Understanding COVID-19: The geopolitics of Vaccine Distribution
Date: 26-01-2021 www.globsecint.org Author: Zachariah Coleman
Introduction
Since the first case outside of China was confirmed in Thailand on 13 January 2020, COVID-19 has the states of South and South-East Asia have descended into crisis. Whilst Thailand, Vietnam, and Singapore, have been praised for effectively controlling the virus, others including, such as India, Indonesia, and the Philippines, have seen widespread outbreaks.
With virus cases continuing to climb worldwide and some states in the region experiencing second waves, states are looking to secure vaccinations to immunise their entire population. While multiple vaccine candidates have been approved, due to global spread of the virus, supplies of the earliest approved vaccines, including Pfizer, Moderna, and AstraZeneca, have been bought out by more wealthy states. This has left the region looking to secure any remaining supply, as well as alternative sources, such as vaccine candidates currently being developed in India, Singapore, and Vietnam.
A state’s choice for what vaccines it will use to vaccinate their population comes down to four main factors; cost, the complexity of rollout, availability, and the influence of major regional and world powers. How these factors will influence the geopolitics of the region in the coming years will be discussed in this analysis.
Summary of Key Findings
Country-wise responses
Indonesia’s COVID-19 response is considered to be one of the least effective in the world. This has resulted in Indonesia being one of the first countries to order Chinese vaccine Sinovac, even before its final trial results were published.
Furthermore, Indonesia’s complex geography, political economy and massive population may severely compromise designs to inoculate two thirds of their population in 15 months.
Despite the efficiency of their purchased vaccines, Bangladesh faces the monumental task of inoculating its massive population, and is currently getting citizens to exclusively register for vaccines through an app. This stands to be an insufficient logistical solution, as only 13% of the population has access to the internet.
The Philippines believes they will purchase enough vaccines in 2021 to inoculate between 50 70% of their population. It is also known to have had one of the worst pre-vaccine responses globally. The nation aims to obtain vaccines from a diverse range of sources, including 25 million from Sinovac, 30 million from Novavax and 13 million from AstraZeneca. It is also looking to purchase doses of Russia’s Sputnik-V. This diverse range of vaccine sources may be reflective of its diverse range of relations with producer states.
Factors influencing vaccine purchases
Every vaccine that has seen some level of approval so far, requires one and a half or two doses. Each vaccine also requires different spacing between the doses to maximise effectiveness.
This creates a major logistical problem, especially since the majority of states will be using multiple vaccines to vaccinate their populations as quickly as possible.
With both India and China having significant vaccine production potential, and India often being regarded as ‘the pharmacy of the world’ other states in the region are lining up to receive vaccine from the two states.
Many of the least developed countries, including East Timor, Myanmar, Bangladesh, and Nepal, are heavily depending on receiving vaccines from the COVAX program.
Geopolitical consequences
Indian influence in South Asia may strengthen once more. Chinese influence in South East Asia may strengthen, as fence-sitting states alter their perception of China, after experiencing their humanitarianism effort first-hand. While the loss of some influence in South Asia will be a blow to China’s String of Pearl’s strategy, the biggest loser of this competing vaccine diplomacy will be the United States.
Given the added costs and complexity of vaccine purchases and rollout, states will most likely become more susceptible to financial influence from corporations, individuals, or other states, as they attempt to regain economic stability.
This could lead to higher levels of corruption, or potentially greater foreign influence in state’s domestic affairs.If China’s vaccine diplomacy efforts are entirely successful and India’s are not, China stands to gain influence and trust within the region, as states aided by Beijing become indebted. This would further weaken India’s influence.
Key Factors Influencing Vaccine Choice
Cost:
Excluding Singapore, every country in the South and South East Asian region are considered developing, with eight classified as ‘least developed countries’. Thus, vaccine cost is a significant factor influencing the choice of vaccine. This may be one reason why the AstraZeneca vaccine, a single dose vaccine that costs approximately $4, is considered more desirable by many countries in the region, including India, Malaysia, Thailand, and the Philippines. On the contrary, the Pfizer vaccine, the first vaccine to be approved by multiple countries, requires a double dose, and is far more expensive at approximately $20 a dose, meaning it will cost countries approximately $40 per person to vaccinate.
This is a significant drawback for countries with low GDP per capita’s, which do not have the funds to purchase such expensive vaccines, especially given the dire economic circumstances caused by the downturn in the world economy that many face. Many of the least developed countries, including East Timor, Myanmar, Bangladesh, and Nepal, are heavily depending on receiving vaccines through COVAX, a worldwide program coordinate by Gavi, CEPI, and the WHO, to ensure every state receives enough vaccines in a timely manner to immunize the most vulnerable 20% of their population.
However, states want to rapidly achieve herd immunity, thus, COVAX candidates will purchase whatever vaccines they can to vaccinate as many people as possible. To help meet this demand, India, the most populous state in the region, and the state with the largest outbreak, with over 10 million confirmed cases, is developing multiple vaccines and scaling up its production to produce other international vaccines, more notably the AstraZeneca vaccine. Given India’s massive population, and low GDP per capita at $1877 USD in 2019, it is aiming to produce enough vaccine at low enough costs to efficiently vaccinate the entire population. Furthermore, India is seeking to aid neighbouring states in obtaining affordable vaccines, and has promised access to cheap, locally produced vaccines to Nepal and Bhutan.
Complexity of Rollout:
Apart from the initial cost of the vaccine, there are other economic and logistical factors that will affect a state’s vaccine choice. Every vaccine that has seen some level of approval so far requires one and a half or two doses. Each vaccine also requires different spacing between the doses to maximise effectiveness. This creates a major logistical problem, especially since the majority of states will be using multiple vaccines to vaccinate their populations as quickly as possible. Monitoring who has received their first or second dose, and ensuring that people receive the second dose of the correct vaccine within that vaccine’s time window, will create an extra layer of complexity that could further complicate what will already be an immense undertaking. Therefore, if a vaccine candidate were to emerge that had similar levels of effectiveness with only a single dose, this vaccine would most likely be highly desired in the region, due to the easier rollout such a vaccine would entail.
Another major logistical issue is the temperature some of the vaccines have to be stored at. Pfizer, the first vaccine to be approved by multiple states, has to be stored at minus 70 degrees Celsius. While the more developed countries in the region, like Singapore, have the funds and pre-existing capacity to store vaccines at this temperature, the majority of states do not, making the rollout of a vaccine like Pfizer completely unrealistic. This increases the regional demand for more easily stored vaccines, such as AstraZeneca and Chinese-developed vaccines, all of which can be stored at normal refrigeration temperatures. As a result, regional production of vaccinations, being led by India and China, is focused on producing vaccines that can be stored at normal vaccine temperatures, rather than the extreme cold required by vaccines like Pfizer.
Availability:
As COVID-19 continues to spread uncontrolled throughout most of the world, the world’s richest countries have poured millions of dollars into securing the first batches of Western vaccine, coming from Pfizer and Moderna. Singapore, the only developed state in the region, has done precisely this, purchasing millions of doses of the Pfizer vaccine through an advance purchase agreement. However, other states in the region, all of which are developing or least developed, do not have the resources to compete with rich, developed states in procuring vaccines. While many of these states are lined up to receive vaccines from COVAX (which will vaccinate the most vulnerable 20% of a population), these vaccinations may still be many months, or even years, away. Therefore, there is a major gap between the supply of vaccine and the current demand, that other producers are looking to exploit.
China currently has three vaccine candidates in phase three trials, developed by Sinopharm, Sinovac, CanSino Biologics, the first two of which have already been approved in China for emergency use. India has also developed a vaccine that is in phase three trials, Covaxin, which is currently pending emergency use authorisation in India. Both these states have significant vaccine production potential, with India often being regarded as ‘the pharmacy of the world’. As a result, others states in the region are lining up to receive vaccine from these two states, with Singapore, the Philippines, and Malaysia among the states looking to buy Chinese vaccines, while Nepal, Bhutan, and Bangladesh are among the states looking to purchase Indian vaccines.
Other states in the region are also playing a part in vaccine development, most notably Singapore with its Lunar vaccine and Vietnam with its Nanocovax vaccine. However, at this current time neither vaccine is in advanced trial stages and distribution is mainly being discussed domestically.
Another major potential source of vaccine for some states is Russia’s Sputnik-V vaccine. Despite Russia’s own significant outbreak of over 2 million confirmed cases, it is shipping its vaccine to multiple states throughout the world. Some states have requested doses, including Afghanistan, Cambodia, and Laos, yet they’re still to be fulfilled.
Case Studies on Receiving Countries
Bangladesh:
Bangladesh has recorded over 530,000 cases and over 8,000 deaths at the time of writing. In response to the pandemic, it implemented similar measures to numerous other countries in late March, placing the state in various forms of lockdown until the end of May. All restrictions on movement were lifted by the beginning of September. Bangladesh also limited international travel into the country to control the spread. However, Bangladesh has been criticised for not making COVID-19 tests free, which health experts believe have decreased testing rates and has led to undetected transmission within the community. These comparatively short lockdown measures have resulted in widespread known transmission, and potentially much more widespread unknown transmission, as reflected in Bangladesh’s poor containment measures score. This failure to properly contain the virus is most likely a major contributing factor in Bangladesh’s great efforts in the latter half of 2020 and the beginning of 2021 in securing vaccines. Bangladesh’s most notable vaccine source is its neighbour and close ally India, from whom it has so far secured 32 million doses of locally produced AstraZeneca.
This reflects the generally more favourable relationship that Bangladesh shares with India, in comparison to other regional powers, including Pakistan, whom it broke away from, and China, who originally vetoed Bangladesh’s accession to the UN in the 1970s. While the Bangladesh-China relation has been improving since the mid-2000s through trade, Bangladesh’s strong relationship with India and India’s desire to properly supply Bangladesh with vaccine supersede any effort by other regional or global powers to gain a foothold in the country through vaccine diplomacy. Moreover, India’s production of the AstraZeneca vaccine, which can be kept at regular refrigeration temperatures and is so far the cheapest to mass produce, makes for a much easier rollout than a vaccine that needs to be stored in extreme cold or is expensive to produce. Furthermore, India has donated 2 million doses to Bangladesh as a sign of goodwill, which will enhance trust between the two states. As a developing nation, Bangladesh has also secured 70 million doses from NGO’s, including the COVAX program and GAVI. This, coupled with India’s assurance that Bangladesh may purchase further vaccine in the coming months, puts Bangladesh on a good path to achieve significant coverage by the end of 2021.
Bangladesh is mainly receiving AstraZeneca, from India, and Pfizer, from COVAX and Gavi, both of which have over 90% efficiency, meaning those vaccinated in Bangladesh are highly likely to develop some level of immunity. Despite the efficiency of their purchased vaccines, Bangladesh faces a monumental task in inoculating its huge population, and is currently getting citizens to register for vaccines through an app. This could complicate the rollout though, as Bangladesh has said only those who register through the app will get it at this current time, something that will provide difficult to millions of Bangladeshi’s, as only approximately 13% of the population has internet access. While it’s likely the government will change their approach as they aim to reach more people, this internet barrier will likely lead to a slower start than wanted to vaccinate the population. Bangladesh’s decision to procure the majority of its vaccine from India is driven by three main factors; access to vaccines, cost of vaccinations and rollout, and the pre-existing relationship that exists between the two states. These factors ensure Bangladesh will be able to mount a widespread vaccination effort to try and rectify their poor COVID response, while incurring less financial burden on its already weak economy.
Indonesia:
Indonesia has recorded over 1 million cases and over 30,000 deaths at the time of writing. Indonesia’s COVID-19 response is considered to be one of the least effective in the world. The central government banned travel from badly affected countries throughout the first quarter of 2020, and implemented large-scale social restrictions at the request of specific provinces throughout April and May. However, many provinces asked to have these measures implemented to help contain their own spread, but and were rejected. Furthermore, Indonesia has one of the lowest testing rates per capita in the world, and one of the highest test-positive case rates as well, which has most likely resulted in a widespread undetected spread in the community. This poor response, has led Indonesia to change its approach of virus control through social restriction, to vaccination,. Indonesia is looking to secure vaccines as early and quickly as possible to stop the now uncontrollable spread. This has resulted in Indonesia being one of the first countries to order Chinese vaccine Sinovac, even before its final trial results were published. While the Indonesian government has been fostering an increasingly warm trading relationship with China, including being a signatory to the Belt and Road Initiative, there is major anti-Chinese sentiment throughout Indonesia, stemming from the late 19th and early 20th century. This is of concern to health officials in Indonesia, due to the worry that Indonesians will refuse to receive a Chinese designed vaccine. This suggests Indonesia is more focused on obtaining vaccine quickly rather than from a trusted source, as they wish to try and rectify their own failures in controlling the pandemic.
Currently, Indonesia has obtained 125 million doses of Sinovac, which the central government says will make up the majority of free vaccinations being offered in Indonesia. Indonesia has also secured 50 million doses of Pfizer, and is in talks to secure doses of AstraZeneca, but no specific deals have been publicly disclosed yet. While Indonesia plans to vaccinate 181.5 million people, or two-thirds of its population, in 15 months, it currently has nowhere near enough doses to do this, especially since Sinovac requires two doses. Moreover, Sinovac has been shown to only be around 50% effective in producing an immune response in recipients. Even if Indonesia does manage to vaccinate large swaths of its population with Sinovac, at least half of those vaccinated will not develop any immunity, which would undermine Indonesia’s efforts to control the pandemic and allow the virus to continue to spread. The ineffectiveness of Sinovac further supports the idea that Indonesia is solely concerned about getting any COVID vaccine into its citizens as quickly as possible, both in an attempt to try and curb the spread in any way possible, as well as present a front of action to their citizens. Further complicating Indonesia’s planned rollout, there is also general vaccine skepticism in the community, as a result of mixed government messaging regarding the vaccine.
Indonesia’s island geography and massive population pose major logistical problems for its weak health system, which may severely inhibit their goal to inoculate the population. Indonesia’s decision to procure the majority of its vaccine from China is driven by one main factor; access to vaccine supply. This is evident from the fact that Sinovac is not the cheapest vaccine, nor the most effective, and requires two doses. However, it can be refrigerated at regular temperatures, and it is readily available, given China’s desire to produce enough vaccine to supply states all over the world. Furthermore, Indonesia’s decision to purchase a Chinese-made vaccine is not based upon any close relationship; instead there is a risk of public backlash. The best conclusion that can be drawn is, Indonesia is solely interested on doing something about the pandemic after not doing enough for months.
The Philippines:
The Philippines has recorded over 520,000 cases and over 10,000 deaths at the time of writing. Like most other states, The Philippines has gone through numerous lockdowns since March. Typhoon Vongfong complicated the pandemic response in affected areas in May, as lockdown became unenforceable as people fled their homes. Like other states, travel bans have been implemented, most recently against the UK after the new strain was discovered. The Philippines has been criticised by health experts for not doing enough testing and contact tracing to properly identify virus spread. Whilst The Philippines scores around 6 points higher than Indonesia or Bangladesh in its COVID-19 response, it is also considered to have one of the least effective responses globally. This failure has driven The Philippines to secure as much vaccine as possible, as they, like many other states in the region, aim to vaccinate their populations as fast as possible to make up for their failure to contain the virus.
This has led The Philippines to obtain vaccine from diverse range of sources, including 25 million from Sinovac, 30 million from Novavax and 13 million from AstraZeneca. It is also looking to purchase doses of Russia’s Sputnik-V. If all of its deals are successful, which include procuring more doses with existing vaccine providers, The Philippines believes they will purchase enough vaccine in 2021 to inoculate between 50-70% of their population. If their higher estimates come to fruition, The Philippines has a good chance of achieving a level of herd immunity within the community by the end of 2021, even if some of its vaccine purchases, such as Sinovac, are less effective than others.
The Philippines diverse range of vaccine sources may be reflective of its diverse range of relations with producer states. The Philippines has had a strong relationship with the US since independence, and has traditionally been considered a major Western ally. However, under Duterte, relationships have grown to include non-traditional allies, notably the Russians. While the relationship with China has marginally improved under Duterte, tensions between the two states are still very high, and continue to escalate, over the South China Sea dispute. Moreover, public perception of China is incredibly low, while perception of the US is incredibly high. Coupled with botched vaccine rollouts in the past, some health officials are concerned that Filipinos will refuse to take certain vaccines, especially those from China due to their comparatively worse trial results and the general distrust that exists within the population.
The Philippine’s decision to procure its vaccine from a vast array of sources is most likely driven by three main factors; access to vaccines, hedging their bets, and pre-existing relationships. These three factors ensure that The Philippines will secure enough vaccine to inoculate a majority of their population in a timely manner, while not being majorly impacted in one vaccine supplier has production issues or is found to be less effective or problematic.
Forecasts and theoretical implications
As demonstrated by the three case study states, the main factor behind which vaccine a state chooses is based universally on access to supply, with a state’s pre-existing relationships coming in as a secondary concern. However, as seen by Bangladesh, having strong ties with a vaccine producing state can be of great assistance to receiver states, as it makes it easier to conduct the procurement, and may also result in better pricing deals. While the receiver states themselves may not be overly fussed about which vaccine they receive, the implications of which state they choose may have unforeseen consequences in the years to come, as receiver states become indebted, both economically and otherwise.
Firstly, if states are unable to secure enough vaccine to achieve her immunity, governments may be grappling with the ongoing health crisis for years to come. Even if states do obtain an appropriate quantity of vaccines, how long the vaccines are effective for and whether or not they are effective against mutations of the virus is unknown. Current vaccinations may not provide the long-term security from COVID-19 that many states hope for.
Secondly, even if a vaccine is fully rolled out and herd immunity is achieved, the cost of vaccinating one’s entire population will cost hundreds of millions, and will become another compounding economic burden on states that were already struggling financially before the pandemic began. Along with the other economic implications of the pandemic, states will most likely become more susceptible to financial influence from corporations, individuals, or other states, as they attempt to regain financial stability. This could lead to higher levels of corruption, or potentially greater foreign influence in state’s domestic affairs.
Finally, the impacts of India and China’s vaccine diplomacy efforts could have long lasting geopolitical impacts, potentially reshaping the regional order. If China’s vaccine diplomacy efforts are entirely successful and India’s are not, China stands to gain influence and trust within the region, as states aided by Beijing become indebted. This would further weaken India’s influence throughout Asia. On the contrary, if India’s efforts are successful and China’s are not, China could lose major influence in South Asia, as India is seen as the more benevolent and caring ally
The most likely scenario, however, is that both will be relatively successful and gain more influence over different states. Indian influence in South Asia may strengthen once more, however an improvement in relations with Pakistan is unlikely, given they are looking to purchase Chinese produced vaccines. Chinese influence in South East Asia may continue to strengthen, as states that are still on the fence come around on China after experiencing their good-natured humanitarianism first-hand. While the loss of some influence in South Asia will be a blow to China’s String of Pearl’s strategy, the biggest loser of this competing vaccine diplomacy will be the United States of America. Completely absent from vaccine rollout, and after four years of isolationist policies, the US will have lost major standing in the region, a complete turnaround from its position only a decade or so prior. This may signal the continued decline of major Western influence in South and South East Asia, instead being replaced by the influence of regional actors, namely India and China.