The Trump administration’s “Operation Warp Speed” involved funneling $18 billion into research for major vaccine candidates. In return, America has received hundreds of millions of doses of vaccines approved after clinical trials. But the country has refused to share vaccines with others and has stayed clear of global efforts to make shots affordable. The argument? America first. President-elect Joe Biden and his team have not yet declared whether they’ll continue with that approach.

2. China and Russia Will

The Trump administration’s logic has left a giant void that Beijing and Moscow have rushed to fill. China has committed loans worth $1 billion to Latin American and Caribbean nations to buy its vaccines, and multiple African nations are in the hunt as well. Meanwhile, Russia has struck deals with Brazil, Mexico, India and Saudi Arabia to supply them with its controversial vaccine, Sputnik V, which it approved even before phase three clinical trials were complete. So far, cutting corners hasn’t hurt Moscow or Beijing — which also approved its vaccines without complete tests — and no major adverse effects have been reported yet.

3. WHO Wants to

… be a millionaire? No, something even more precious at the moment: to be immune from COVID-19. The World Health Organization is leading the world’s largest-ever collaborative vaccine project — COVAX — that aims to provide at least 2 billion affordable COVID-19 vaccines to the developing world by the end of 2021. The European Union has pitched in with more than $600 million in funding, and China — after initially sitting out — has also joined the effort. The WHO’s efforts could determine how soon the world reaches herd immunity, the point at which further spread of the disease becomes minimal.

4. India as Well

Prime Minister Narendra Modi promised the United Nations in September that India, the world’s largest manufacturer of vaccines, would ensure vaccines were made available to the rest of the world. India has also joined with South Africa to try to convince the World Trade Organization that COVID-19 vaccines be exempt from rigid intellectual property regulations so they’re more affordable. But at the moment, India is behind Russia and China in the race. It’s unclear when New Delhi will be in a position to export vaccines.

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1. Expand Influence

At a moment when COVID-19 threatens to shadow the global economy and test public health systems around the world for at least several more months, there’s no better way to gain influence than by offering subsidized vaccines to smaller friends. In fact, some experts argue that reversing Trump’s approach and diving into vaccine diplomacy should be the incoming Biden administration’s first foreign policy priority if it wants to rebuild America’s standing.

2. Market Access

The global vaccine market — for all diseases — is expected to be worth $57 billion by 2025, driven for the most part by the demand for COVID-19 immunization. And like any other industry, early market access can give those that get in the door an advantage. Once countries are used to and trust Chinese or Russian vaccines, their American or Indian counterparts would need to offer cheaper shots or other sweeteners to compete.

3. Image Fixing

China’s relationships with the world suffered in 2020. First, it was opaque about the origins and initial spread of the coronavirus. Then, while the world battled the crisis, it used trade and military threats to pressure multiple neighbors. But it’s counting on its vaccine outreach to rebuild its image in different parts of the world, an opportunity made possible by the absence of a rival American effort.

4. Testing Labs

There’s one final — but critical — reason why vaccine diplomacy is useful. China, for instance, managed to contain the virus after its initial spread. By the time its vaccines were ready, it had almost no active cases of COVID-19, which meant that it couldn’t test the vaccines on its own population. That’s where diplomacy came to its aid. China has promised preferential access to its vaccines for nations that conduct phase three trials on their populations instead. From Brazil to Bahrain, Mexico to Morocco, and Peru to Pakistan, multiple nations have signed up.

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1. Halal Only

Yet even astute vaccine diplomacy can run up against surprising challenges. Indonesia has bought 3 million doses of China’s Sinovac vaccine but is waiting for halal certification from its top body of Muslim clerics before launching the inoculation program. There’s history here. In 2018, Muslim clerics announced a fatwa against a measles and rubella (MR) vaccine, calling it haram (forbidden in Islam). They later reversed their decision, but by then only 8 percent of children in remote Aceh province, which follows Sharia law, had taken the MR vaccine, compared to 70 percent nationally. Indonesia can’t afford a repeat with COVID-19.

2. Middle East Divide

By the start of last week, Israel had inoculated 14 percent of its 10 million citizens. The 1.4 million Israelis already vaccinated outnumber those who’ve received jabs in Germany, France, Russia, Spain, Italy and Canada combined. Yet, Israel has been slow to share vaccines with Palestinians in Gaza and the West Bank. Though the regions are formally governed by Palestinians, they’re either landlocked or blockaded, and so need Israel’s assistance to receive critical medical supplies. “ Israel’s vaccination capacity — if it were to be extended to Palestinians in the West Bank and Gaza — would provide [Prime Minister Benjamin] Netanyahu with a unique opportunity to thaw hostility and garner sympathy domestically, as well as across the region and the wider world,” Mukhtar Karim, CEO of humanitarian charity Lady Fatemah Trust, which is active in Gaza, tells OZY.

3. Vaccine Politics

More than 200,000 Brazilians have lost their lives to the pandemic. But President Jair Bolsonaro — who has consistently downplayed the virus, even though he was infected himself — has tried to block the approval of a Chinese vaccine that São Paulo’s governor, João Doria, has been advocating for. Doria, a traditional right-wing politician, is expected to challenge Bolsonaro in the 2022 presidential election. Critics accuse Bolsonaro of trying to prevent Doria from emerging as a savior before that vote.

4. Troubled History

When South Africa launched clinical trials for a COVID-19 vaccine candidate in July, activists hit the streets arguing that Africans were being used as guinea pigs. Indeed, pharma giants have a spotty history on the continent. After a trial in Nigeria in 1996 on 200 patients, 11 children died of meningitis, sparking a legal battle and inspiring John le Carré’s novel The Constant Gardener. Will African societies be able to overcome their understandable cynicism to embrace COVID-19 vaccines? What the world’s second most populous continent does could be critical to efforts to get close to herd immunity globally.

1. Heidi Larson

She needs to check her schedule before confirming lunch with the king of Belgium. The 63-year-old London-based anthropologist is the founder of the Vaccine Confidence Project, the scientific community’s most prominent initiative to track and battle anti-vaccine sentiments around the world. And in 2021, she has her hands full. Larson’s team carries out the largest global surveys of confidence levels in vaccines. Yet Larson’s message to Big Pharma and world leaders — multiple governments, from India to Rwanda, seek advice — is simple: Social media misinformation only feeds off a lack of trust in traditional institutions, so fix that first.

2. Roberto Burioni

With just a few seconds left in a 2016 TV debate against popular anti-vaxxers, the Italian virologist with a salt-and-pepper mane was blunt: “The Earth is round, gasoline is flammable, and vaccines are safe and effective. All the rest are dangerous lies.” That moment turned Burioni, who only got onto social media in 2015, into a leading public figure contesting vaccine skepticism. Today, he’s followed by more than 740,000 people on Facebook, where he debunks myths about vaccines with a cocktail of wit and science.

3. Tedros Adhanom Ghebreyesus

Trump has accused Adhanom of turning the World Health Organization into China’s “puppet,” while Secretary of State Mike Pompeo has gone personal, accusing him of being “bought” by Beijing. Dismissing those unsubstantiated slights, the Ethiopian chief of the WHO is leading the COVAX effort to get affordable vaccines to developing nations. And this month, he has shed any perceived softness toward China, criticizing Beijing after it initially blocked access to Wuhan — the birthplace of the virus — for a WHO team.

Like the WHO chief, Gates is the victim of multiple conspiracy theories. But the Bill & Melinda Gates Foundation has for the past two decades been the driver of a global alliance of nations, researchers and pharma firms called Gavi that has been responsible for getting affordable shots to millions of people in some of the world’s poorest nations. Now Gates and his foundation are partnering with WHO on COVAX.

5. Adar Poonawalla

Without his Serum Institute of India, the world’s largest manufacturer of vaccines, all the science in the world won’t save us. Five major pharma firms, including AstraZeneca, are counting on the Serum Institute for their vaccine supplies. So when Poonawalla speaks, the world listens. Like when he cautioned in September that there might not be enough COVID-19 vaccine doses for everyone until 2024. Or when he warned last week that India might not be able to export vaccines anytime soon.

The Pfizer, Moderna and AstraZeneca COVID-19 vaccines need to be delivered in two shots to ensure peak immunity. So, amid a shortage of doses, Germany, Denmark and the U.K. are preparing to delay second jabs. But what if a single dose could release half the vaccine at a later, preprogrammed date? That’s the technology Becraft is pioneering. It could cut by half the number of vaccine doses the world needs and help get the vaccine to poorer nations that risk being left behind.

You may remember reading about Edward Jenner in school. But he was more than just the creator of the modern world’s first vaccine, for smallpox. The British scientist used his vaccine to build bridges with France in a period of constant war between the two nations at the start of the 19th century. Jenner also helped spread the vaccine in Russia, Turkey and Spain, and among Native American communities in Mexico, Canada and the U.S. Yes, vaccine diplomacy is as old as vaccines themselves.

2. What Cold War?

They were threatening each other with nuclear weapons and publicly waging ideological battles. But behind the scenes — or the Iron Curtain, rather — the U.S. and the Soviet Union decided to temporarily set their differences aside and coordinate on the polio vaccine as the disease ran rampant. American Jonas Salk had developed a vaccine, but the rush to release it to the public led to 260 cases of polio from an accidentally distributed vaccine that carried the active virus. By the time a more sophisticated vaccine developed by Albert Sabin was ready in the mid-1950s, there was little appetite for large-scale clinical trials in America. That’s when a team of visiting Russian scientists met Sabin, and they agreed to collaborate. The vaccine was trialed on 10 million Russian children, and once it proved successful and safe, was adopted back in the U.S.

3. Days of Peace

There’s not much that the Taliban, more-liberal Afghans, the U.N. and others in the international community agree on. But even at the peak of the Taliban’s rule and the years of civil war in Afghanistan, the different factions agreed to tiny windows of peace each year starting in 1993. Called Days of Tranquility, these were meant specifically to allow health workers to carry out mass inoculation campaigns that were otherwise impossible amid constant conflict. It’s a practice that has continued even after the Taliban was ousted from power.