Deborah Seligsohn, Jenny Lei Ravelo
One year ago this month, a handful of Chinese military scientists reportedly received an experimental coronavirus vaccine. Almost certainly the first human trial, the injection was a shot across the bow: As manufacturers and governments across the globe raced to develop vaccines, China’s would be at the forefront. In the U.S. and Europe, vaccine rollouts have gotten off to rocky starts. China, meanwhile, has already sent tens of millions of doses to Turkey, Indonesia, the Philippines, and elsewhere, with many more coming. Like most of the world, China has also joined the World Health Organization’s COVAX, a global initiative to subsidize COVID vaccine research, production, and delivery to ensure the poorest countries have sufficient vaccine access.
Beijing stands to reap major rewards by becoming the supplier of choice—or necessity—throughout low- and middle-income countries. China has expanded its international aid efforts in recent years and stressed its commitment to “south-south” cooperation. Under the umbrella of its ambitious and controversial Belt and Road initiative is a Health Silk Road. Though still vague, the term reflects China’s ambitions to make itself a global public health leader. Winning the vaccine race would be a diplomatic boon.
Public concern over the vaccines, however, may pose a roadblock to achieving inoculation targets. Some mistrust around the world of Chinese-manufactured COVID vaccines stems from a lack of public data about them, previous safety issues of Chinese-produced vaccines, but also to far more nebulous political or emotional responses. Chinese state media has gone on the defensive, attacking Western vaccines and raising questions over their safety—efforts that have fed into foreign anti-vax movements, but have done little to raise public faith in Chinese-produced vaccines.
With billions of dollars on the line and major geopolitical implications, can Beijing change the narrative? What could and should China be doing to improve its global vaccine rollout, and what are the long-term implications for China’s Health Silk Road? —The Editors
Let’s start with the obvious: We should want the Chinese vaccines to be widely available and effective. There are not enough vaccines globally, so the more effective vaccines on the market the better. The question still outstanding is how good the two Chinese vaccines are. There is more and more evidence suggesting they are actually pretty good, but as of yet there is no conclusive data like the Russian vaccine’s phase 3 data just published in The Lancet.
Chinese vaccines were promising from the beginning because they built on traditional vaccine development methods, and China had previous experience developing a vaccine for SARS-CoV-1. Chinese companies have faced more hurdles than their U.S. counterparts with their phase 3 trials; with so few cases in China, they had to run multiple trials in different countries. The use of varying research designs adds complexity, thus slowing the approval process. The good news is that two Chinese vaccines have now been approved by China’s National Medical Products Administration and have been submitted to the World Health Organization (WHO) for review. The U.S. is now reengaged with the WHO and its COVAX vaccine development and distribution project. Our top vaccine researchers will be able to assess and give their imprimatur if the vaccines pass muster.
Chinese companies regularly produce and supply vaccines to the country’s large population. They have great production capacity and distribution know-how. China has also long been a supplier of drug and vaccine precursors to other countries’ manufacturers. (Indeed, Chinese manufacturers have now supplied active ingredients to a Brazilian manufacturer to produce the AstraZeneca vaccine.)
It is in manufacturing, however, that Chinese companies have run into problems in the past, with manufacturers falsifying records and producing substandard vaccines. The Chinese government has already arrested dozens in a fake vaccine scam. Regulators are clearly watching, and we hope to continue to see such vigilance. With only two major companies’ COVID vaccines approved (and possibly a third soon), the Chinese government should have an easier time monitoring the export supply chain.
The Chinese, Russian, Indian, and AstraZeneca vaccines also all have advantages when it comes to shipping and storage. Since they do not need the special cold chain that Pfizer and Moderna do, they are much easier to distribute through existing supply chains, a major advantage in developing countries.
There is every reason to hope that the Chinese vaccines are successful. We don’t want to jump the gun before WHO approval, but we also don’t need to assume the worst. To get back to anything close to normal we need the world vaccinated, an enormous challenge. The international community should be making every effort to work within the COVAX program to see as many vaccines as are safe and effective are approved and distributed collaboratively around the world. Thus far, Chinese companies have been selling most of their vaccines to middle income (and some fairly well off) countries. Countries that cannot afford to pay also need them. Vaccines have long been one of the most cost-effective public health interventions we have, and COVID vaccines are no exception. We need to supply vaccines to poor nations, and we should be encouraging all of our counterparts, including China, to do the same.
Amid outstanding questions on the efficacy of some of China’s leading COVID-19 vaccines, several governments in Southeast Asia have gone ahead and made deals or agreed to use donated Sinopharm and Sinovac vaccines. Indonesia started inoculating its citizens in January with Sinovac’s CoronaVac; Laos has used early donations of the Sinopharm vaccine to vaccinate its healthcare workers—and just got 300,000 more doses on Monday; and Cambodia began its vaccination drive with the Sinopharm vaccine Wednesday.
But there is also caution in some countries and territories that have made purchase agreements or are in the middle of negotiating doses of Chinese vaccines, as they seek further data from the vaccines’ phase 3 clinical trial results. Hong Kong, for instance, was expecting Sinovac vaccines to be the first to arrive in the country in January 2021, allowing the government to start its mass inoculation campaign. But incomplete trial data has led to delays in government recommendation for emergency use of the vaccine.
Such delays have created uncertainties on government vaccination timelines. Before Indonesia proceeded with its vaccination campaign, there were questions whether it would go as planned, with the government’s regulatory body still awaiting trial results less than a week before the planned vaccination schedule.
This further underscores the need for Beijing—which has already been criticized for its early handling of the pandemic—to be transparent with its vaccine trial data, as experts have repeatedly called for. Chinese manufacturers have been releasing press statements and video interviews on their vaccines’ safety and efficacy, an approach that was also initially taken by Western-based vaccine manufacturers and was frowned upon by health experts. One way these companies can be more transparent is to publish phase 3 trial results in a peer-reviewed journal. Russia laid to rest similar concerns after it published data last week from its phase 3 clinical trial in The Lancet, a respected medical journal. Prior to the publication, the Sputnik V vaccine had already received approvals in a number of low- and middle -income countries, and in some high-income countries such as Hungary. After publication of its trial results, the vaccine received positive comments from European Union leaders, including German Chancellor Angela Merkel.
Transparency and timely submission of vaccine data can help allay fears and doubts over Chinese vaccines. It can also help inject speed in the administration of vaccines for those most at-risk of COVID-19.
One year ago, Belt and Road (BRI) projects in the developing world ground to a halt as local workers, fearing COVID infection, stayed home. Faced with mounting criticism at home and abroad, China’s leaders launched a remedial campaign. Beijing’s subsequent “face-mask diplomacy” was clumsily handled and, if anything, further damaged its image. Beijing’s image-recovery effort rebooted with the publication in June of an English-language white paper titled “Fighting COVID-19: China in Action.” It begins with a revisionist and self-congratulatory description of China’s “test of fire” and ends with saccharine bromides about the sun shining after a storm. In between, it features recommendations and claims about China’s contributions to the international community’s fight against the virus.
In keeping with Xi Jinping’s call to bolster China’s “discourse power,” Beijing has added new slogans to the fight to control both the COVID-19 narrative and the nation’s image. A “community of common health for mankind” has now been added to the “Community of Common Destiny.” And the preexisting “Health Silk Road,” a subsidiary of the BRI brand, is being refurbished as a pathway to soft power advancement. One component of that effort is the pledge to provide priority vaccine access to selected developing countries and millions of doses to others later on. Chinese vaccine diplomacy aims to immunize Beijing against criticism and serve as a booster shot to its strategic influence in the developing world.
The soft power efficacy of vaccine diplomacy is not to be disparaged. The Biden administration, although its hands are full at home coping with the badly botched performance of its predecessors, understands the importance and urgency of getting the vaccine into the arms of people all around the world—both as a matter of epidemiology and of diplomatic strategy. But vaccine distribution does not make a Health Silk Road. I once saw a decaying Chinese-built hospital in a third world country that had never been used. The project had ended when construction was complete, without water, electricity, or for that matter, medical equipment and training. A Health Silk Road should be paved with well-conceived and adequately funded initiatives that combine hardware, software, and training to establish sustainable public health infrastructure in the developing world.
Health has been a critical part of China’s plan for overseas development for almost 50 years, beginning with the dispatch of the first Chinese medical teams to Algeria in 1963. Since then, the Chinese government has dispatched over 23,000 medical professionals to 66 countries. This form of bilateral aid is also paired with hospital construction, donations of pharmaceuticals and medical equipment, malaria control, and the training of health professionals. China’s assistance was crucial to the 2014 response to Ebola in West Africa, sending teams of clinical and public health professionals and building high-tech labs that are still in operation. Xi Jinping also committed to one hundred projects to support maternal and child health in the developing world. Despite all of these efforts and the work they’ve been doing to fill in the voids in global health left by the U.S. in recent years, China is still not considered a global health giant alongside the U.S. and other Western nations that have defined the field. Stopping the spread of COVID-19 through vaccine distribution offers China the next big opportunity to claim its foothold in the field. And it is, perhaps, uniquely positioned to do so.
Like the U.S. and other Western countries, China began work on developing a vaccine to prevent transmission of COVID-19 as soon as researchers sequenced the virus and made the sequence publicly available. China faces several challenges, though, in rolling out distribution and convincing the world, and maybe even its own citizens, of the value of a vaccine developed on its home turf. The first is China’s recent record with vaccines, several of which have resulted in the serious illness or even death of children. This has eroded trust in the regulatory system that governs approval of vaccines. Parents who can afford to do so often pay for foreign vaccines for their children rather than accept free Chinese-produced vaccines. Additionally, China’s success at controlling the virus thus far has worked against its efforts to test a vaccine. Without enough infections to carry out efficacy trials inside China, manufacturers have deliberately been testing their vaccines on people going abroad, including construction workers working on China’s many BRI projects. While safety trials show the vaccines are safe, it is harder to pin down results on efficacy. Trials conducted around the world on the Chinese Sinovac vaccine measure anywhere from 50 percent in Brazil to 91 percent in Turkey, most likely because the trials are conducted in very different environments among people at varying levels of risk.
The best way to change the narrative would be through a global approval process like the one the WHO uses to certify vaccines, but the WHO process favors vaccines produced by Western countries. More and more countries will begin turning to Chinese produced vaccines, though, because they do not have access to the expensive Western-produced vaccines. If the vaccines are effective, this will help China put that next, large notch in its global health belt.
China’s global response to COVID-19 has come under heavy scrutiny, particularly in the West. There are enduring debates about the origins of COVID-19 and intense skepticism about China’s international vaccine rollout. Beijing’s long-standing opaqueness about public health reporting and the early mixed results of Chinese-manufactured vaccine efficacy have not helped. Yet, despite these concerns, there remains strong interest in access to Chinese vaccines, especially among developing countries. It is not hard to understand why.
Year two of an unabated global pandemic and inequitable access to vaccines mean that this is a basic problem of demand and supply. As high-income countries hoard, administer, or waste vaccines by the millions, only 25 doses were given in one lower-income country. Countries that have opted for Chinese vaccines have done so not out of political allegiance, alignment, or affection but for more mundane, practical reasons. These include sheer necessity from unrelenting infection rates and logistical feasibility. Sinovac’s vaccine, for example, can be stored at regular refrigeration temperatures, reducing distribution challenges in developing countries below the equator.
China has refrained from openly touting its international vaccine rollout as part of the Health Silk Road (HSR). This may prove a strategic move, depending on the outcomes of its vaccine diplomacy. There are, after all, many potential pitfalls in the long road to inoculating against COVID-19, amid emerging variants and the uncertainties of longer-term side effects. It also remains to be seen whether Chinese production capacity can keep up with Beijing’s pledges to help vaccinate countries of the Global South. And while shoring up trust through transparency remains China’s greatest public relations challenge, at the moment, there is less scope for such misgivings among those in greatest need of vaccinations. It is not that lower-income countries are naïve to powerful agendas, interests, or narratives. It is that their priorities, threat perceptions, and lived experiences are simply different.
If China’s international vaccine rollout proves successful in safely immunizing the public in the longer-term, China will no doubt be better placed to position itself as a reliable leader in global health. Given the vague parameters of the HSR, China may see the benefit of retroactively folding into it its pandemic response efforts, including its provision of protective gear to many parts of the world earlier in the outbreak. The 2017 “Beijing Communiqué of the Belt and Road Health Cooperation & Health Silk Road” provides a wide enough cooperative ambit to do so. Looking ahead, as China’s economy recovers faster than most, the pandemic may also provide an impetus for Beijing to shore up health infrastructure assistance in developing Belt and Road-participating countries sorely in need of it. This, in turn, should nudge competing or complementary efforts by the developed world to meet international public health demands and potentially better manage the effects of the next pandemic.
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