China's global vaccine gambit
Production, politics and propaganda How Beijing has shaped the international COVID immunization drive
October 12, 2021
Timeline of China's vaccine diplomacy
Countries and regions that have accepted Chinese vaccines:
Total doses delivered from China:
As of September 2021, China had exported 1 billion COVID-19 vaccine doses to 109 countries and territories -- a majority of the world's nations and home to about 3 billion people.
A top-level welcome party greeted the crates of Chinese COVID-19 vaccines, piled on the runway at Zimbabwe's Harare airport and bathed in the purple light of the southern African dawn.
A beaming Constantino Chiwenga, Zimbabwe’s vice president and minister of health, welcomed the donation with Chinese Ambassador Guo Shaochun and proclaimed, “The Chinese aid came in the morning light, bringing the dawn of Zimbabwe's return to normal social life and an early realization of economic recovery.”
Each container of the Sinopharm jab in that Feb. 15 consignment bore a sticker with the Chinese flag and the text “中国援助,” or China Aid.
This was China putting its vaccines where President Xi Jinping’s mouth was. Xi had made a mantra of calling the shots “global public goods” that reflected his country’s status as a “responsible power.” While Western countries were initially reluctant to share limited supplies of coronavirus vaccines made with cutting-edge technology, China relied on a conventional production method and rapidly increased its capacity. Even as it rushed to inoculate its own population, it also sent planeloads of vials abroad.
While the new technologies of the mRNA vaccines pioneered by Pfizer/BioNTech and Moderna have grabbed the headlines, China has quietly become the world’s largest supplier of COVID-19 jabs.
The country exported about 1 billion shots to 109 countries and regions from November 2020 to September 2021, according to Airfinity, a British life science intelligence company. About 50 million of those were donations. Most -- about 800 million -- went to Asia and South America. The most prominent export destinations are countries involved in China’s Belt and Road infrastructure development initiative.
The U.S. has stepped up donations, with the government saying that over 150 million doses had been given to countries in need -- nearly triple China's donations.
Meanwhile, European countries -- the Netherlands, Switzerland, Germany, Belgium and the U.K. -- shipped 730 million combined. All told, a total of 139 countries have received vaccines from the U.S. and Europe. This puts them ahead of China in terms of geographic scope, but they still lag in the number of shots shipped.
There are 96 destinations that have received vaccines from both China and Western countries. This overlap, seen from Latin America and the Caribbean to Africa and Asia, represents the front line of China's drive to turn international opinion in its favor.
Domestic inoculations versus exports
China's vaccine diplomacy is a nuanced tale founded on feats of both production and propaganda. Chinese jabs have saved lives and formed a vital part of the global immunization drive. But Beijing has talked much less about lingering questions over the drugs’ efficacy and the transparency of data on their clinical trials. While it is now conducting its own trials for Sinovac, South Africa in August cited such concerns in rejecting shots from China’s Sinovac through the World Health Organization’s COVAX initiative. Nigeria chose to prioritize four other vaccines despite having approved Sinopharm.
Above all, China has tried to use its vaccine contribution to scrub the stigma of COVID-19’s emergence in the city of Wuhan -- and the still unanswered riddle over the coronavirus’ origin.
"China wanted to eliminate its reputation as a pandemic epicenter with a vaccine with a nation stamp on it," said Margaret Myers from the Inter-American Dialogue, a U.S.-based think tank.
With more than 2 billion shots administered within China as well, the country accounts for more than half of all doses used globally. This is the story of what it has done to help inoculate the world -- and how it has promoted itself and its interests in the process.
Not the best -- but good enough for some
A debate over the effectiveness of Chinese vaccines has raged since they first became globally available in late 2020. The answer appears to be that they are not as potent as the main Western-manufactured jabs, but generally do a good job of preventing COVID-19’s most severe consequences.
According to WHO guidance published in June, the vaccine made by private Chinese pharmaceutical company Sinovac "prevented symptomatic disease in 51% of those vaccinated and prevented severe COVID-19 and hospitalization in 100% of the studied population."
The WHO estimated the efficacy rate of another vaccine made by Sinopharm, a Chinese state-owned enterprise, for preventing symptoms and hospitalization to be 79%.
China's media eagerly promotes its vaccines
For comparison, Phase 3 studies found the Pfizer vaccine offered 95% overall protection against infection, with Moderna close behind at 94%. Another vaccine developed by AstraZeneca and Oxford University has shown an efficacy rate of 63%, while one made by Johnson & Johnson’s Janssen has been found to offer 66% protection from symptomatic infection.
The efficacy of Chinese vaccines might be lower than the premier Western shots, but they "still can help in reducing hospitalization, and thus, saving lives," stressed Jin Dongyan, a molecular virologist at the University of Hong Kong.
There are growing questions about the long-term effectiveness of Western vaccines, too, particularly against more infectious variants like the delta strain. Israel, which relied on Pfizer shots for its rapid vaccination drive, observed waning antibodies and now considers only people who have had a third jab “fully inoculated,” rather than the current standard of two.
The Chinese shots also have an advantage in that they can be stored in regular freezers, the same as AstraZeneca’s and Johnson & Johnson’s. Pfizer’s and Moderna’s vials must be kept at -20 to -80 °C, though they can be stored at regular freezer temperatures for a couple of weeks.
However, Jin noted that Chinese shots "still have problems" as well, saying better data is needed since the original efficacy data was not disclosed in its entirety.
In a boost for Sinovac’s reputation, a Malaysian government study recently showed the vaccine was highly effective at preventing serious disease. Out of 7.2 million people who received the Chinese jab, only 0.011% came down with COVID-19 so severe that they needed treatment in intensive care units. The comparable ratio for Pfizer was 0.002%, and 0.001% for AstraZeneca.
China’s shots are categorized as inactivated vaccines -- a technology that has been used to fight influenza, polio and other diseases. Making them requires the mass cultivation of the virus itself using a growth medium such as fertilized eggs, followed by a process to weaken its infectivity. Preparation for mass production can be time consuming.
But Sinovac and Sinopharm benefited from a history of specializing in the production of inactivated polio and flu vaccines. They were able to draw on such experience to respond quickly to COVID-19.
In contrast, Western companies such as Pfizer and Moderna are using a new technology called messenger RNA-based vaccines, which train the immune system by injecting the genetic information of coronaviruses. In theory, once a virus has been discovered, mRNA vaccines can be prepared faster than inactivated ones, but this pandemic marks their first large-scale usage.
Even though the Chinese vaccines are made with widely used technology, few developed nations have approved them. In Europe, fewer than 10 countries recognize Sinovac injections as valid vaccinations. The European Medicines Agency was still reviewing Sinovac and said Sinopharm had not applied for approval.
The struggles of some countries that have used Chinese vaccines heavily have also given other governments pause. Chile achieved a rapid vaccine rollout, relying almost entirely on Sinovac doses, only to see daily infections rise higher than ever before around April 2021. Multiple factors were likely behind the surge, but it fueled skepticism of the Chinese shots. In June, Italian Prime Minister Mario Draghi cited “Chile’s experience” in expressing concern about China’s jabs.
Nor are China’s vaccines the cheapest on the market. While Sinopharm, at $15 to $36, and Sinovac, at $10 to $33, cost less than Moderna's mRNA shots, they are more expensive than Pfizer’s -- and much pricier than the AstraZeneca jab. That jab has a base price of just $2 to $5 and has been pitched as a vaccine for the world, according to disclosed contracts collected by UNICEF.
Even so, until recently there have been few signs of Chinese exports losing momentum.
Since June 2021, at least eight countries, including Bangladesh, Uganda and Nepal, have signed new or additional contracts for Chinese vaccines, according to the Duke Global Health Innovation Center. COVAX, intended to promote equitable vaccine access, also signed contracts with Sinopharm and Sinovac to make a total of 110 million vaccines "immediately available” to recipient countries in July.
China’s vaccine outreach to the developing world is in line with its longstanding efforts to position itself as a public health player and improve its image, even before COVID.
The SARS outbreak in 2003, when China was criticized for belatedly reporting the virus, underscored the importance of public diplomacy. Three years later, China was able to dispatch Margaret Chan to serve as WHO Director-General.
Xi Jinping’s administration, inaugurated in 2013, has gone further. Alongside its Belt and Road infrastructure initiative, Xi first mentioned the concept of a “Health Silk Road” in 2016. The following year, he signed a memorandum of understanding with the WHO committing to follow through on that vision.
"It is possible that China already realized [that distributing vaccines] is one of the tools” to help pull countries into its political orbit, “and China is also trying to use it as a tool to compete with the U.S. and its alliance," said Lai-Ha Chan, a professor at the University of Technology Sydney.
In the current pandemic, Beijing reached out to poor countries and found willing partners.
A new jab world order
Chinese vaccines forecast to be filled and finished outside China in 2021
China is not only exporting huge numbers of vaccines but also building production facilities around the world. Locations include key importers like Mexico, Indonesia and the UAE. Some countries expect to fill and finish more than 100 million doses within their own borders.
Mexico: Divide and conquer
Mexico was shocked in March 2021, when the U.S. said it would not share doses with its southern neighbor. Instead, President Joe Biden was “focused on ensuring that vaccines are accessible to every American."
It was China that stepped in to help America’s neighbor in need.
According to Airfinity data, the U.S. accounted for only 5% of all COVID-19 vaccines imported into Mexico from December 2020 to August 2021. China provided 32%. China had exported a total of 25 million doses to Mexico as of the same month.
Mexico did try to procure more jabs from the U.S. and elsewhere. Foreign Minister Marcelo Ebrard, charged with obtaining vaccines, negotiated with American vaccine makers including Moderna and Novavax but has been unable to strike a full deal so far.
Without substantial supplies from next door, Mexico became the first and so far only country in the Americas to approve three Chinese vaccines: from Sinopharm, Sinovac and CanSino, a listed private company offering a single-jab option In particular, for "reasons of geography and logistics, [the] CanSino vaccine was the best option, with only one dose,” said Natalia Rivera Angel, a professor at the National Autonomous University of Mexico.
CanSino also stepped in to help Mexico set up vaccine filling and completion facilities.
Meanwhile, Mexico has been conducting clinical trials on new mRNA vaccines developed by Chinese entities -- Walvax, Abogen and the Academy of Military Science. On May 11, Ebrard confirmed that Mexico’s regulatory body was assessing the Chinese mRNA shots.
"In Mexico, the winner of this whole vaccine diplomacy is China, while the U.S. could have done better," said Aribel Contreras Suarez, coordinator of the global business undergraduate program at Ibero-American University and an expert on vaccine diplomacy. "Western countries will be charged a 'political invoice' for not helping developing countries."
Not only has China offered supplies to Latin America, it has extended $1 billion worth of loans to help 13 countries in the region purchase vaccines, including Mexico, Argentina and Chile.
This could help China pull more countries into its orbit, although Beijing has previously faced accusations that it has drawn countries into debt traps through loans given for infrastructure projects. Beijing denies this. Contreras warned that the loans are "a Chinese trap where countries will be engaged [with] China” for the long term.
The political fallout could affect Taiwan. Of the 15 governments that recognize the island territory -- which Beijing considers a renegade province -- as independent, more than half are clustered in Latin America. Already there are signs of a shift: Honduras is reportedly considering opening a trade office in China in pursuit of vaccines. Belize accepted Chinese shots.
Paraguay, another Latin American country that recognizes Taiwan, has had a rocky experience with Chinese vaccines. It was receiving Sinopharm doses via the United Arab Emirates, but the UAE suddenly suspended deliveries at the end of July. Paraguay’s Health Minister Julio Borba said the shipments stopped for a “quite geopolitical” reason.
It is a sign of how the shockwaves of Beijing’s vaccine outreach may cross continents -- and cause political changes that have nothing to do with the pandemic.
Indonesia: A publicity coup, with complications
Indonesia, the world’s fourth most populous nation, was desperate to source vaccines for its 270 million people. Around spring 2020, the government started negotiations with various manufacturers in Europe, the U.S. and China through embassies. The response from the West was all but non-existent -- China was a different story.
On Jan. 8, 2021, the Indonesian Ulema Council, which rules on Islamic practices in the Muslim majority nation, announced that the Sinovac vaccine was "holy and halal,” or religiously permitted. A few days later, on Jan. 11, the government approved the shot for emergency use. President Joko Widodo insisted that he be the first Indonesian and political leader outside China known to be vaccinated with Sinovac. Authorities said he took the jab on Jan. 13.
The crisis also deepened Sinovac’s existing relationship with Bio Farma, an Indonesian state-owned pharmaceutical company. Bio Farma was established during Dutch colonial rule as the National Institute of Vaccine Development. In recent years, it has exported vaccines for diseases like polio and measles to more than 150 countries, making it one of the largest vaccine producers in Southeast Asia. Before COVID-19, the pair were collaborating on inactivated vaccines for polio. Sinovac in August 2020 agreed to supply its Indonesian partner with raw coronavirus vaccine and technology licensing for local production.
This helps Bio Farma "develop the necessary technical experience, expertise and scale to process and produce Chinese vaccines,” said Khairulanwar Zaini, research officer for the regional strategic and political studies program at Singapore’s ISEAS - Yusof Ishak Institute think tank. “So they would be well-positioned to serve as a secondary supply chain for Chinese vaccine exports in the future, especially if Sinovac booster shots are needed," he added.
But not all the publicity has been positive. Like elsewhere, efficacy doubts have dogged Chinese vaccines in Indonesia. Although more than 95% of the country’s health care workers were inoculated with Sinovac, about 500 died of COVID-19 during July according to Lapor COVID-19, an Indonesian civil society coalition.
Indonesia eventually resorted to giving Moderna booster shots to medical personnel -- a sign of the doubts that linger over China’s vaccines.
UAE: You scratch my back, I’ll scratch yours
In May 2021, a desert facility in the United Arab Emirates began filling Sinopharm vaccine vials. The operation in the Khalifa Industrial Park demonstrated another crucial aspect of China’s COVID vaccine diplomacy: a tie-up with a rich, geopolitically strategic country to boost the jabs’ international reach and credibility.
The company responsible is the UAE’s Group 42. It is producing the shots under the name "Hayat-Vax," aiming to produce 200 million doses a year. “Hayat” means “life” in Arabic.
In August, 100,000 doses were shipped to the Philippines as the first batch of exports.
To further expand vaccine production, a purpose-built research and development hub for life sciences and biotechnology R&D is currently being set up in the Khalifa Industrial Zone in Abu Dhabi.
The UAE had been the first outside China to approve a Chinese-made vaccine, back on Dec. 9, 2020. Sinopharm team members were on the ground during the initial phase to facilitate the trial operations. Perhaps most importantly for the UAE, from a business perspective, China allowed the rebranding to Hayat under a partnership agreement.
The UAE sent vaccines to Egypt, Indonesia and the Seychelles, widening its international influence. "It is a win-win situation as of now, especially in view of the two countries' current geostrategic goals," said Azmal Hussain, a researcher at the Amity Research Center.
The UAE was seen as “the perfect partner [for Sinopharm] for their demographic diversity and capability to rollout the Phase 3 trials quickly and adeptly,” according to Ashish Koshy, CEO of G42 Healthcare. He also mentioned advantages of Sinopharm as an inactivated vaccine, which can be stored and shipped at regular refrigerated temperatures and has been proven safe, as the technology has been widely used for many other diseases.
“None of this would have been possible without the partnership and collaboration with Sinopharm and the bilateral arrangements between China and UAE,” Koshy said, expressing gratitude for China’s help with the UAE’s coronavirus fight. We are happy that the fruits of our partnership are now seen in the UAE and beyond.”
China had sought out the UAE for pharmaceutical cooperation before COVID-19. In 2018, a delegation from the China Chamber of Commerce for Import & Export of Medicines & Health Products visited the Abu Dhabi Investment Office, seeking to team up with leading local companies. G42, which has close ties with the Abu Dhabi royal family, answered the call. The company's chairman, Sheikh Tahnoun bin Zayed Al Nahyan, is a national security adviser and the son of the first Emirates president, Zayed Al Nahyan.
"China has strengthened pharma sector cooperation with the entire Middle East, and the UAE has an important role," observed Amity Research’s Hussain. With the Sinopharm-G42 joint venture going well, he suggested that the UAE is likely to continue to expand its collaboration with China in the pharmaceutical sector.
The UAE, like Israel, has also managed to secure Pfizer doses. But in the broader Middle East, some countries have not had the luxury of choosing their preferred shots.
The image of Chinese vaccines has also benefited from online rumors. Scattered reports of deaths following AstraZeneca jabs fueled a flurry of misinformation in Jordan and Egypt. There have also been reports that some people prefer China’s traditional jabs because they feel mRNA technology is “too new.”
China, alongside Russia, has even been accused of fanning such fears. A European Union report earlier this year alleged the two countries were engaging in "state-sponsored disinformation" meant to sow concern about Western vaccines and promote their own. Beijing insists these allegations are unfair.
Some also claim Beijing has insisted on a quid pro quo in exchange for vaccines. Diplomatic sources told The Associated Press earlier this year that China had threatened to withhold supplies unless Ukraine distanced itself from scrutiny of the treatment of minorities in China's Xinjiang region.
Speed trumps perfection
China’s whole approach is based on one obvious but crucial fact: in a world crying out for vaccines, countries are willing to accept something well short of ideal. The pandemic has highlighted the importance of acting quickly and decisively. That is why many nations have concluded that getting an adequate vaccine quickly is better than waiting months for a more effective one.
Now a major concern is emerging as developed countries like the U.S., Israel and some European states resort to booster shots to counter potent variants and reports of fading antibodies. The fear is there will be even fewer doses to go around for the world’s poorer nations.
Some experts say richer countries are shooting themselves in the foot if they fail to do more to aid less wealthy nations. "If they would not help the emerging countries, variants are eventually coming to the developed countries too, because the virus is likely to mutate in places whose vaccination rate is low," predicted Ezequiel Carman, a public health consultant at Global Americans, a U.S.-based think tank.
The WHO is also urging Western countries to refrain from additional vaccinations and to actively export vaccines to the places that need them most.
White House Press Secretary Jen Psaki, however, rejected the WHO's call. She said: "We believe we can do both, and we don't need to make that choice” between administering boosters and exporting doses.
Once again, if there is a void, many countries may look to China to fill it.
"Given that the delta variant is now spreading all over the world and the global manufacturing capacity has not been able to meet this huge demand, there will be a strong demand for more vaccines, including Chinese ones," said Yanzhong Huang, a senior fellow for global health at the Council on Foreign Relations. He said China is most likely to continue its vaccine diplomacy mainly through bilateral contracts, with economic ambitions in mind.
In Indonesia, despite skepticism fueled by the post-vaccination health worker deaths, the government still accepted more than 40 million doses from China in July. "In order to deal with this pandemic, we need more vaccines to distribute [to] a huge population in Indonesia," explained Dicky Budiman, an Indonesian epidemiologist at Griffith University who used to work with the Indonesian government on health policy.
Even Singapore, which has used Pfizer and Moderna shots to inoculate over 80% of its population, has warmed to Chinese vaccines. Residents concerned about side effects from the mRNA jabs are welcome to take Sinovac. And while the government initially did not consider Sinovac takers “inoculated,” it recently changed its tune and accepted it along with all other shots on the WHO’s emergency-use list.
The COVID-19 pandemic is not the first time that low- and middle-income countries have been left behind in a global health crisis. The question is whether Western countries have repeated past errors -- allowing China to take advantage.
"I can tell you at this point the priority is getting the vaccine to citizens in this country, and that's what we're working on 24/7." This was said not in 2020, but in October 2009, by then U.S. Health Secretary Kathleen Sebelius.
That year, advanced economies kept a tight grip on vaccine supplies when H1N1 swine flu spread around the world. The WHO was critical, saying: "The lion's share of these limited supplies will go to wealthy countries. Again we see the advantage of affluence."
In the COVID-19 pandemic, "the U.S. and other developed countries have made the exact same mistakes," said Anthony McDonnell of the Centre for Global Development, a nonprofit think tank.
David P. Fidler, a senior fellow for global health and cybersecurity at the Council on Foreign Relations, said that "since the end of the Cold War, the persistent problem with vaccine access has been that research, development, and manufacturing capabilities have been concentrated in Western, developed countries."
The difference this time is that China has driven a wedge into the Western-dominated market for jabs. Fidler said developing countries suddenly “had access to new vaccines created for a pandemic from countries [such as China] that previously did not develop, produce and make available vaccines."
The U.S. -- locked in an intensifying battle with China for economic and political supremacy -- appears to recognize that its own image took a hit and is trying to undo the damage.
Washington is not just donating millions of vaccines. American lawmakers want recipient countries to know exactly where they came from, even if they are delivered through the multilateral WHO-backed COVAX initiative.
At a hearing of the U.S. House of Representatives Foreign Affairs Committee in late June, members of both the Democratic and Republican parties said that the American flag should be on the country’s COVAX donations.
Essentially, according to Carman of Global Americans, the U.S. is mimicking its geopolitical rivals. “What the U.S. is doing is showing off its presence, just like China and Russia have done." He warned that "it would break the [international] spirit of COVAX if more countries imitated this marketing."
China’s gains -- and their limits
China has cast itself as a good global citizen, but there is no doubt it sees strategic gains in its vaccine diplomacy. A striking example is in the western Balkan country of Serbia, which borders four EU countries but is not part of the bloc.
"This is an extremely important day for Serbia, but also for the entire region because we will have the vaccine here, closer," Serbian Prime Minister Ana Brnabic said in July at a ceremony celebrating cooperation with China on vaccine production.
Serbia plans to start domestic production of 24 million doses of the Sinopharm vaccine per year by the end of 2021. The plan is to export the jab to neighboring countries and to strengthen its influence as a vaccine hub. As in the UAE, the Chinese government and companies have extended significant support. In March, Serbia's Deputy Prime Minister Branislav Nedimovic said that the government only provided the land but would not pay any subsidies.
According to Airfinity, out of all vaccines Serbia had received by August, about 50% were from China, while shipments from the EU accounted for about 40%. Previously, China sent state-of-the-art equipment and experts to Serbia for a coronavirus testing laboratory called "FireEye," set up in just five days.
The Chinese attention reflects Serbia’s position at a geopolitical crossroads. It is a candidate to join the EU, but rights groups and others have attacked the government’s record on corruption and authoritarianism. China will make no such criticisms.
Back in March 2020, Serbian President Aleksandar Vucic kissed the Chinese flag when he welcomed a medical support team from China in Belgrade. Vucic called European solidarity, on the other hand, a "fairytale on paper" and blasted export restrictions on personal protective equipment by EU.
"Given that Serbia still wants to join the EU, but its approval status has been frozen so far, Serbia is likely to continue further cooperation with China,” said Vuk Vuksanovic, a researcher at the London School of Economics and Political Science.
The tension between Serbia and the EU created an opening on Europe’s doorstop, just as Beijing found one near the U.S. in Mexico. Likewise, China has scored geopolitical points in key countries in Asia and the Middle East.
Western countries have shrugged off widespread criticism for hoarding vaccines, but they appear to have paid little attention to the wider strategic consequences of China’s international vaccine outreach. If they fail to take a longer and broader view of Beijing’s gambit, they may find they have lost more than just global goodwill.
This is the first part of a series exploring China’s vaccine strategy, capabilities and role in the global health supply chain -- and how it fits into preparations for the next pandemic.