BERLIN — In the new frontier of vaccine diplomacy, there are two paths: stockpile or share.

The first way is unfolding in the United States — with two promising coronavirus vaccines by Pfizer and Moderna on the cusp of approval — as the Trump administration focuses on domestic distribution from private labs.

The European Union and other wealthy democracies have bought up much of what’s left of the initial doses, but they also will lend support to a World Health Organization-linked effort to eventually expand supplies to countries in need.

The other approach comes from China and Russia, which have rushed to share their own state-backed vaccines with nations scrambling for supply, positioning themselves to possibly expand their political and economic interests in the process.

The contrast goes well beyond the crisis of the pandemic, reflecting how the post-World War II world order is challenged by the rise of authoritarian powers and the retreat of the United States during the outgoing Trump administration.

“Global health and pharmaceutical interventions are getting sucked into balance-of-power politics,” said David Fidler, senior fellow for global health at the Council on Foreign Relations. “For the U.S., this creates geopolitical nightmares, because we are not in the game.”

The pandemic, he said, becomes a “force multiplier,” accelerating the waning of U.S. influence.

The ultimate outcome depends, of course, on how the vaccine race plays out.

On Monday, another group in the vaccine hunt, a collaboration between the University of Oxford and the British-Swedish pharmaceutical giant AstraZeneca, said its vaccine was up to 90 percent effective when subjects received a half-dose, followed by a full dose one month later.

Vaccines as 'bargaining chip'

Beijing and Moscow are marshaling the vast powers of their states to develop vaccines for domestic and international use, accompanied by grand claims of scientific and manufacturing prowess.

There are critical questions about safety and efficacy — or even how much each country can produce. But, for the moment, those questions are overshadowed in a seller’s market.

So far, the United States has essentially ceded the field. It has declined to join more than 170 other countries in Covax, the WHO-backed program to deliver billions of vaccine doses to less-developed nations, and has not outlined a plan for sharing doses with anyone else.

Kendall Hoyt, an assistant professor at Dartmouth’s Geisel School of Medicine, predicted that President-elect Joe Biden would find some way to engage — either by joining multilateral efforts on vaccines, forging bilateral deals, or both.

“It’s the most powerful bargaining chip there is right now,” Hoyt said.

But China is signing agreements for early vaccine access in regions where it has historically battled the United States for influence. Western pharmaceutical companies say that just meeting their existing orders from Europe and elsewhere will be a huge logistical challenge.

A recent analysis from researchers at Duke University found that high- and middle-income countries have already purchased 3.8 billion doses of promising vaccines, with options for 5 billion more. The team predicted that billions of people in developing countries could be waiting until 2024.

Creating a new vaccine can involve thousands of people over several years. Here's what it takes to produce a new FDA-approved vaccine. (The Washington Post)

The WHO-linked Covax effort is seen as an important backstop for poorer countries that would otherwise struggle to obtain vaccines. But efforts have been slow to get off the ground, with German Chancellor Angela Merkel warning at the virtual Group of 20 summit this past weekend that “the Chinese are knocking at the door” of developing nations.

“And [the Chinese] are saying that they have a vaccine they’ll make available to me now in the short term,” Fidler said. “Not later, when Covax might have something available.”

China's vaccine roadshow

China has five vaccine candidates in the final stages of trials, which have taken place in regions of strategic importance to Beijing. Testing is underway in more than a dozen countries, including Indonesia, Pakistan, Turkey, Egypt, Saudi Arabia and Brazil.

In the United Arab Emirates, where Dubai’s ruler, Sheikh Mohammed bin Rashid Maktoum, is among those to receive a vaccine, China’s Sinopharm received emergency-use approval months ago.

Beijing has offered $1 billion in loans to countries that would otherwise struggle to pay to buy its vaccine, according to the Mexican Foreign Ministry.

But perhaps the biggest advantages for Beijing could be won in Southeast Asia, where China and the United States compete for strategic and cultural influence.

China has signed agreements with Malaysia and Indonesia for priority access to the Sinovac Biotech vaccine, moving in swiftly with trials earlier this year as cases mounted in the two nations and economies faltered.

Wearing a mask stamped with the Indonesian flag, Ridwan Kamil, the governor of West Java, held his arm out for the cameras after receiving his coronavirus jab in September.

One of 1,620 volunteers to receive the Sinovac vaccine, he has raved about his experience. It’s seen as gesture of solidarity with China aimed at helping Indonesia get back on its feet as the country of 268 million people — now the worst-hit by the coronavirus in Southeast Asia — stares down a recession.

Indonesia’s food and drug agency said Thursday that Pfizer, AstraZeneca and the developers of Russia’s Sputnik V vaccine have all contacted it about the possibility of vaccine trials and partnerships with Indonesia’s pharmaceutical companies.

Sinovac, one of China’s coronavirus vaccine front-runners, published mixed findings from its two first clinical trials last week. The company reported that the vaccine generated lower levels of protective antibodies in the bloodstream compared with those arising in recovered coronavirus patients.

Beijing has said it won’t use the vaccine for diplomatic leverage. But in public remarks, Chinese officials have linked the vaccine to greater cooperation and outreach — echoing China’s foreign policy strategy, the Belt and Road Initiative, which seeks to build transport and commercial links across Asia and beyond.

As the Trump administration has stepped back from global health leadership, most notably by threatening to withdraw from the WHO, Beijing has pointedly stepped in.

Chinese President Xi Jinping in a video statement Saturday told the G-20 that China was “willing to strengthen cooperation” with other countries to accelerate vaccine development and distribution.

“We will fulfill our commitments, offer help and support to other developing countries, and work hard to make vaccines a public good that citizens of all countries can use and can afford,” he said.

There are questions about what depending on China for doses could mean for countries in Southeast Asia, particularly as they push back against Beijing’s claims in the South China Sea, for instance.

Sebastian Strangio, author of a recent book on Beijing’s relationship with Southeast Asia, said China’s vaccine strategy is part of a broader campaign to cast itself as a “helpful, understanding regional partner — and an inevitable one.”

Strangio predicted that Beijing’s use of leverage will generally be “subtle” rather than a straightforward quid pro quo, such as China’s request to the Malaysian government to release dozens of Chinese fishermen held for illegally entering Malaysia’s waters last month. The appeal came during the same meetings as negotiations on a vaccine. The men remain jailed, and a news portal, Malaysiakini, published letters from Malaysians about the case, including one saying Malaysia will not be “held to ransom” by the Chinese vaccine.

China is “going to be smart about it,” Strangio said. “It is going to be a lot of small concessions that add up over the long term.”

Russia's Sputnik gambit

Russia’s vaccine diplomacy is part of a broader push by President Vladimir Putin to reassert the country’s status as a global power. Even the name it chose for its first covid-19 vaccine — Sputnik V — evokes the 1950s Cold War space race.

Russian officials claim to have provisional orders from some 50 countries for 1.2 billion doses of Sputnik V in the next year and say they have negotiated deals with firms in South Korea, India, China, Kazakhstan and E.U.-member Hungary, led by nationalist President Viktor Orban.

Trials are underway or planned in India, the U.A.E., Brazil, Venezuela and longtime Russian ally Belarus.

The rush to roll out the vaccine before Phase 3 trials has raised questions about the safety and efficacy of the vaccine.

Sputnik V’s developers, the Gamaleya National Center of Epidemiology and Microbiology and the Russian Direct Investment Fund (RDIF), say the vaccine is 92 percent effective. A second Russian vaccine has been registered and a third is in development.

Kirill Dmitriev, head of the RDIF, declined an interview request but has portrayed criticism of Sputnik V as a Western effort to undermine the project.

The Kremlin, too, is hailing Sputnik V in its diplomatic outreach. “Nowadays, the issue appears on the agenda of Putin's discussions with all of his foreign colleagues,” Kremlin spokesman Dmitry Peskov said in a recent interview with journalists.

Russia has always tried to project soft power by emphasizing its technological achievements, said Grigory Golosov, political analyst at the European University at St. Petersburg. “This only adds one more topic to this more or less continuous flow of propaganda,” he said.

But the international push is also aimed at building support for the Russian vaccine at home, he added. An August poll in Russia by the Levada Center found that 54 percent of those surveyed would not take the vaccine even if it was free because of distrust and fear.

And then there is the question of capacity.

Speaking at an investment forum last month, Putin conceded that Russia faces problems in swiftly ramping up production because it lacks the equipment. Russia has been forced to slash its overly optimistic plans to make 30 million doses this year; it now estimates it will produce roughly 2 million.

“Russian vaccines exist. They work, and they are safe and efficient,” Putin said last Tuesday at a summit of BRICS nations — Brazil, Russia, India, China and South Africa. “The question is how to arrange the mass production.”

He told the G-20 virtual summit Saturday that vaccines must be made universally available to all countries, rich or poor, and said Russia was ready to distribute its vaccines to those who need them.

“Products for immunization need to be common public assets,” Putin told the summit. “Russia, of course, is ready to provide needy countries with vaccines developed by our scientists.”

'Strategic game going on'

The White House opted out of multilateral efforts, in part because of its ongoing feud with the WHO over the agency’s initial coronavirus response and Trump’s claims that the U.N. agency was “China-centric.”

Biden has pledged to rescind the WHO withdrawal letter but has not publicly committed to Covax or any other plan.

But the race has already started, and analysts say China and Russia are likely to take every advantage they can before a Biden administration gets into gear or private Western companies look to markets further afield.

“There’s a strategic game going on, but the U.S. is not playing,” said Yanzhong Huang, a senior fellow for global health at the Council on Foreign Relations.

Rauhala reported from Washington, Mahtani from Hong Kong and Dixon from Moscow. Eva Dou in Seoul and Ainur Rohmah in Surabaya, Indonesia, contributed to this report.