Health geopolitics and vaccine diplomacy

The irruption of the pandemic and, especially, the vaccination campaigns, have been feeding the geopolitical debate and dozens of articles were published on the geopolitics of health, vaccine geopolitics and the geopolitics of COVID-19. What is geopolitics? In what way would a geopolitical analysis of this phenomenon differ from other analyses produced by International Relations or Development scholars? Geopolitics considers that geography is a key factor explaining the dynamics of power in the international relations and the behaviour of states and other relevant international actors. Therefore, those analyses attempt to grasp the extent to which geographic factors have shaped health-related decisions in areas such as restricting or permitting mobility, production, purchase, and distribution of vaccines and other medical equipment. The pandemic has been, in any case, a powerful reminder that, contrary to the notion of its death as conceptualised by Richard O’Brian,² geography is very much alive.

There is no single approach to geopolitics. Classical geopolitics is seen as the realm of those studying states and their capacities to impose themselves over their competitors through their control of the territory, critical routes or highly valuable natural resources. Consequently, a geopolitically driven foreign policy or diplomatic action would be one focusing on competition and trying to take advantage or eventually improve its geostrategic position. However, this is only a certain way of thinking and acting geopolitically. Critical geopolitics has widened the scope of the actors analysed to include non-state actors as well as supranational bodies, and it has also sought to identify the conditions under which geographical elements might favour cooperation over competition and conflict. Critical and innovative approaches to geopolitics go beyond the study or material assets and take into consideration ideational, symbolic and emotional considerations.³

Until recently, health was not among the top priority topics for students of international relations. Paradoxically, health was a fertile terrain for international cooperation and one in which functional relations flourished earlier. It is worth recalling the first international sanitary conference, held in Paris, aimed at setting a number of common standards to struggle against the cholera in 1851 or the creation of an international bureau for fighting against epidemics in 1919, a predecessor of what later on would become the World Health Organisation (WHO), to cope with the needs and learning the lessons from the so-called Spanish flu (1917-19) which caused the death of around 50 million people (2.5% of the world’s population at the time). COVID-19 has propelled health as an emerging area of study when it comes to the study of cooperation and competition, both among great powers and among a wide range of state and non-state actors.⁴

As COVID-19 erupted, the initial focus of attention was the impact this pandemic might have on China’s role as a world power and as a role model, China being the country where the virus was first recorded and one imposing very drastic measures to contain it after the first weeks of contradictory information and secrecy. Gradually, two other topics escalated in the agenda of priorities: the shortcomings of the WHO when dealing with the health crisis - fuelled by the contestation of the global multilateral framework by Donald Trump - and the shortages in facemasks, tests, ventilators and personal protective equipment, which would trigger episodes of cooperation in the form of bilateral donations and the invocation of solidarity mechanisms, but which mainly translated into harsh competition to purchase the scarce units that were on the market as well as forms of protectionism. In those circumstances, a precedent of what is now referred to as the ‘vaccine diplomacy’ emerged. Emerging countries such as China, but also Turkey and Morocco, put forward what was temporarily referred to as a ‘mask diplomacy’ or ‘medical diplomacy’, in an attempt to strengthen existing relations, promote new ones and overall build a reputation as ‘problem-solvers’.

The appearance of the first vaccines against COVID-19 was a game-changer and yielded contradictory effects. The vaccine undoubtedly accelerated competition among the limited number of countries that had the means to discover and produce those vaccines. These countries were competing not only for the vaccination of their own population, but also in terms of whose vaccine came first, which one was more effective and how many agencies validated their use. Evoking the notion of an ‘arms race’, it was common to refer to a ‘vaccine race’, in which possessing the vaccine was tantamount, all differences aside, to possessing nuclear weapons. In that vein, in this article we refer to vaccine powers in the same way that the scholarship has referred to nuclear powers. In a second stance, those vaccine powers also competed through the use of contracts and donations to consolidate or enlarge their areas of political and economic influence, or even as a bargaining chip when negating other issues.

At the same time, the vaccine favoured very different forms of international cooperation. For instance, several countries, philanthropies, private sector and international organisations joined efforts in the framework of the Global Alliance for the Vaccination and the Immunisation (GAVI), and created a new international platform, COVAX (global equitable access to COVID-19 vaccines), to facilitate the arrival of vaccines in the countries with fewer resources. Some regions also witnessed a significant boost in cooperative efforts, not only in dealing with the health crisis but also with the economic consequences of it.

Therefore, the analysis of vaccine diplomacy should contemplate both competitive and cooperative strategies. The latter may take place in the scope of bilateral or multilateral frameworks and, very often, in both of them.

The peculiarities of the Atlantic space

The Atlantic space is a huge area comprising North, Central and Southern America, Europe and Africa. These territories have been linked through a shared and often tragic history, by intense people-to-people cultural connections and dynamic trade and investments flows.

The Atlantic space is an area in which multilateralism through interregional frameworks has been vindicated. For instance, the EU and Latin America have invested in the EU-CELAC summits, but also in other subregional cooperation schemes and, while doing so, they referred to a ‘community of values’. More recently, the EU and the African Union (AU) have also vowed to upgrade and substantiate their bi-regional partnership. In the EU-African summit, in February, the leaders reaffirmed their commitment to working together to promote effective multilateralism within the rules-based international order, with the UN at its core. This adds to decades-old partnerships around the Mediterranean, now under the Union for the Mediterranean umbrella.

One of the most interesting developments in the Atlantic space was the emergence of institutionalised south-south bi-regional frameworks. However, the last South America - Arab States summits (ASPA) took place in 2015, and the Africa-South America summit in 2014. Therefore, whereas different EU-Africa, EU-Mediterranean and EU-Latin American fora have been a space to discuss how to best cope jointly with global challenges - including the most recent health crisis - the south-south connections have lost relevance, at least at a bi-regional level. Coordination and contacts did take place among states in multilateral settings such as the World Trade Organization (WTO), but not structured regionally.

Therefore, when it comes to finding a solution to the health crisis, the Atlantic Space is better predisposed than others regarding multilateral, interregional and regional solutions. Did this predisposition translated into effective measures and how did it impact the vaccine diplomacies in the Atlantic space? The following section will shed light on this.

Another peculiarity of the Atlantic space is that, despite not having been the origin of the virus, it encompasses some of the territories that have been more severely affected in terms of contagions and casualties, but also regarding the economic and social effects of the pandemic. According to the estimates in May 2022 collected by Our World in Data, the US and Latin America hold a ratio of 3,000 deaths per million people, and the EU 2,440. Some countries present exceptionally high numbers, such as Peru, with the highest death rate all over the world (6,388.18). The exception to this trend in the Atlantic space are the countries of the African continent, with less than 200 deaths per million inhabitants.

The uneven rates in mortalities and infections is partly related to the age structure, with older societies experiencing higher levels of mortality. This is not the only factor, however. High densities and social inequalities in some countries, particularly in Latin America, also contributed to the spread and mortality of the pandemic.

COVID-19 is not only a health crisis but also a socio-economic one. Here the effects were particularly severe in those countries relying on tourism and international mobility, but also those with large segments of the labour force irregularly or infra-employed. There are some extreme cases in the Caribbean, but countries around the Mediterranean and some emerging touristic destinations in West Africa - such as Senegal - also experienced a major economic shock. In fact, the dependence on tourism explains the growth shock in 2020; even more than the development level and the lockdowns’ intensity.⁵ For other countries the vulnerability stemmed from high levels of indebtment and subsequent risks of currency and debt crises. This affects not only low-income countries but, first and foremost, middle-income ones.

On the other side of the coin, the Atlantic space has become one of the epicentres in vaccine-related research (mainly in Europe and North America, but South Africa’s scientific community has also played a very important role in the study of the virus and its new variants). Interestingly, a small Atlantic state, Cuba, remains the only small country in the global south that has been able to come up with its own vaccine. The countries around the Atlantic have significantly increased their capacities to produce vaccines, building on already existing industrial complexes both in the northern countries but also in some larger Latin American and African countries. Although India remains the ‘pharmacy of the world’, the countries of this region and the Atlantic space as a whole have upgraded their production and export capacities, playing a significant role in the process of immunising the world’s population. However, parts of the Atlantic space such as most Sub-Saharan African countries still present very low immunisation rates.

The other peculiarity of the Atlantic space is its role in vaccine production. The EU, the UK and the US are among the top vaccine manufacturers (AstraZeneca, Pfizer, Moderna, Janssen, Novavax). Cuba has also managed to develop two vaccines (Abdala and Soberana) and, in 2022, South Africa also announced the first RNA vaccine designed, developed and produced at lab scale in the African continent (Afrigen). In May 2022, the EU represented 39.7% of the world’s exports, while the US occupies third position with a 15% share.⁶ On top of it, some Latin American and African countries also reached deals with global producers to manufacture vaccines in their territories. Such is the case of Mexico (AstraZeneca and CanSino), Venezuela (Abdala), Brazil (Afrigen, CanSino, Pfizer and Sinovac), and Argentina (Gamaleya and Afrigen), Morocco (Sinopharm), Algeria (Gamaleya and Sinovac), Tunisia (Afrigen), Egypt (Sinovac and Afrigen), Chad (Pfizer and Afrigen), Nigeria (Afrigen), Kenya 8Moderna), Rwanda (Pfizer), Botswana (Biological E), and South Africa (Janssen, Afrigen).⁷

As the next sections will outline, the Atlantic space has become a domain for geopolitical competition with and among non-Atlantic vaccine producers. The EU’s Strategic Compass, a document unanimously adopted by the EU members in March 2022, which sets a shared diagnose on threats and regarding the policies and tools to face them, referred to the role of vaccines in this increasingly competitive world. The document refers to the weaponization of interdependence and soft power, listing vaccines among other assets as instruments of political competition.⁸

To a large extent, COVID-19 has accelerated previously existing trends. China’s presence in Africa is evident to any observer, being particularly visible in the extraction and commercialisation of raw materials but also in large investment in infrastructures as well as public debt. European countries and the EU have openly presented this as a challenge and have vowed to strengthen their relations with Africa, including in infrastructures with the Global Gateway project. This quote by the High Representative Josep Borrell shows clearly that Europe perceives it as competition and that health-related factors may have heightened this competitive dimension:

‘The pandemic has also moved geopolitical competition in Africa beyond investment and business opportunities to include values and governance models. We find ourselves confronted with other global actors whose methods and agendas are very different from our own. Many of them will not hesitate to use disinformation campaigns and other forms of hybrid warfare to undercut European influence. Despite these difficulties, we still have compelling reasons for wanting to make Europe Africa’s partner of choice’.⁹

The opening of a Chinese military base in Djibouti, in 2017, marked a new phase when it comes to China’s presence in the continent, and the possibility of China opening a second African base in Equatorial Guinea would add a new layer of complexity in the geopolitical competition in the Atlantic space.¹⁰

China has also increased its presence in Latin America, a strategy that has been built on the same pillars: raw materials, investments, and public debt. The main difference is that the security component is still negligible. Yet, Chinese political choices (support to Cuba, Venezuela, and Nicaragua) have been interpreted in light of the global competition with the US.

Russia’s capabilities to expand its influence in Africa and Latin America are significantly smaller than those of China, but they are particularly relevant on the security front. Russia supplied 30% of the total weapons purchased by Sub-Saharan African countries in the period 2016-20, and also stood as the primary supplier to North African states such as Algeria and Egypt.¹¹ The Russian presence in Africa has also grown through the involvement of Russian private military contractors such as the Wagner Group, operating in Mali, Libya and the Central African Republic, among others. On the military front, the countries of East Africa as well as the Sahel seem to feature more prominently in the Russian agenda than the African countries in the Atlantic shoreline. In Latin America, Russia has also opted to openly back those governments that are at odds with the US. The case of Brazil is more complex, as the relationship between Brasilia and Moscow has been mainly built on both countries’ BRIC membership, a relationship that has been recently nurtured by the conservative affinity between Vladimir Putin and Jair Bolsonaro.

India, the other non-Atlantic vaccine producer analysed in this paper, has also increased its attention to the African continent. The first India-Africa summit took place in 2008 and, once more, the spotlight has been thrown on the East African countries In Latin America, the BRICS also provided a platform for the strengthening of relations with Brazil. Yet, Latin America and the Caribbean is still a relatively unexplored priority in Indian foreign policy. Things may change, if for no other reason than because India aims at projecting itself as a global rather than a regional power.

All in all, the next section will illustrate how vaccine diplomacy deployed since 2021 reinforced rather than modified already existing cooperation and competition logics in the Atlantic space. For some Atlantic producers, this added to already existing policies to prioritise relations with the closest neighbours, through both bilateral and regional frameworks. Interregional frameworks have also been used to go beyond the inner circle of neighbours, and this is particularly relevant when referring to an area as wide as the Atlantic space. Among the Atlantic producers we can also observe a mix of cooperative and competitive tactics, a traditional feature in transatlantic relations. For the non-Atlantic producers, this was an unexpected opportunity to consolidate and expand emerging relations with countries from the global south, thus reinforcing the Atlantic space as an area for geopolitical competition.

Neighbours first: proximity strategies

For any country it is advantageous that their closest neighbours manage to keep the pandemic in check. This is due to several factors, among which, the fact that they are more exposed to health-related problems in its vicinity due to mobility and tourism; the fact that they tend to have particularly strong commercial relations with their neighbours and COVID-19 has represented not only a health crisis but also a socioeconomic shock; the willingness to be perceived by their neighbours as problem-solvers and as preferential partners. And yet, not all the actors have prioritised the neighbourhood approach when making choices on how and where to deploy the vaccine diplomacy. The two which have done so are the EU and the US.

The very existence of the European Neighbourhood Policy (ENP) and the fact that article 7 of the Treaty of Lisbon states that ‘the Union shall develop a special relationship with neighbouring countries, aiming to establish an area of prosperity and good neighbourliness’ are the best evidence that the EU has a differentiated approach regarding the countries in its vicinity. More recently, the New Agenda for the Mediterranean adopted on February 2021 aimed at reinforcing ties with the southern neighbours, with the intent to ‘contribute directly to a long- term vision of prosperity and stability of the region, especially in the social and economic recovery from the COVID-19 crisis’.¹² Accordingly, by July 2017, the EU had already delivered a support package of over €2.3 billion.¹³ Besides, the EU, in collaboration with the European Investment Bank, mobilised over €2.5 billion to support the eastern neighbours in addressing the pandemic and socio-economic recovery.¹⁴

Beyond the ENP, the Western Balkans have occupied a privileged place in EU’s response to the pandemic, as the Communication from the Commission to the European Parliament, the European Council and the Council ‘A united front to beat COVID-19’ shows.¹⁵ A €70 million package under the Instrument of Pre-Accession was created to help them access EU Member States’ vaccines.¹⁶ However, the presence of Russian and Chinese vaccines all over the Western Balkans demonstrates that the EU has not reached the coveted problem-solving role in the region.¹⁷

The US does not have a ‘neighbourhood policy’, but the extensive borders with Canada and Mexico, as well as the differentiated treatment of ‘hemispheric affairs’ in the decision-making process, suggest that proximity is also a relevant factor when analysing US foreign policy and international aid choices. However, US’ narrative and practice regarding vaccine and aid sharing evolved during the pandemic. Joe Biden’s global and multilateral approach is, up to a point, a response to Donald Trump’s unilateralist and free-riding discourse. Nevertheless, it is worth noting that the Trump administration hosted a high-level meeting with Lopez-Obrador at the White House to secure cooperation on July 2020, whereas it refused to work together with other partners and withdrew from the WHO and therefore from the Pan American Health Organization (PAHO).¹⁸

Biden gave fresh impetus to US’ multilateral commitment to project a different kind of leadership. The US reengaged with the multilateral institutions that Trump had abandoned and expressed a cooperative attitude ‘sharing […] not to secure favo[u]rs or extract concessions’, but to ‘save lives and to lead the world in bringing an end to the pandemic’.¹⁹ Moreover, being part of the WHO again enabled the US to regain its role in the PAHO, favouring Canada and the southern neighbourhood. The North American Leader Summit was also used as a framework within which to enforce cooperation.²⁰

Regionalism

The EU followed a successful regional approach when delivering vaccines. As data show, by the end of 2021, close to 80% of EU’s adult population was fully vaccinated, with little differences between Member States.²¹ As it was committed to the principle of leaving no one behind, it ensured enough vaccines for its members while at the same time contributing extensively to COVAX facilitation. They gave priority to MS but without incurring in ‘vaccine nationalism’.²²

In order to reach the goal of vaccinating EU Member States’ citizens, an agreement was approved on procuring COVID-19 vaccines on behalf of them. This way, EU-level Advance Purchase Agreements with vaccine manufacturers were made possible.²³ Thus, the European Commission (EC) negotiated with several producers ‘to build a diversified portfolio of vaccines for EU citizens at fair prices’.²⁴ In fact, by January 2021, the EC had already secured 2.3 billion doses of different vaccines against COVID-19.²⁵ Moreover, they made a great effort to negotiate also stepping up vaccine manufacturing capacity in the region, aiming at producing 3.5 billion doses in 2022 in the EU.²⁶

In Africa, regional and international organisations have a long record in managing crises that transcend national borders. This past experience assisted the AU in developing a ‘Joint continental strategy for COVID-19 outbreak’. Member States appeared committed to pull in the same direction, coordinating efforts and available resources to respond in a regional way to the pandemic. The African Vaccine Delivery Alliance (AVDA) became an essential tool to coordinate doses delivery among Member States of the African Union, alongside with the African Vaccine Acquisition Trust (AVAT), a creation of the African Vaccine Acquisition Task Team (AVATT). The AVAT mechanism ‘acts as a centralised purchasing agent on behalf of the African Union Member States’,²⁷ and it has secured more than 50 million doses. The AVDA, on the other hand, was set up to facilitate logistics and correct functioning of vaccine deployment based on a whole-of-Africa approach.²⁸

The downturn of this activism is that some of the initial expectations were not met. The aim of the AU was to vaccinate 70% of the population by June 2022; however, only 20% of the adult population was fully vaccinated by then.²⁹ In order to ensure access to vaccines, the AU has established a cooperation with international organisations such as de World Bank³⁰ the United Nations, the WHO³¹ and NGOs as OXFAM.³²

In Latin America, on the other hand, regional institutions have failed to build a coordinated response to COVID-19 and to make joint vaccine acquisitions.

Empowering regional bodies: inter-regionalism in motion

Perceiving itself as a role model of regionalism, the EU is particularly keen on establishing region-to-region frameworks which may include the creation of joint institutions. Very often there is more than one regional organisation per region, particularly when taking into consideration the subregional realities. Therefore, this offers the EU a wide range of options when deciding which partners to choose.

The EU-LAC has been an important inter-regional communication channel for the European Union with the Latin American and Caribbean States Community (CELAC) during the pandemic. These ties rely on bilateral relations between EU Member States and a number of Latin American regional, national and sub-national actors. Among those, we can include the Iberoamerican summits, which have been essential to bring together Spain and Portugal and Latin American countries. At n the commemoration of the 30th anniversary of these summits, Rebeca Grynspan acknowledged Europe as one of the greatest suppliers of COVAX.³³ Moreover, the Spanish PM committed to donate around 7.5 million doses to the region in the XXVII Iberoamerican Summit of Heads of State and Government.³⁴

The EU-LAC Foundation organised several dialogue sessions on financial initiatives for equitable vaccine distribution against COVID-19 in middle-income Latin American countries, a resilient recovery after pandemic and a study on labour market during and after the pandemic.³⁵ Besides, different policy briefs and papers have been published making recommendations to achieve more effective and fruitful cooperation, such as: ‘COVID-19 Vaccines: The Global Challenge of Equitable Distribution and Access’³⁶ and ‘Relations between the EU and Latin America and the Caribbean in the context of the pandemic: between the past and the future’.³⁷ Regional cooperation also takes place with institutions such as The European Humanitarian Aid providing €0.9 million to the Pan American Health Organisation to strengthen local health systems. The EU also supported the Central American Integration System during the negotiations to secure medical supplies.³⁸

As for the Caribbean, the EU has conceded €8 million to the Caribbean Public Health Agency to treatment, vaccines, test reagents etc.³⁹ In addition, €7 million have been delivered to CARICOM (Caribbean Community) in order to implement a programme coordinated also by the PAHO.⁴⁰ The European Investment Bank has partnered with Caribbean Development Bank to deliver €30 million to face health related emergencies.⁴¹

The EU also follows a multi bi-regional approach when it comes to Africa. African Union Development Agency (AUDA-NEPAD) will receive €100 million from the EU and Bill and Melinda Gates Foundation throughout the next five years, in order to support the African Medicine Agency (AMA) and other similar initiatives at subregional level. Cooperation between the AMA and the European Medicines Agency is expected to increase in the near future. These funds are part of EU’s commitment to improve COVID-19 vaccine access, equity and minimum health standards all over the world.⁴²

The European Commission is enforcing its partnership with the WHO, aiming at boosting access to vaccines, medicines and health technologies in Africa, together with boosting local manufacturing. The total contribution consists of €24.5 million and is divided into three categories of action.⁴³

In addition, the European Centre for Disease Prevention and Control and the African Centre for Disease Control and Prevention launched a four-year partnership in December 2020, financed by the European Development Fund to scale up preparedness for health emergencies. A meeting took place on November 2021 in which experiences together with successes and lessons learnt were shared.⁴⁴

Cooperation and competition among Atlantic producers

Since Biden’s administration replaced Trump’s, both the US and the EU have maintained a high profile in common multilateral institutions such as the WHO and the UN. Furthermore, they have created a ‘US-EU Agenda for Beating the Global Pandemic: Vaccinating the World, Saving Lives Now, and Building Back Better Health Security’.⁴⁵ This initiative brings together the two largest Western vaccine producing powers, a transatlantic alliance aimed at the world’s vaccination. To that end, COVAX is the key element; and data shows that US has donated 87% (465.71 million doses) through this mechanism, the EU 85% (400 million doses).⁴⁶

However, some clashes have arisen within the WTO. South Africa and India began a campaign intent on waiving intellectual property protection in vaccines. Countries owning those rights have not welcomed this proposal, except for the US.⁴⁷ In what represented a significant departure from previous positions, Biden backed this proposal instead of trying to persuade its transatlantic partners to jointly discuss how to address the production shortage. This was widely seen as another form of vaccine diplomacy, allowing the US to project itself as a more generous partner than the EU and the UK, while aware that the policies would not change due to European resistance and [?] would prevent an agreement at the WTO. The EU, and particularly the Commission and some leaders such as Merkel and Macron, reacted by claiming that the EU had been very more generous both in donations and even more so in exports, contributing more decisively than other producers to the world’s immunisation.

The EU and the UK also clashed on 17 March 2021, when Italy blocked a shipment of 0.25 million AstraZeneca doses to Australia. The EU protested that it was a moment when the Union suffered a shortage of vaccines and the Member States were expecting UK’s vaccines. The latter invoked a shortfall to justify their delay and to send the abovementioned doses to Australia, which was a bigger quantity than the one sent to Member States.⁴⁸

Despite this crisis, the EU and the UK have achieved remarkable agreement on other areas such as the mutual recognition of vaccination certification. The NHS COVID Pass was declared equivalent to the EU certificate, facilitating mobility between them as NHS joined EU Digital Covid Certificate.⁴⁹ Moreover, even if COVID-19 made it more difficult to maintain regular contact post-Brexit between both parties, a few interparliamentary conferences have been organised virtually, including the COSAC conference which the UK attended as an observer.⁵⁰

Regarding the intellectual property protection waiving, the UK had the same position as the EU, opposing to it. Hence, the UK has been on n the same side as the EC, while the European Parliament was pressuring it to accept the proposal.⁵¹

The global geopolitical competition

As seen above, the Atlantic space was part of a global competition between traditional Atlantic powers and re-emerged non-Atlantic ones well before the spread of the pandemic. However, COVID 19 has accentuated this competitive or even conflictual dynamics, somehow anticipating the dynamics that became apparent after the Russian invasion of Ukraine in February 2022.

Russia was the first country to announce its vaccine, deliberately portrayed as a national success and a sign that ‘Russia is back’. The chosen name (Sputnik V), reminiscent of the spatial race during the cold war, reinforced the idea that reputation and competition were key ingredients in Russia’s vaccine diplomacy. The relative ease of transporting and storing it allows its use in Africa and Latin America,⁵² thus contributing to position Russia as a relevant actor beyond its traditional areas of influence.

Russia’s early entry into Latin America enabled the speedy growth of influence in the region before the US joined the competition. It follows a strategy of challenging the US in its own frontiers, a response to the behaviour of this Western power in Russia.⁵³ Moreover, vaccine diplomacy is used to nurture political relations at the highest level as shown with the invitation to the Russian PM to Mexico.⁵⁴

As to Africa, Russia had offered the AU the opportunity to buy 300 million doses of Sputnik V, which was rejected due to the high prices. This Eastern power suffered another major throwback as SAPHRA rejected the approval of Sputnik V. It was a shock for Putin as he took for granted the Indian, Chinese and South African markets. In general, ‘Kremlin’s vaccine diplomacy in Africa is just one tool in a broader campaign to portray Russia as a development, economic, political, and security partner to the continent’.⁵⁵ In order to do that Russia exploits historical linkages, for example in Angola, pushing Sputnik V’s approval.

China’s vaccines appear soon after and, following the pattern of the facemask diplomacy, served the goal of changing from being the ‘source of the problem’ into being the provider of solutions.⁵⁶ China had the unique opportunity to be the binder of non-Western countries, particularly as the West was focused on immunising its own population first.

In this approach, China prioritised those countries with whom it had already established a cooperative relation such as the members of the Belt and Road Initiative (BRI) in Latin America and the Caribbean. This includes Antigua & Barbuda, Argentina, Barbados, Bolivia, Chile, Costa Rica, Cuba, Dominica, Dominican Republic, Ecuador, El Salvador, Grenada, Guyana, Jamaica, Nicaragua, Panama, Peru, Suriname, Trinidad & Tobago, Uruguay and Venezuela.⁵⁷ Nevertheless, China aimed also at exploring new relations and reached out to some traditional partners of the US such as Colombia - which in return supported China in the Human Rights Committee at the UN⁵⁸ - and Mexico, furthermore entering the technological sector - pressuring not to exclude Huawei from 5G concessions in Brazil and the Dominican Republic.⁵⁹ The defence of the ‘One China’ idea is also an important element of this country’s vaccine diplomacy. In 2018, El Salvador, Panamá and Dominican Republic backtracked on the recognition of Taiwan as they became members of the BRI. In 2021, Nicaragua did the same in exchange for receiving the first 0.2 million doses from the promised one million.⁶⁰

China also gives priority to BRI members in Africa. In fact, they launched the African Vaccine Manufacturing Partnership (AVMP) in cooperation with the African Union. China’s foreign policy has focused on promoting cooperation mainly in the fields of health and sustainable development. The latter has been ongoing for years due to the infrastructure built under the BRI and South-South Cooperation Initiative.⁶¹ The former is clearly patent in the donations of 125 million doses to 47 countries.⁶² Beyond health, military interests also play a role when choosing where to donate vaccines. China intends to build a naval base in Equatorial Guinea. Consequently, it supplied 0.6 million doses to the country, 0.1 of them being donations.⁶³

Moreover, as part of the competition with Western powers, China also entered Eastern Europe and the EU itself, where five million Sinopharm vaccines were purchased. Despite the non-approval of the European Medicines Agency, the eastern neighbourhood of the EU has received a large quantity of doses; some of them with caveats - Ukraine was required to stop criticising the Uighurs’ situation in Xinjiang.⁶⁴ Russia’s vaccines provided to Hungary seem to have played a similar role as recently shown with Budapest’s stances regarding the war in Ukraine.

Thus, both Russia and China aim at being recognised as major world powers and vaccine diplomacy is a useful tool to reach this foreign policy goal. The Global South was their main target, but they also deployed their vaccine diplomacies in the Global North.

The vaccine diplomacy used by India - the other major non-Atlantic producer - presents some similarities but also a few differences. India is the world’s largest vaccine producer, but its vaccines are not produced by state companies but by private industries with strong international connections.

A case in point is AstraZeneca, showing how the colonial reminiscence affects the relation with the UK.⁶⁵ India has played an essential role when it comes to vaccine access in low-income countries, before and after COVID-19. The Indian government has also been one of the drivers of the proposal presented at the WTO aiming at waiving intellectual property protection. All this contributes to project India as the protector of the middle- and low-income countries with initiatives as Vaccine Maitri,⁶⁶ and is reminiscent of the role India played in the non-aligned movement and the support to decolonisation processes.

While this position can be seen as one of competition on the normative and reputation front with the Atlantic producers, there has been another layer of the vaccine diplomacy in which China has been the great contender. India is trying to compete with China as a major Asian and World economy, and this is reflected in areas such as infrastructures, with India developing its own corridors and boycotting the BRI Summit in 2019.⁶⁷ India’s health diplomacy in Africa preceded COVID-19, supplying drugs to fight HIV/AIDS and Malaria along with other programmes under SDGs, 2030 Agenda and Agenda 2063: The Africa We Want.⁶⁸ The rivalry with China can be seen in East Africa, in countries in the Indian Ocean region, where they project their regional dispute as well. Although not central in this competition, it is worth noting that India’s donations in the Atlantic space have prioritised those countries that recognize Taiwan - St Kitts & Nevis, St Lucia, St Vincent & Grenadines and Belize in the Caribbean, Guatemala and Paraguay in Latin America.⁶⁹

Recipient countries are not passive actors in this global geopolitical race. Instead, they take advantage of the competition among the great powers, prioritising self-interests when making decisions about donation receptions or manufacture allocations.

The case of Mexico clearly illustrates the above. In the absence of major US or European support, the Mexican government purchases Chinese PPE material and the establishment of the air-bridge,⁷⁰ which prepared the ground for subsequent agreements on vaccine purchases and production with both China and Russia. This may have improved Mexico’s negotiating position with the US, as Washington likely feared Mexico becoming too dependent on the US’ global rivals.⁷¹ Similarly, Argentina took advantage of the opportunity to strengthen ties with China and Russia, in an attempt to keep IMF and the US satisfied at the same time. In fact, the donations of Sputnik V vaccines may have had a measure of influence in the initial non-condemnation of Russia’s intervention in Ukraine.

Trinidad and Tobago is a fascinating case too, as both China and India have provided significant amounts of vaccines to this Caribbean country, the former delivering 1.1 million doses whereas the latter supplied the country with 40,000 vaccines.⁷² Before COVID-19, it showed China’s ability to profit from its lending capacities, particularly among countries that aimed at avoiding structural readjustment requirements imposed by the International Monetary Fund (IMF).⁷³ As for India, the choice of Trinidad, but also smaller but crucial donations to other Caribbean states such as St Kitts and Nevis, St Vincent & Grenadines and St Lucia, indicates that India wants to project itself as a global and not merely as an Asian or Indo-Pacific country, and that while doing so it can take advantage of old people-to-people connections such as the strong links with Trinidad and Tobago through migration during the times of the British colonial rule.⁷⁴

Among African counties, Morocco and South Africa are telling examples of proactive foreign policy. Morocco carried out a facemask diplomacy delivering facemasks and hydroalcoholic gels to fifteen African countries during the summer of 2020.⁷⁵ The EU’s approach, as a part of the southern neighbourhood, made possible the recognition of the Moroccan vaccine certification inside the EU, facilitating mobility between them.⁷⁶ Simultaneously, Morocco also strengthened its ties with China, which led to Sinopharm vaccine production and the signing of the BRI implementation, Morocco becoming the first North African country to do so.

The case of South Africa is a complex one. Despite being part of the BRICS, the South African Medical Agency rejected the approval of Sputnik V. Instead, South Africa has coordinated many initiatives, including within the WTO, with India, and in February 2022 the South African regulator approves Sinopharm COVID vaccine.

Smaller countries may also attempt to profit from this geopolitical competition. The cases of Equatorial Guinea and Djibouti are quite telling. Growing security interests translated into significant vaccine deliveries there.⁷⁷

Angola’s case is also interesting due to the variety of vaccine providers in the country. China was the first supplying them with vaccines, and it has delivered 7.28 million doses of Sinopharm and Sinovac in total.⁷⁸ This may have been intended to improve Beijing’s relations with Joao Lourenço, the new president who has voiced his concern regarding Angola’s dependence on China, because of the loans they have received for development and oil infrastructure improving.⁷⁹ Moreover, China is the first destination of Angola’s exports, Beijing importing $14.3 billion of crude oil per year. Russia’s interests in the region concern mineral extraction, as it can be seen with the donation of 25,000 Sputnik V and Light doses to the Government by Alrosa, a Russian partially state-owned diamond mining firm.⁸⁰ The colonial past is the key aspect that stands out when we look at donations, as Portugal is the second bigger donor with almost two million doses, which constitutes the 25% of the total Portuguese donations. Moreover, common frameworks as the Community of Portuguese speaking Countries provide an opportunity to strengthen ties between both parties.