San Marino, the micronation within Italy, stokes envy with speedy Russian-supplied vaccine campaign

San Marino has administered at least one vaccine dose to 27 percent of its population. (Davide Bertuccio for The Washington Post)
San Marino has administered at least one vaccine dose to 27 percent of its population. (Davide Bertuccio for The Washington Post)

SAN MARINO — Just weeks ago, the nation of San Marino was in a panic. It stood as the lone country in Western Europe without a supply of coronavirus vaccines. Its hospital employees, still unprotected, were threatening to no longer enter covid wards. One parliamentarian called the situation “dangerous.” Another said the long wait for vaccines was costing “human lives every day.”

San Marino’s solution, the country’s leaders now say, was driven by that moment of alarm. Seeking emergency help, it turned to Russia — and Russia swiftly obliged. An initial batch of Sputnik V doses was soon on the way, escorted by police. Health-care workers received the first jabs. San Marino now expects to cover its entire adult population of 29,000 by the end of May.

“We simply made a choice out of necessity,” San Marino’s foreign minister, Luca Beccari, said in an interview.

But in easing its own vaccine crisis, this hilltop micronation — which is not a member of the European Union — has become a foil for a much larger crisis playing out beyond its borders. While San Marino has raced ahead with a vaccine not authorized by the E.U., Italy and much of the rest of Europe have moved at a crawl, with a problem-plagued inoculation drive that has prioritized equitable access across the bloc’s members but prolonged the period of lockdowns, economic suffering and apprehension.

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San Marino initially expected to rely on Italy for its vaccine supply, but it has had to turn to Russia. (Davide Bertuccio for The Washington Post)

In the shuttered “red zone” Italian regions that surround San Marino, the tiny republic has suddenly become the example of a go-it-alone approach, with implications for both geopolitics and local jealousies. Some politicians — as well as mayors of towns near San Marino — say Italy, too, should be considering the state-made Russian vaccines. Meanwhile, hundreds of anxious Italians have attempted in vain to book appointments in San Marino for Sputnik V. Some have tried to enter false San Marino ID numbers in an online system.

“Almost everybody asks me, ‘Can I get it, too?’” said Bruno Frisoni, 76, a San Marino resident. “I tell them it’s not possible.”

[Europe is confronting a third wave some say it could have avoided]

For the moment, then, San Marino’s vaccine strategy has created a strange alternate bubble in the Italian countryside, where one’s fortune in the pandemic hinges on national identity.

On both sides of the barely noticeable border between San Marino and Italy, people speak the same language, eat the same stuffed pastas, use the same currency. People from both sides cross to the other for work. The economies are deeply connected, too: In normal times, tourists break away from the Italian Adriatic beaches for day trips to San Marino, whose territory is a mix of medieval fortresses, perfume shops and duty-free electronics stores.

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TOP: The beach of Riccione, Italy, is about 10 miles from landlocked San Marino.
BOTTOM LEFT: A cable car carries people to San Marino's historic center, near the top of Monte Titano.
BOTTOM RIGHT: Most shops remain closed in San Marino because of coronavirus restrictions and the drop-off in visitors. But, unlike Italy, the nation has allowed restaurants to stay open for lunch. (Davide Bertuccio for The Washington Post)

But now, deep into the pandemic, there is a critical difference, even as the virus again surges on both sides of the border. San Marino has administered at least one dose to 27 percent of its people, and could eventually emerge as a protected enclave while other parts of the continent are still fighting the worst of the virus. In Italy, where 12 percent of people have received at least one dose, many young people will be waiting long into the summer or autumn for their jabs, a delay amplified by questions about the safety of the Oxford-AstraZeneca vaccine. The E.U., which acquires and authorizes vaccines on behalf of its members, is reviewing Russia’s Sputnik V, but the process is likely to take months.

“I applaud San Marino,” said Domenica Spinelli, the mayor of Coriano, a town 10 miles away. “They found the Plan B that Europe doesn’t have.”

A vaccine ‘like vodka’

Even before the vaccine doses arrived, San Marino had been something of a pandemic aberration. With the state’s coffers empty, unable to offer subsidies to shuttered businesses, San Marino was often reluctant to follow Italy into hard lockdowns. When Italy last autumn required restaurants to close at 6 p.m., San Marino’s stayed open until midnight; now the Italian ones are shuttered all day; San Marino’s still serve lunch.

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People sit outside a bar in San Marino. Italy has extended its lockdown through April. (Davide Bertuccio for The Washington Post)

Still, it had been San Marino’s intent — at least initially — to rely entirely on Italy for its vaccines. In January, it signed a deal in which Rome agreed to redirect one of every 1,700 Europe-supplied doses. That seemed to ensure San Marino would vaccinate at whatever pace the E.U. would. The agreement, though, required not just a sign-off from Italy, but also from Brussels and the vaccine providers. Paperwork delayed the arrangement by nearly two months.

“Once the delays began, we found ourselves dealing with a very strong protest from the citizens,” said Health Minister Roberto Ciavatta. “We needed to offer solutions.”

San Marino considered options aside from Sputnik V. But Chinese-made vaccines had no peer-reviewed studies showing how well they worked. India’s, too, felt like a “leap into the dark,” Ciavatta said. Sputnik V had an advantage for several reasons: A Lancet medical journal paper showed the vaccine was 91.6 percent effective in preventing symptoms of covid-19 and fully effective in stopping severe cases, giving it nearly the efficacy of those produced by Moderna and Pfizer. Plus, it was relatively cheap — at roughly $10 per dose. Its design — an adenovirus vector — made it similar to vaccines from AstraZeneca and Johnson & Johnson.

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The office of Health Minister Roberto Ciavatta is inside San Marino's only hospital. (Davide Bertuccio for The Washington Post)

Because San Marino has no drug regulator equivalent to the U.S. Food and Drug Administration or the European Medicines Agency, it simply put the question about Sputnik V’s use to a small bioethical committee.

The members gave Sputnik V the green light.

[How Russian biotech trampled protocols — and challenged the West — in race for Sputnik V vaccine]

The rollout of the doses — with a Russian TV documenting one early day in the campaign — made San Marino a pandemic outlier in a new way: It has become the lone Western European county to authorize Sputnik V.

Though more than 50 countries around the world are now issuing Sputnik V jabs, the other users in Europe are closer to Russia’s geographic sphere — Serbia and Moldova, for example. Among E.U. members, Hungary is the only one to have authorized use. Slovakia and the Czech Republic have also broken away from the E.U.'s unified purchasing arrangement and acquired Sputnik V for their populations; Austria is considering a similar step. Some other Western European countries, including Germany and Italy, have said they would be happy to use Sputnik V, but with the caveat that it first should be approved by the E.U.’s regulator.

Sputnik V’s production capacity is small enough that countries would have to set up their own manufacturing hubs to use the vaccine on a mass scale. For now, Russia seems to be best off sending doses to countries like San Marino, where it can make a big splash with even a small quantity of the product. Russia initially provided 15,000 doses — enough to cover 7,500 people — but San Marino officials say they will probably soon ask for more.

Igor Pellicciari, a professor at the University of Urbino in Italy, who is also a San Marino ambassador and consulted on the Sputnik V deal, said Moscow is deploying the vaccine “as a soft power tool,” using exports to expand its influence, including in places where it is viewed warily or under sanctions.

“Like vodka in the 1970s,” he said. “This is the strongest asset Russia has.”

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TOP: Almost all the intensive care beds are occupied in the San Marino hospital, though officials say that without vaccinations, the situation would be much worse.
BOTTOM LEFT: Sputnik V vaccine supplies are unpacked on the ground floor of the hospital.
BOTTOM RIGHT: Igor Pellicciari, a professor of international relations, consulted on the Sputnik V deal. “Like vodka in the 1970s,” he said. “This is the strongest asset Russia has.” (Davide Bertuccio for The Washington Post)

Hoping for the pandemic’s end

San Marino’s top health official, Agostino Ceccarini, says the vaccine is clearly working. Nobody among the more than 7,000 who have received it has ended up with a grave form of covid-19. Though the country is now also receiving a trickle of Pfizer doses from its agreement with Italy, Sputnik V accounts for 85 percent of San Marino’s administered shots.

Ceccarini says the Russian doses have kept the nation’s single hospital from “exploding,” because they have protected the older population at a time when a severe third wave, driven by a more transmissible and likely deadlier British variant, has caused more dire cases among the young.

[As Europe’s vaccination efforts falter, Russia and China are now seen as options]

Despite its vaccination campaign, San Marino’s situation remains critical. The country’s death rate, though similar to northern Italian regions, is technically the highest of any nation in the world, according to Johns Hopkins University. Ten people have died in San Marino over the past month, bringing the overall toll to 84 — deaths that mostly come in a crammed ICU on the hospital’s fourth floor.

On the ground level, nurses unpack the day’s Sputnik V doses.

“Let’s hope this can bring the pandemic to an end,” said patient Anna Maria Toccaceli, 75, minutes after receiving her second dose.

“We were lucky,” said Daniele Ceccoli, 74, another patient who received a jab. “This virus, it’s still something very explosive."

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Daniele Ceccoli, 74, was grateful and optimistic after getting vaccinated at the hospital in San Marino. (Davide Bertuccio for The Washington Post)

Just beyond San Marino’s borders, the same pressures are at play, and hospitalizations are at the highest point during the pandemic. The difference in Italy is the sense that an endpoint still feels out of reach.

At a hotel that he owns 10 miles from the border, Italian Gianmaria Castaldo said people were losing much of the hope that surged with the beginning of Europe’s vaccination campaign in December. Few have gotten shots, he said, and “everybody I know is infected” — including himself. Castaldo was speaking over the phone, still in isolation after recovering from symptoms.

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Hotel owner Gianmaria Castaldo, 30, said Italians have been losing hope. (Davide Bertuccio for The Washington Post)

He said he looked at San Marino with a bit of envy. He worried that the slow pace of vaccinations in Italy was endangering the tourist season. He said his hotel couldn’t survive another year like the last one — when he earned a quarter of the usual income. He said he worried, above all, about his father, Vittorio, a 59-year-old with whom he shares the business, which also includes three other properties. Vittorio has a lung condition and yet has been traveling to the other hotel sites across northern Italy, with no vaccine appointment in sight.

Castaldo said he didn’t really care what vaccine he or his father got, so long as it came quickly.

“If the solution is a Russian vaccine, let’s just take it,” he said.

Chico Harlan is The Washington Post's Rome bureau chief. Previously, he was The Post’s East Asia bureau chief, covering the natural and nuclear disasters in Japan and a leadership change in North Korea. He has also been a member of The Post's financial and national enterprise teams.
Stefano Pitrelli is a reporter in the Rome bureau for The Washington Post.