By Nitsan Chorev and Salma Mutwafy

The SARS-CoV-2 virus has been referred to by some as the “Chinese virus” and its mutations as the “South African” or “British” variants. If the virus and its variants have nationality, the vaccines that were developed certainly have nationality too. Vaccine development has been used as a geopolitical tool for establishing a hierarchy of innovators, based on which country uses which vaccine. Drawing on the experience of Kenya, we suggest that these international contests over innovation, combined with vaccine diplomacy as well as instances of health nationalism, have an important impact on both the availability of vaccines and their perception in low-income countries.

Innovation is integral to countries’ pursuit of economic growth, military dominance, and geopolitical influence. The race to develop a COVID-19 vaccine therefore came with high reputational stakes. The United States and Western Europe, still considered leading innovating forces, produced four of the vaccines currently in use. American companies developed Pfizer/BioNTech (with a German company), Moderna, and Johnson & Johnson (J&J). Oxford-AstraZeneca was developed through a collaboration between the United Kingdom’s Oxford University and AstraZeneca, a British-Swedish company. China, which has been investing in becoming a global knowledge power, has produced five different vaccines including by Sinovac Life Sciences and Sinopharm. Russia, not considered a serious player in this game, has developed Sputnik V – whose very name demands geopolitical respect. Other countries are advancing their own vaccine development, most notably Cuba.

Geopolitical competition over innovation also encouraged “vaccine diplomacy” – donating, subsidizing, or selling vaccines to low-income countries. The US government is a major contributor to the COVAX Facility – a pooled procurement initiative led by the World Health Organization (WHO) aimed at improving vaccine access worldwide. COVAX has so far distributed mostly AstraZeneca vaccines, and smaller quantities of Pfizer and J&J vaccines. China has contributed only minimally to COVAX, but recently declared that it would donate 10 million vaccine doses, thus promoting the use of its own vaccines. The stakes for China are high: for the donations to be accepted, the WHO must first qualify the vaccines as safe and effective. In addition, China and Russia have donated or sold their vaccines directly to low- and middle-income countries, with Americans warning that this was a way to wield influence and buy political favors.

Innovation contests and vaccine diplomacy are playing out within institutional arrangements that reflect American and European dominance. The US Food and Drug Administration (FDA) has so far issued emergency use authorization only to the three “American” vaccines. The WHO listed for emergency use AstraZeneca, Pfizer, and J&J. China and Russia received emergency use approval from some countries, but have not received WHO authorization yet. Competition over hierarchy takes place through informal channels as well. Some European countries and US commentators were quick to dismiss the “Russian” and “Chinese” vaccines. Other reports have, in turn, described a concerted Russian misinformation campaign in Spanish-speaking countries that disparaged vaccines developed in the West.³¹

Vaccine diplomacy, which encourages countries to support vaccine distribution in other countries, may clash with “health nationalism,” by which countries attempt to ensure vaccine availability to their nationals first. Health nationalism led the European Union and India to ban the export of AstraZeneca. Vaccine diplomacy may further clash with health nationalism when countries, to minimize the risk of adverse reactions to their own population, refuse to use vaccines that they offer to others. In such cases, health nationalism may also clash with innovation contests. Indeed, at the time of this writing, the hierarchy of vaccines is in disarray. Several high-income countries have temporarily paused the use of AstraZeneca and J&J due to concerns over blood clots. Further undermining the assumed reputational order, Sputnik V joins Pfizer and Moderna in the tier of vaccines considered highly effective and with no reported side effects. What are the implications of a divided distribution, where high-income countries hesitate to endorse exactly those vaccines that reach poor countries?

The ongoing vaccine distribution in Kenya reveals the ground-level ramifications of health nationalism and reputational contestations at the international level. Kenya is currently distributing AstraZeneca vaccines manufactured in India and acquired through a cost-sharing agreement with COVAX. The country is set to have 30% of its 53 million people vaccinated by 2023. The first consignment, containing 1.02 million doses, arrived in early March. The vaccine is provided free of charge. The Sputnik V vaccine, which was approved for emergency use by Kenya’s Pharmacy and Poisons Board (PPB), was briefly available in select private clinics at a cost of up to $80 per dose, before its importation was prohibited by the Ministry of Health. This onset of vaccine distribution is occurring against the backdrop of new lockdown measures imposed in response to a surge in COVID-19 cases: the number of new daily cases, around 1,000, is the highest that Kenya has experienced since the beginning of the pandemic.

The start of the vaccine distribution was marked by a slow uptake by healthcare and other essential workers who were eligible for the vaccine: less than 1% of vaccines were administered within the first 2 weeks of their arrival.³² As a result of this lukewarm reception – but also due to the surge in infections – the second phase of Kenya’s vaccine rollout, which expanded vaccine eligibility to adults above 58 years old, was pushed up from July to the end of March. As of late April, around 650,000 vaccines have been administered. This means that only 1.24 doses are available for every 100 people, compared to a global average of 12 doses per 100 people.

There are important local factors impacting the limited vaccine availability and the slow rollout, but global institutional arrangements and political contestations are consequential as well. To begin with, in justifying the decision to reverse the PPB’s approval of Sputnik V, the Ministry of Health held that the vaccine had to be cleared by the WHO and only then by the PPB.³³ In a separate incident, the WHO’s Regional Office for Africa emphasized that the AstraZeneca vaccine “has been reviewed and found safe not only by the WHO rigorous process but also by several stringent regulatory authorities, including the United States FDA and the European regulatory authority.”³⁴ These two cases illustrate how an institutional order – where American and European institutions are ranked higher than the WHO, which is ranked higher than Kenyan regulatory authorities – help reproduce current hierarchy by legitimating the rejection of a Russian vaccine in the private sector and the use of a European vaccine provided by COVAX. It is one of the ways by which global contestations over innovation shape health politics and policies in places like Kenya.

As for “health nationalism,” export restrictions by India and the European Union resulted in the interruption in COVAX supply, which is the only source of vaccine supply in Kenya and many other countries. In addition to availability, “health nationalism” has impacted the legitimacy of vaccines as well, possibly intensifying vaccine hesitancy. This has occurred in those instances in which vaccines given to poor countries – namely, AstraZeneca and J&J – have been temporarily paused for use in several high-income donor countries. In Kenya, concerns regarding the efficacy and safety of the AstraZeneca vaccine, and suspicions surrounding the reasons for its selection, were common. While some “politicians, captains of business, government officials and even journalists” found ways to jump the queue and get vaccinated,³⁵ others have urged against the vaccine, at times employing conspiracy theories.³⁶ Why put faith in a vaccine that rich countries are refusing? As Catherine Kyobutungi, the Executive Director of the African Population and Health Research Center in Nairobi, summarizes, “Fears and suspicion about COVID-19 vaccines have not been helped by reports linking the AstraZeneca vaccine to the development of blood clots.” Kyobutungi empathetically continues, “AstraZeneca is currently the only available vaccine in Kenya.”³⁷ By pausing the use of certain vaccines, high-income countries have signaled that although they do employ stringent levels of safety requirements for vaccines approved for emergency use elsewhere, they hold even lower risk tolerance for vaccines they allow at home. For countries where there is access to a wider array of vaccines, including those that require transportation and storage facilities, this zero-tolerance is a feasible strategy. It may not be for Kenya.

The geopolitics of vaccines, then, involve a multiplicity of double-edge swords. Innovation contests have likely contributed to the development of a large number of vaccines and to their distribution as part of “vaccine diplomacy” efforts, but the same contests have also led to the reputational undermining of competing vaccines. Vaccine diplomacy, in turn, improved access to vaccines in many low-income countries, but it also restricted, in some cases, access to other vaccines. Finally, health nationalism may serve the public health interests of some populations, but it undercuts the availability of vaccines in some cases and the legitimacy of vaccines that are available in others.

Nitsan Chorev is the Harmon Family Professor of Sociology and International Studies at Brown University.

Salma Mutwafy is a graduate student in the Department of Sociology and a Predoctoral Trainee in Sociology at the Population Studies and Training Center at Brown University.

References

³¹ Sheera Frenkel, Maria Abi-Habib and Julian E. Barnes. 2021. “Russian Campaign Promotes Homegrown Vaccine and Undercuts Rivals.” New York Times, February 5. https://www.nytimes.com/2021/02/05/technology/russia-covid-vaccine-disinformation.html

³² Hassan, Saada. 2021. “Covid-19 Vaccine Rollout off to Slow Start as Hesitancy Grows.” The Standard, March 16. https://www.standardmedia.co.ke/kenya/article/2001406446/covid-19-vaccine-rollout-off-to-slow-start-as-hesitancygrows

³³ Waliaula, Beldeen, and Gloria Milimu. 2021. “Private Jab Imports Banned as the UK Blacklists Kenya.” Standard Health, April 3. https://www.standardmedia.co.ke/health/article/2001408337/private-jab-imports-banned-as-the-uk-blacklists-kenya

³⁴ Mwakisha J. March 4, 2021. “WHO Statement on the Catholic Doctors Association of Kenya Advisory on COVID-19 Vaccines and Treatment.” WHO | Regional Office for Africa.
https://www.afro.who.int/news/who-statement-catholic-doctors-association-kenya-advisory-covid-19-vaccines-and-treatment-0 (accessed April 11, 2021)

³⁵ Gathara, Patrick. 2021. “What Is Going on with Kenya’s COVID-19 Vaccine Drive?” Al Jazeera, April 3. https://www.aljazeera.com/opinions/2021/4/3/what-is-going-wrong-with-kenyas-covid-19-vaccine-drive

³⁶ Nzwili, Fredrick. 2021. “Some Kenyan Catholic Doctors Say No to Vaccine, but Bishops Push Back.” Catholic Philly. https://catholicphilly.com/2021/03/news/world-news/some-kenyan-catholic-doctors-say-no-to-vaccine-but-bishops-push-back/ (accessed April 23, 2021)

³⁷ Kyobutungi, Catherine. 2021. “Kenya’s COVID-19 Vaccine Rollout Has Got off to a Slow Start: The Gaps, and How to Fix Them.” The Conversation, April 8. https://theconversation.com/profiles/catherine-kyobutungi-259737