine was already low before the first shot had even been delivered.  China’s vaccine efforts hit two further stumbling blocks early in the process having started from this difficult position. 

Despite being among the first vaccines in the world to begin clinical trials, both the Sinopharm and Sinovac vaccines received skepticism due to the slowness of both manufacturers to publish trial data. Further, doubts emerged regarding the transparency of that data even after publication. Sinopharm did not publish interim results from its Phase III trials until May 2021, after more than 200 million doses had already been administered worldwide. Moreover, WHO experts voiced “very low confidence” in Sinopharm’s data about BBIBP-CorV’s risk of serious side effects. Sinovac was also criticized for a lack of published trial data and the WHO expressed a “low level of confidence” on data related to adverse reactions for those over the age of 60. 

Sinopharm and Sinovac did publicize efficacy data early on, however, which attracted further controversy. Sinovac in particular faced sharp criticism over efficacy, after various Phase III trials reported inconsistent efficacy numbers; the worst result came from the vaccine’s Brazil trial, which reported an efficacy of only 50.4%, barely above the regulatory minimum of 50% efficacy. Gao Fu, director of the Chinese Center for Disease Control and Prevention, was reported saying “...that current vaccines don’t have very high protection rates,” a quote taken by many as an admission of the vaccines’ low efficacy (although Gao Fu and Chinese state media would later claim his remarks were misrepresented).

Taken together, these controversies certainly damaged, but did not totally discredit, China’s vaccine diplomacy efforts. Doubts and worries over scientific transparency and efficacy were, for many, insufficient to discredit  the unique benefits of a Chinese vaccine - speed, numbers, and logistics -particularly where no other vaccine was available. In the early days of vaccine rollouts, some protection from a Chinese vaccine immediately was better than the promise of better protection from a Western vaccine months or even years later. 

New Developments

As the pace of global vaccination efforts continues to pick up, what is next for China and Chinese vaccine diplomacy? There are two important developments to keep track of in the coming months and perhaps years. 

Current global vaccine numbers: China vs the West

Finally, it is worthwhile to compare the numbers of vaccines delivered by China versus the West. The absolute numbers of vaccines promised and delivered by both China and the West do not show a complete picture of the global vaccine situation; China’s early efforts give it a considerable advantage. Moreover, a simple dichotomy of “China versus the West” does not truly capture the complexities of the global challenge of manufacturing and distributing various vaccines; Russia, India, and other nations all must also factor into the global vaccine picture.  Nonetheless, this comparison tells us about the scale of China’s vaccine diplomacy efforts, and how much ground the West is looking to make up. Note that, however, a fulsome comparison accounting for both the vaccines sold and donated to low and middle income nations by both China and the West is beyond the scope of this analysis. 

Beijing-based Bridge Consulting reports that, as of July 19, 2021, China has sold 884 million vaccine doses abroad, and donated 27 million doses. Of these, 472 million doses have been delivered. According to the Bridge tracker, the vast majority of these doses have been the Sinopharm or Sinovac vaccines. The scale of these numbers is undoubtedly impressive, speaking to the speed and volume of China’s vaccine efforts highlighted earlier. 

It is more difficult to measure the western effort in vaccine diplomacy thus far- there is no single, consolidated tracker or measure available. In any case, much of the stock from western manufacturers has been bought up by western governments. For example, while 3 billion doses of the Pfizer-BioNtech vaccine are expected to be produced throughout 2021, much will be eaten up by commitments such as the 20 million doses promised to Canada.  Thus, we will merely focus on the commitments by western governments to donate vaccines - not an insignificant factor in the global race to get vaccines to low and middle income nations.

The West arrives

Figure 3: G7 leaders pose for the “family photo” during the 2021 summit in Cornwall. Source: The White House

It was noted earlier that one of China’s biggest selling points for their vaccines was the sheer inaccessibility of Western vaccines - both in terms of the inability of many countries to obtain them and complications in refrigeration and other logistics. This situation is beginning to change, as the West has rolled out its vaccines to the rest of the world, stepping into the vaccine diplomacy fray - both through sales 

The most significant competition to China’s vaccine diplomacy efforts is the United States. President Biden’s announcement that the United States would buy and donate half a billion Pfizer shots, to be distributed through COVID-19 Vaccines Global Access (COVAX). This initiative is set to provide low-income nations with more effective vaccine alternatives. In tandem, G7 leaders agreed to add an additional billion doses to their commitments. Canada’s contribution to this effort totals 100 million vaccine doses. While the Biden administration and Western nations cannot turn back the clock and match the speed in which China shipped vaccines to low-income countries, these commitments, if filled, will help match the numbers of Chinese vaccines arriving in countries around the world. Moreover, Western vaccines - particularly the mRNA Pfizer and Moderna shots - have significant advantages in terms of efficacy and public trust. 

The worldwide appeal of western vaccines over Chinese products is apparent even in China itself. On the one hand, Fosun Pharma has partnered with BioNtech to produce a version of the Pfizer-BioNtech vaccine that will likely win the approval of Chinese regulators in the coming weeks. Meanwhile, Western countries have been reluctant to recognize Chinese vaccines, despite WHO requests to do so. 

Safety and data concerns fade, but efficacy doubts return

Faced with stiffer competition from the West, what do China’s vaccines have to offer? As more data has been released and millions of doses have been administered, concerns over safety and a lack of data have gradually faded. Importantly, the WHO’s listing of the Sinopharm and Sinovac vaccines for emergency use was a significant vote of confidence in the safety Chinese-made vaccines, validating China’s vaccine efforts worldwide. 

However, efficacy problems continue to trouble China’s vaccine efforts. In some of the nations that had benefited from China’s speedy vaccine rollout there has been a sharp uptick in cases, despite the fact that these countries had already vaccinated a significant part of their populations. In the Seychelles, for example, a third of new cases had already received a vaccine shot. Given the increased availability of western mRNA vaccines and the surge in cases of the highly virulent Delta variant, questions of efficacy have returned to the forefront. Bahrain, for example, is now offering Pfizer booster shots to those who received Sinopharm jabs. Costa Rica recently rejected the Sinovac vaccine due to efficacy concerns. 

What’s next? 

In many ways, China has already reaped much of the benefits from their vaccine diplomacy efforts. The speed in which China shipped large numbers of vaccines to nations with few other options was the keystone of China’s vaccine diplomacy efforts, and that cannot be replicated. However, it seems efficacy concerns will continue to trouble China’s vaccine efforts moving forward. 

For the most part, China aims to solve this problem with new and more effective vaccines. The most prominent of these is Convidecia, a viral vector vaccine developed  by CanSino Biologics. China is looking to use this vaccine as a booster shot for existing vaccines. China is also producing its own mRNA vaccine to compete with the Pfizer and Moderna shots. 

Much of China’s vaccine diplomacy effort has already occurred. Millions of Chinese vaccines have arrived on the shores of nations all around the world in the early months of the global vaccine rollout, when no other vaccine was available to much of the world (particularly the Global South). However, the global vaccine rollout still has a long way to go. As the West, China, and other nations/actors continue to roll out new and existing vaccines to the world, it is clear that the vaccine picture will only become more complicated. The role that Chinese vaccines will play in the future remains uncertain, and is likely dependent on what new vaccines and technologies continue to emerge from China; however, it is clear they will continue to play a significant part in the global effort against COVID-19.