Everything about Indonesia’s first Covid-19 inoculation was choreographed for the cameras. Sitting in front of flowers and a red sign that read “Vaccine: Safe and Halal,” Joko Widodo, Indonesia’s president, slowly rolled up his white shirt sleeve as the medical professional next to him held up a small box to the assembled audience. The box, which contained the president’s vaccine dose, was embossed with a single, Chinese brand: Sinovac. 

It was January, and with Indonesia’s Covid cases surging to a high of over 14,000 new cases a day, the country became the first — other than China itself — to approve Sinovac, one of the three Chinese vaccines in use. At the time, little was known about the efficacy of the drug. There was no peer-reviewed data available, and the only thing to go off of were preliminary trial numbers from Brazil, Turkey and Indonesia itself, which showed the drug to be highly effective. 

Widodo knew he was taking a risk, but with no end to the pandemic in sight, China’s original offer of 3 million Sinovac doses — plus the authorization of Bio Farma, an Indonesian company, to produce Sinovac locally — was a risk worth taking. 

After a very calm injection, Widodo wrote on Facebook, “My fellow countrymen, at 9:42am this morning, I started a big effort as an Indonesian citizen to be free of this pandemic by receiving the Covid-19 vaccine. This Covid-19 vaccine is what we have been waiting for for a long time.” 

In the three months since, Indonesia has administered more than 19 million vaccine doses, the vast majority using Sinovac. While current Covid-19 infection numbers are likely unreliable due to underreporting, experts say the country is faring much better than it was in January. 

Indonesia’s president Joko Widodo received the Sinovac shot in a televised event in January.

How much of that is attributable to Sinovac remains unclear. There is still no peer-reviewed data of the vaccine, which is the normal process for vaccine development, and the data now coming out of other countries, such as Brazil, suggests an efficacy rate of only 50 percent — the World Health Organization’s minimum threshold and a far cry from the over 90 percent efficacy of U.S. vaccines like Moderna and Pfizer-BioNTech. The head of the Chinese CDC even said recently that protection from Sinovac and Sinopharm, another Chinese vaccine, has been weak, and they’re considering mixing the vaccine doses. 

But for Indonesia, which is still enduring one of the worst outbreaks of Covid-19 in Southeast Asia, there are few other options. 

“It is not that the public and officials are particularly fond of Sinovac; it’s just that it has been the most available and affordable one,” says Rocky Intan, international relations researcher at the Center for Strategic and International Studies in Jakarta. “Indonesian officials still believe the best vaccine is the next acceptable one we can get our hands on.”

Countries using Chinese vaccines include…

Belarus, Hungary, Montenegro, Turkey, Serbia, Azerbaijan, Brunei, Cambodia, Indonesia, Laos, Mongolia, Malaysia, The Philippines, Pakistan, Thailand, Argentina, Brazil, Bolivia, Chile, Colombia, Dominica, Dominican Republic, Guyana, Mexico, Peru, Bahrain, Jordan, United Arab Emirates, Algeria, Congo, Egypt, Equatorial Guinea, Gabon, Guinea, Morocco, Mozambique, Senegal, Seychelles, Sierra Leone and Zimbabwe

That mentality is not unique to Indonesia. Nearly all the public health experts The Wire spoke to agree that the risk of untested vaccines are outweighed by the rewards — namely, some level of protection against tens of thousands of deaths a day. With the pandemic still raging, waiting for the WHO’s official stamp of approval for Chinese vaccines, which is being decided on this week, has not been a feasible option.

“In the context of a vaccine shortage, the Chinese vaccines are great news,” says Fiona Russell, a principal research fellow at Australia’s Murdoch Children’s Research Institute who specializes in vaccines. Even in the absence of peer-reviewed data, Russell says, “If something is 50 percent efficacious, that is good enough. That is efficacy we should be celebrating. We have 8 billion people to vaccinate globally. We need all the vaccines.” 

Leaders all across the world, especially in Southeast Asia, South America, Africa, and Eastern Europe, agree, and often express gratitude that China, unlike the United States, is exporting the majority of its vaccines. Through its ‘vaccine diplomacy,’ China is now the world’s largest exporter of vaccines, exporting 200 million doses abroad, as compared to the 3 million doses that the U.S. has shipped abroad, according to Airfinity data. 

There is an international effort to help nations get access to vaccines called Covax, which is backed by the World Health Organization and partly funded by wealthy nations, including the U.S. India and the European Union are doing their parts to contribute to the global vaccine rollout, together exporting close to 150 million doses, but with rare side effects reported from the EU’s AstraZeneca vaccine and domestic outbreaks still not under control — India is currently battling over 360,000 new cases a day — China has, so far, been the country best positioned to offer a helping hand. And with much of the world still reeling from the virus, observers say the Chinese vaccines are a welcome tool. 

“Beggars can’t be choosers. People don’t care about which vaccine they take, because there is a degree of despair,” says Vuk Vuksanovic, a former Serbian diplomat who is now a researcher at the London School of Economics and who has been tracking Chinese vaccine diplomacy in Serbia. 

The lack of data or transparency regarding China’s vaccines, Vuksanovic adds, is not especially troubling to a lot of countries since it tracks with “China’s modus operandi — they aren’t transparent on anything,” he says.

Yet, for others, China’s opacity, no matter how expected, is still not acceptable.

“It is ridiculous,” says John Moore, a virologist and professor of microbiology and immunology at Weill Cornell Medicine. “Unless countries have information, how are they supposed to judge the vaccine? If this were the licensed American vaccines, we could look at the clinical data. And when safety concerns arise, like with Johnson & Johnson and AstraZeneca, there is confidence that they will be dealt with. But with the Chinese vaccine, it is so opaque.” 

It doesn’t help, observers say, that China’s lack of transparency helped create this pandemic in the first place. When Covid-19 first emerged in Wuhan, in late December of 2019, Chinese Communist Party leaders didn’t alert their own population or the outside world about the pandemic for nearly a week. Beijing also sanctioned whistleblowers like Dr. Li Wenliang, and effectively prevented reporting of the outbreak that could have helped other countries prepare for what would become the greatest public health crisis in over a century. 

“In every aspect where transparency, accountability and good governance have been important to the Covid response, China has been an utter failure,” says Lawrence Gostin, the director of the World Health Organization’s Collaborating Center on National and Global Health Law and a Georgetown professor. 

Beggars can’t be choosers. People don’t care about which vaccine they take, because there is a degree of despair.

Vuk Vuksanovic, a former Serbian diplomat who is now a researcher at the London School of Economics and who has been tracking Chinese vaccine diplomacy in Serbia

And although it’s currently enjoying widespread praise for its vaccine diplomacy efforts — especially compared to criticisms that the U.S. has been hoarding its vaccines — Gostin says that China’s strategy of using the vaccine as a political and economic tool is “a big gamble.” 

“China is trying to project an image of scientific and technological prowess that proves that their system of government is better than western democracies. And they might get away with it,” he says. “But if something goes wrong with this vaccine — and it could because we have no idea how safe and effective it is — then it will come back to really haunt China for a generation.”

THE VACCINE RACE

By all accounts, China had a head start in the vaccine race. Covid-19 was spreading widely in the country before it was in other parts of the world, and Chinese scientists were the first to code the new virus’ genetic sequence. Plus, for years China’s central government has designated biotechnology a national priority and invested heavily in the field. Vaccine makers had the full support of China’s government-backed economic machine, and doses were ready for shipment as early as December of last year.

So, in early April, when Gao Fu, the head of China’s Center for Disease Control and Prevention, announced that China’s Covid-19 vaccines “don’t have very high protection rates,” it was a stunning admission. Although the world’s medical community had suspected it for months, Gao’s comments set off a storm of press and were censored in China. He quickly walked back his remarks, saying that it had all been a “complete misunderstanding.”

“He was walking on a tightrope,” says William Hsiao, an economics professor emeritus at Harvard’s T.H. Chan School of Public Health. “Gao Fu is an honest person with a strong scientific background. He understands that there is a world standard. And as a person with a strong scientific background, I imagine he would want China to follow the standard.”

Given China’s scientific expertise and intense political will to develop an effective vaccine, what went wrong? Experts say there were two critical missteps that hampered the country’s vaccine development. First, it focused its efforts on inactivated vaccines; and second, its clinical trials weren’t stringent enough. 

Almost immediately after the pandemic hit Wuhan, Chinese scientists fanned out to work on many different types of vaccines. The first ones that were ready for widespread use were inactivated vaccines, which use a killed version of the germ to inoculate people against the virus. At the time, very little was known about Covid-19, and inactivated vaccines seemed like a safe approach: vaccine makers had experience making them since they are used for viruses ranging from hepatitis A to polio. 

There was just one issue, which nobody could have known at the time: it would turn out that inactive vaccines are not as effective as the different, perhaps riskier, approach that Western vaccine makers were taking.

Pfizer and Moderna had staked their hopes on a never-before-tried technology based on messenger RNA, which teaches cells how to make proteins that trigger antibodies. AstraZeneca and Johnson & Johnson were using relatively new viral vector technology, which had been used to fight Ebola and uses a harmless virus to teach cells how to fight off a harmful virus.¹CanSino Biologics, the third Chinese vaccine that is beginning to be rolled out abroad, also uses the viral vector approach. It turned out the mRNA vaccines were extremely effective — both had over a 94 percent efficacy rate in trials — and the viral vector vaccines have rates in the 70 percent range.

“Should China have developed an mRNA vaccine earlier? Looking back, of course,” says Yanzhong Huang, a senior fellow for global health at the Council on Foreign Relations. “But they wanted to be number one, and so they wanted to go down a low-risk path.” 

But then the clinical trials, experts say, presented another problem: at the time, in China, there was no fast spreading virus present. China’s draconian lockdown measures had almost completely stopped the spread of Covid-19 in the country, making it hard to find places to do drug trials. So China’s vaccine makers again took a shortcut: they tested their vaccines in areas where there were flare ups within China, but didn’t prioritize completing — and releasing — peer-reviewed data on their vaccines’ efficacy in places with widespread contagion. 

“This was a mistake,” says Harvard’s Hsiao. “As a nation, if I want my vaccines accepted, I would push the companies: you have to go to Mexico, to South Africa to do the tests. You have to follow the international scientific standard.”

Hsiao notes that the huge demand for vaccines, especially from Middle Eastern countries, might have distorted China’s decision making. “If someone already wants my product,” he poses, “why should I go through huge expenses to go through a clinical trial?”

Indeed, although most countries receiving Chinese vaccines are low and middle income, Chinese vaccines are being sent in large quantities to the Gulf, which is home to some of the world’s richest countries. That is partly because, experts in the region say, those countries are seeking a closer relationship with China.

“This is just one component of a bigger overall trend,” says Jonathan Fulton, a political science professor at Zayed University in Abu Dhabi. “China has developed a significant presence in the Gulf. There has been a sense that the U.S. provides security and political leadership while China is just here on business. The vaccine diplomacy is symbolic of China arriving in the region for more than just business.”

But just last month, in a blow to the diplomatic relationship and the entire vaccine rollout, the distributor of Sinopharm in the United Arab Emirates announced it would give a third shot of the Chinese vaccine in some cases, due to inadequate antibodies after the normal two-dose schedule. Though the distributor claimed that this would only be needed in a “very small number” of patients, the announcement left some in the U.A.E. feeling like they had been misled and made many wonder what lay ahead for countries who relied on the Chinese vaccine.

China may be waking up to this potential for backlash. During his speech at Chengdu, Gao Fu touted the efficacy of mRNA vaccines, a sign that China may now prioritize and invest more in the new technology. There is already a joint effort, for example, between Walvax Biotechnology, a Chinese vaccine maker, the Academy of Military Sciences, and Suzhou Abogen Biosciences, which has created an mRNA vaccine that is currently going through final stage testing. Gao also mentioned that China is considering mixing different technologies, including mRNA and inactive vaccines, to boost efficacy.

Overall, however, there hasn’t been much pushback from the countries receiving the Chinese vaccines, even with efficacy concerns. Denise Garrett, a Brazilian-American epidemiologist at the Sabin Vaccine Institute, says that a new study released in April in Chile, not yet peer-reviewed, suggests the Chinese vaccine effectiveness might be above 50 percent. “Although in few aspects the Sinovac vaccine may not compare favorably with other COVID-19 vaccines,” she says, “this is one of our main options. And it is a good vaccine in terms of reducing hospitalizations and deaths”.

There has not been pushback yet — the key word is yet… Right now, people in Mexico are just grateful to have a shot in the arm.

Jorge Guajardo, the former Mexican ambassador to China

But, Jorge Guajardo, the former Mexican ambassador to China, notes, “There has not been pushback yet — the key word is yet.” Mexico, which traditionally has been a strong U.S. ally, has made a big bet on Chinese vaccines, accepting more than 35 million doses from various Chinese companies due to lack of supply from American companies. 

“The Chinese have been able to act as the saviors,” Guajardo says. “But we are closely following what is happening in Chile, where despite the inoculations [with Chinese vaccines], the virus is surging. Right now, people in Mexico are just grateful to have a shot in the arm, but the efficacy may be an issue going forward.”

THE GEOPOLITICS

Vaccinating the world is a marathon, not a sprint. And experts say that while China had some advantages at the starting line, the race will soon be entering its next phase. 

“There is a strong potential for the U.S., by the end of the year, to really be at the forefront of exporting vaccines,” says Krishna Udayakumar, the director of Duke University’s Global Health Innovation Center. “By July, we expect that the U.S. will have substantive excess doses available to start exporting. And given the ramp up of manufacturing capacity, we expect the U.S. will be manufacturing 200 to 300 million doses of vaccine per month by the fall into the winter.”

Already, the Biden administration has promised to send materials to make 20 million doses of the AstraZeneca vaccine to India. The ‘Quad’ — a partnership between Australia, India, Japan and the U.S. that has traditionally focused on maritime security — announced in March a plan to fund the production of 1 billion doses of Johnson & Johnson in India and distribute them across Southeast Asia. 

“Strategically and functionally, the Quad’s recent focus on vaccines could pay dividends,” says Karthik Nachiappan, a research fellow at the Institute of South Asian Studies at the National University of Singapore. “One advantage the Quad’s vaccines will have is that they are trusted and reliable with enough efficacy data to back them up. And countries will want access to safe and effective vaccines that have been proven.” 

Although Beijing (with the help of Russia) is already trying to sow distrust in the U.S. vaccines, Chinese vaccines will soon face stiff competition. And the U.S. version of vaccine diplomacy will likely draw a sharp contrast to China’s, which, observers note, is often very transactional. There have been reports that Beijing is pressuring countries to give something up, including diplomatic concessions and access to national 5G networks, in exchange for vaccines. If the vaccine doesn’t hold up its end of the bargain, then, it could cause some ill will. 

“These will be quick wins [for China] that seed resentment in the future,” says Mexico’s Guajardo. “When they say diplomacy, there is nothing diplomatic about this. It is strictly transactional. For example, they have been pressuring Paraguay about its relationship with Taiwan in exchange for vaccines. That is not a universal public good if they are using it for leverage. Don’t assume countries are not noticing.”

Beyond geopolitics, the repercussions could trickle down to China’s domestic matters as well. First, some of the initial drive behind China’s vaccine diplomacy was to help its pharmaceutical companies secure overseas markets. And though their inoculation campaign has boosted name recognition for companies like Sinovac and Sinopharm, if the vaccines turn out to be ineffective, that could actually hurt their brands.

“If the vaccine you are giving is less effective, people will treat it as an inferior product,” says Harvard’s Hsiao. “And that view carries over; it affects the public perception of other Chinese products.”

“China is trying to be all about quality in technology,” adds Guajardo. “And in most cases, they do have a good product. But, with the vaccine, they are staking a lot on a product that is clearly inferior.”

Moreover, if the vaccines don’t turn out to be effective, China’s domestic population faces a practical barrier to resuming business as usual. Beijing signaled in late April that it will soon approve the Pfizer vaccine, which will be made by Shanghai Fosun Pharmaceutical Group, for domestic use. But the country will still likely incolulate the majority of its population with Chinese-designed vaccines. Given the presumed efficacy rates of the Chinese vaccines, China will have to inoculate 100 percent of its population in order to reach herd immunity. With a population of 1.4 billion people — and a citizenry that feels no urgency to get vaccinated due to the near eradication of Covid-19 in China — that will be a difficult task. Experts warn it could be 2022 before China opens its borders.

“With the current strategy, where everyone needs to be vaccinated in order for the country to be safe against Covid, I think it’s going to be some time before China opens its borders to travel,” says Benjamin Cowling, head of epidemiology and biostatistics at the University of Hong Kong’s School of Public Health. “I think restrictions and quarantines will be in place longer than in other places in the world.”

And that, Huang, at the Council on Foreign Relations, remarks, could spell disaster. “If the Western countries open their borders, and China is still closed, that is dangerous. It is immunologically dangerous because of the immunity gap it will create between China and the rest of the world. And it is politically dangerous, because it undermines the narrative that they controlled Covid so well.” Plus, Huang adds, the 2022 Winter Olympics, which are being hosted by Beijing, are just around the corner, adding pressure to China to figure out some way to safely open its borders by then. 

Of two evils — the U.S. hoarding or China pushing its untested vaccine — which is the worst evil?

Lawrence Gostin, the director of the World Health Organization’s Collaborating Center on National and Global Health Law and a Georgetown professor

Of course, none of these scenarios will play out if the Chinese vaccines turn out to be more effective than current predictions. And, as Gostin adds, it is important to remember that the U.S. is no saint either: stockpiling its vaccine supply has been criticized as a moral failing, and it created the vacuum for China to fill in the first place. 

“Of two evils — the U.S. hoarding or China pushing its untested vaccine — which is the worst evil? Probably hoarding the vaccine is the worst evil,” says Gostin. “But maybe not. If it turns out that the Chinese vaccines are not safe or not effective, then that’s the worst evil. If it’s not safe, it will create huge problems of trust and confidence in vaccines and governments.”

The coming two to three months, Huang says, represent something of a “golden era” for China’s vaccine diplomacy. But after that, Western vaccine makers like Moderna and Pfizer will be looking for new markets for the 3 billion doses each company plans to manufacture next year. 

“This will be a good thing for the low income countries,” Huang says, “but it will not be good news for Beijing. When you have alternatives, you compare. Which would you choose?”

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