Preface

On October 7, 2021, United Nations secretary general António Guterres published an article titled “The Road to Global Vaccine Equality,” in which he pushes for a global vaccination plan to achieve global immunization. ¹ On October 30, 2021, Chinese president Xi Jinping proposed a global vaccine cooperation initiative in a speech at the 16th G20 Leaders’ Summit.² The success of vaccine cooperation at present rests on adhering to the ethics of global health cooperation with a true spirit of solidarity (守望相助) and collaboration (团结协作), so as to increase vaccination rates and quickly build up population immunity while ensuring freedom and equality. This article will look back on the most successful global vaccine cooperation to date—the global smallpox eradication program—and review the ethical dilemmas encountered and the measures taken to solve them, in the hope that relevant lessons from the past may help promote global vaccine cooperation today and build a global community of health for all.

1 Global Smallpox Eradication Program

Smallpox is a severe infectious disease that plagued humanity for more than 3,000 years. According to incomplete statistics, smallpox caused 300 million deaths in the twentieth century alone. Coordinated by the World Health Organization (WHO) and led by major powers such as the United States and the Soviet Union, a smallpox eradication campaign was carried out between the 1950s and the 1980s, which involved tens of thousands of healthcare workers from around the world and saw vaccine cooperation on a global scale. With the concerted effort of all parties, 500 million vaccinations were given in about 10 years at a cost of over $300 million, leading to the successful eradication of smallpox. The campaign has thus saved countless lives and prevented an annual loss of nearly $1 billion worldwide. On May 8, 1980, the 33rd World Health Assembly officially declared: “The world and all its peoples have won freedom from smallpox.” ³

As early as 1948, at the first World Health Assembly, smallpox was listed as a key public health issue. In 1953, Brock Chisholm, the then director general of the WHO, proposed a worldwide smallpox eradication initiative, but the United States, Britain, France, and a number of other countries objected on various grounds, from funding to technological feasibility. Soon after the Soviet Union had rejoined the WHO, Viktor Zhdanov, the Soviet deputy health minister, put forward a resolution at the 11th World Health Assembly in 1958 urging the global eradication of smallpox, ⁴ with vaccines pledged by the Soviet Union. The resolution was passed unanimously, and the WHO formally set up the Smallpox Eradication Program (SEP) the following year. However, over the next seven years, the SEP stagnated due to a lack of funding and staffing, which would remain unaddressed until 1965. In 1967, finally supplied with sufficient funds and personnel, the WHO began to intensify its effort at global smallpox eradication. Over the following decade, the SEP was rolled out in dozens of countries on three continents across the northern and southern hemispheres, from Brazil in South America and the western Sahara Desert in Africa to the Indian subcontinent and the Indonesian archipelago in Asia. Although conflicts of interest between the various parties led to many twists and turns during the process, the public health ethos of solidarity and cooperation ultimately prevailed. With the active leadership and assistance of the WHO, the United States, and the Soviet Union, different countries, peoples, communities, families, and international organizations joined forces for the common good. In less than three decades, the stubborn disease that had plagued humanity for more than 3,000 years was completely eradicated, which significantly improved the health and living conditions in developing countries, especially for vulnerable people afflicted by malaria. During this period, China made great contributions to the global smallpox eradication effort. A country at the forefront of smallpox elimination, China had launched a nationwide vaccination campaign in 1950, long before the SEP was proposed. By the end of 1952, the national vaccination rate had reached 88 percent, and the last smallpox patient was discharged in 1961. However, it was only in December 1979 that the WHO finally certified China’s smallpox eradication, as the country’s seat in the WHO was not restored until 1972 and as the certification was a lengthy process, China had to wait until December 1979 to finally obtain WHO certification, which can be considered the “final flourish” of the SEP. After China returned to the WHO, moreover, it increased its financial support for the organization, contributing almost the same amount as did a Western developed country. It also actively assisted other developing countries in smallpox eradication. For example, China strengthened vaccination cooperation with countries like Myanmar, Laos, and Vietnam, creating a 4,061 kilometer-long smallpox immunity belt along its borders. Chinese medical aid teams helped local countries with the prevention and treatment of smallpox and other serious infectious diseases, raising public awareness of epidemic prevention.⁵

Looking back on the history of smallpox eradication, we can see how factors such as the international political environment, institutional environment, and culture and customs have jeopardized adherence to ethical principles in health cooperation—solidarity, collaboration, and proportionality between equality, freedom, and efficacy—and seriously hindered progress on vaccine cooperation. In order to overcome these tensions, politicians, medical and public health experts, and community health workers engaged in coordination and mediation at different levels. From these efforts, many solutions to ethical conflicts still have important significance for vaccine cooperation today.

2 Ethical Issues in the Smallpox Eradication Program

2.1 U.S.-Soviet rivalry jeopardized solidarity among countries.

Solidarity is an ethical underpinning of global health cooperation. It is based on the fundamental concept of “standing up beside” and involves “standing up for” (aiming to support and help others), “standing up with” (acting in concert with others to improve the situation of the victims), and “standing up as” (putting oneself in the shoes of another party). In essence, it means standing with the victims and bearing some costs for the greater collective benefit.⁶ However, the evolution of the world order, changes in the relations between major powers, and the international balance of power directly influence the degree to which the ethical value of solidarity is realized. In particular, superpowers’ opposing national interests and ideologies often lead to “competition over the route to take” (路线竞争) or even “confrontation over the route to take” (路线对立) in global health cooperation. The mutual distrust between superpowers, coupled with their narrow views of international power and neglect of the interests of developing countries, makes it difficult for them to consider the interests of humanity as a whole and actively provide global public goods for health, which jeopardizes global health cooperation. Despite being the most successful case of global health cooperation to date, the SEP did not escape the impact of rivalry and collision between the United States and the Soviet Union during the Cold War, their struggle for hegemony shaping the course of the program throughout. In the early stage of cooperation, the United States and the Soviet Union went through periods of tension and détente, but the tension was rising, especially in the realm of ideological rivalry. The Soviet Union believed that the United States had initiated a malaria eradication program to benefit the capitalists behind multinational chemical and pharmaceutical companies and to expand its influence in the third world. In contrast, the United States believed that the Soviet Union’s proposal of smallpox eradication was mainly motivated by a desire to spread the “Soviet approach” to smallpox across the world and enhance the global influence and standing of the Soviet bloc.⁷ In the smallpox eradication proposal that Zhdanov submitted to the WHO in 1958, he particularly emphasized the successful practice of eliminating smallpox through compulsory vaccination in the Soviet Union and suggested that a five-year plan should be formulated for the compulsory vaccination of all humans (excepting the population of a few countries and regions). In order to demonstrate their resolve, the Soviet Union and its ally Cuba promised to provide 25 million and 2 million doses, respectively, of freeze-dried vaccines each year.⁸ Although the United States remained silent on the Soviet Union’s effort to expand its influence, it believed that if the Soviet Union was genuinely interested in global health, it should participate in the U.S. malaria eradication program. From the mid-1960s, the tension between the two superpowers eased, and the United States gradually adopted a strategy of “peaceful evolution” and competed globally with the Soviet Union in the realm of soft power, such as political systems and ideologies. To a certain extent, the entry of the United States into the SEP in 1965 was the result of competition and opposition in soft power: U.S. officials believed that joining the program and working with the Soviet Union on smallpox eradication would help showcase U.S. soft power and “enlist the Soviets to assist in their own demise.”⁹ On the ground, the ideological rivalry between the two powers featured prominently in the vetting of the officials in charge of the SEP, the appointment process, and the finalization of the wording in the documents. Against the backdrop of the U.S.-Soviet struggle for hegemony, malaria-plagued countries in the third world became an arena for competition over national interests, political systems, and ideological lines between the superpowers, which directly hindered the SEP from truly standing up beside malaria-afflicted countries and providing tailor-made support.

2.2 Ethical controversies about disease eradication hampered unity and collaboration.

Unity and collaboration is an important ethical value that brings together various actors in global health cooperation. Public health requires wide-ranging, multilevel, and multidimensional collaboration among different actors such as states, international organizations, nongovernmental organizations, and communities.¹⁰ However, disputes among different actors, or even within the same actor, about which public health issues should take precedence and how best to solve them often hamper unity and collaboration. Although the SEP is generally seen as a major achievement of the WHO, the actual implementation of the program encountered opposition from all levels of the organization. This mainly ensued from the controversial nature of the eradication campaign—that is, whether eradication was the best way to deal with infectious diseases. Many experts—including Marcolino Candau, the second director general of the WHO—had objected to the SEP, arguing that it would be impractical to vaccinate everyone in the world against smallpox. Others saw the program as utopian and cautioned that the program would result in a series of unpredictable biological, political, economic, and social consequences. Still others argued that eradication meant replacing prevention and vigilance with indifference and trust. ¹¹ Since the inception of the WHO, furthermore, two models of health intervention—horizontal and vertical—had been in competition with each other. The “horizontal” approach to international health assistance focused on helping developing countries establish and improve basic healthcare services that were sensitive to the local economic, social, and cultural contexts. The “vertical” approach, on the other hand, targeted specific health problems for elimination. Some WHO officials believed that vertical interventions such as the SEP put too much emphasis on quantifiable results, leading to inadequate development of horizontal projects and insufficient progress in systemic medical reform in developing countries. Therefore, when the members of the World Health Assembly unanimously voted to make the global eradication of smallpox a “main objective” in 1965, senior WHO officials who supported the horizontal approach were quite dissatisfied.¹² Candau and the member states engaged in negotiations over the implementation of the SEP, and WHO officials in the regional offices were even more skeptical, seeing the program as secondary or contrary to the goals of horizontal health interventions. Just two months after the official launch of the SEP, two of Candau’s top deputies drafted a memorandum to the regions, noting that “the establishment of permanent basic health services should be given the highest priority since it is a prerequisite for the success of the smallpox eradication programme in any area.”

2.3 Compulsory vaccination jeopardizes the principle of proportionality

Efficacy, freedom, and equality are the most fundamental ethical values in health cooperation, and how to ensure their proportionality is a particular point of difficulty. ¹³ In order to push ahead with the SEP, many regions tried to resolve vaccine hesitancy with compulsory or coercive measures, which caused a conflict between an individual’s right to equality and freedom and the pursuit of efficacy in the form of vaccination rates, giving rise to human rights disputes. The root of vaccine hesitation could often be found in local cultures and customs, especially in the case of South Asian countries such as India. Owing to the influence of colonial politics and culture, as early as the beginning of the 19th century, some Indians associated vaccination—which they saw as a prelude to a capitation tax—with repressive colonial policies.¹⁴ In addition, the pursuit of bodily purity, worship of cows, veneration of the goddess of smallpox (Sītalāmata), and deep belief in fatalism in Hinduism led to strong opposition to vaccination among groups such as Brahmans. Mahatma Gandhi even condemned vaccination as “sacrilege” and “a filthy remedy” in 1913.¹⁵ As a result, the SEP encountered significant resistance in India, with some Indians demonizing the vaccination teams as “robbers.” In implementing the SEP, the Indian project team exerted various forms of pressure on individuals who resisted vaccination: insistent verbal persuasion; social and legal pressure; door-to-door search, surveillance, and containment; and in extreme cases, forced inoculation with the help of the military. A WHO vaccinator acknowledged that in India, “women and children were often pulled out from under beds, from behind doors, from within latrines … When they locked their doors, we broke down their doors and vaccinated them.” Compulsory vaccination in the implementation of the SEP has raised doubts about whether a disease eradication campaign is democratic and sparked debate on the suppression of individual rights in the name of collective well-being.¹⁶

3 The Resolution of Ethical Issues in the Smallpox Eradication Program

3.1 A scientific and professional consensus achieved in the professional communities

Although the U.S.-Soviet struggle for hegemony jeopardized the ethical principle of solidarity in public health cooperation, health experts and epidemiologists reached a professional consensus on the global eradication of smallpox despite conflicting national interests and ideologies. They then brought the consensus into policy formulation, laying the scientific foundation for solidarity. This consensus was twofold. First, smallpox was the only disease that could be eradicated globally at the time. Epidemiologically speaking, smallpox was easier to control compared with other infectious diseases such as malaria, yellow fever, polio, and tuberculosis. For example, as smallpox transmission did not require an animal vector, eliminating smallpox would not require too much intervention in the ecosystem. Moreover, the symptoms of smallpox were obvious, and the vaccine was more effective, with milder side effects. When the U.S.-led malaria eradication program failed in the 1960s, therefore, U.S. health experts gradually turned their attention to smallpox. From 1962, a number of them wrote to James Watt, director of the Office of International Health at the United States Public Health Service, stating that smallpox was the only global infectious disease that could be eradicated at the time. Since most U.S. health officials had professional medical backgrounds, they quickly reached a consensus with the health experts. The consensus soon had a direct influence on the U.S. president Lyndon Baines Johnson: smallpox eradication, as the experts had suggested, would not only be less expensive and less controversial, but would also improve the international image of the United States. As a result, toward the end of the 1960s, the United States finally abandoned its malaria eradication program, with policymakers reaching a consensus on smallpox eradication. Second, although the United States and the Soviet Union competed for hegemony and each tried to demonstrate their ideological superiority, the two countries reached a high degree of “modernist” or “scientific” consensus in relation to the developing countries—that is, both advocated overcoming nature and backwardness with science. The technocratic elites and mid-level health officials of the United States and the Soviet Union unanimously believed in modern medical and technological means and hoped to apply them to the third world. Such a consensus usually arose from the bottom up, first forming among mid-level professionals and then gradually influencing the upper ranks. As relations between the major powers changed, when top officials signaled an intention to cooperate, mid-level professional personnel put it into effect. Such professionals’ shared backgrounds in science, technical capabilities, and funding guaranteed by their organizations allowed their opinions to transcend geopolitical and ideological disagreements. Even though the Cold War intensified and the rift widened between the top politicians of the United States and the Soviet Union, professional health officials and workers were still able to cooperate closely in the interests of developing countries and jointly formulate scientific solutions to malaria [sic].

3.2 A consensus on health cooperation reached between leading countries and developing countries

Although within the WHO there were differing views on the ethics and feasibility of the SEP, both the leading superpowers—the United States and the Soviet Union—and a large number of emerging independent countries agreed on smallpox eradication, collaborating with one another to provide concrete support for the program. The United States and the Soviet Union strongly backed the SEP. Playing a leading role, the Soviet Union kept its pledge at the 1958 World Health Assembly to supply 25 million vaccine doses per year, donating a total of 1.4 billion doses between 1958 and 1979, along with over 290 million doses to the WHO Voluntary Fund for Health Promotion, the Special Account for Smallpox Eradication, between 1967 and 1984. The United States was the main source of funding and provided nearly one third of the project’s $98 million cost, while also supplying 190 million vaccine doses. It sent Donald A. Henderson, director of the Epidemic Surveillance Section of the Communicable Disease Center (CDC), to the WHO to head the SEP from 1967 to 1977, to whose success he contributed enormously. On the other hand, during the 1950s and 1960s, emerging independent countries looked forward to opportunities to receive international aid and improve their citizens’ living conditions, thereby consolidating their nascent regimes. After the Soviet Union proposed the SEP, therefore, it won the support of many developing countries suffering from smallpox. In May 1965, with the backing of developing countries, the World Health Assembly finally listed the global eradication of smallpox as a main objective of the WHO. More and more countries rushed to join the SEP following specific pledges made by the United States. For example, having heard about the U.S. commitment at the World Health Assembly in 1965, the health minister of Upper Volta (now Burkina Faso) in West Africa contacted the United States Agency for International Development (USAID) while visiting Washington and expressed a strong desire to join the SEP. Johnson’s announcement of U.S. support for the SEP ignited the enthusiasm of many developing countries and contributed to a consensus among high-level politicians in favor of smallpox eradication. In 1966, when director general Candau submitted an “excessive” SEP budget for the next year, some developed countries complained, but the overwhelming support from developing countries helped it pass with just a few votes over the required two-thirds majority—the narrowest margin on a budget vote in WHO history.¹⁷

3.3 Engaging with local cultures to improve how vaccination was presented

To balance efficacy with freedom and equality, and to solve the problem of vaccine hesitancy in the implementation of the SEP, the WHO—working together with local health officials, experts, and workers—pushed for legislation that would make elements of the SEP official health standards. At the same time, to compete with the traditional methods of dealing with smallpox, vaccinators took local customs and beliefs into account and came up with new ways to present vaccinations. In West Africa, for example, SEP personnel had to work with priests of the local smallpox deity (Sopona) to promote vaccination. In India, vaccinators studied the goddess of smallpox and various rituals related to her worship, cooperated with local priests, and even made up appropriate morality tales, such as one titled “A Variolator Gives Up His Profession and Encourages His Son to Become a Vaccinator.”¹⁸ Despite conflicts and resistance due to ethical reasons, overall, there was no large-scale opposition—no doubt thanks also to the WHO’s extensive use of local staff. According to statistics, more than 150,000 SEP field workers were drawn from the local populations. Their familiarity with and understanding of the local environments, cultures, and customs greatly reduced the amount of ethical friction arising from local conditions. On the whole, proportionality was achieved between efficacy, freedom, and equality.

4 Lessons for Vaccine Cooperation Today

4.1 Emphasize exchanges and cooperation among health experts, achieve professional consensus, and raise awareness that humanity shares a common destiny.

Global health cooperation is profoundly affected by the international political situation, just as the trajectory of the SEP mirrored the evolution of U.S.-Soviet relations during the Cold War. Today, with major changes unseen in a century, the world is accelerating into a period of turmoil and transformation, and the balance of power in the world order is changing rapidly along the existing trends.¹⁹ In global health, the Covid-19 pandemic has yet to subside, and monkeypox—caused by a virus that belongs to the same Orthopoxvirus genus as the smallpox virus—has reared its head. Global health security and biosecurity are facing severe challenges, and yet an effective mechanism for global health governance and coordination is absent. Global health has fallen into the “Kindleberger Trap,” a situation in which the dominant power is unwilling or unable to assume the responsibilities associated with global leadership, which results in a deficit in global health public goods and disorder in global health governance.²⁰ In this context, China, as a responsible major country, upholds the concept of a community of common destiny for humanity and actively promotes and participates in international health cooperation, safeguarding regional and global public health security. Standing by the ethical principle of solidarity, it has advocated a global community of health for all, proposed a global vaccine cooperation initiative, and called on the international community to abandon vaccine nationalism and cooperate extensively to provide vaccines and other public goods that are in short supply for developing countries. Some politicians in the West, however, still cling to a narrow view of international power and security and follow the law of the jungle in international politics, exacerbating the failure of global health governance.²¹ Therefore, we can draw on the experience of U.S.-Soviet vaccine cooperation. First, in the context of weakening cooperation, it is ever more necessary to strengthen cooperation with the WHO and among major countries, to abide by the International Health Regulations (2005), and to strengthen the top-level mechanism for epidemic information exchange, prevention, and control among major countries. The experience of smallpox eradication can be applied to the response to the Covid-19 pandemic and the monkeypox epidemic today. Second, we must pay more attention to the role played by experts and mid-level technocrats in health and facilitate cooperation between major countries through consensus building among mid-level professionals. We should thus take advantage of multilateral platforms or create opportunities to set up such platforms, so as to facilitate cooperation and enhance the exchange of scholarship and experience among experts and officials working on health, infectious diseases, and vaccines. It is important to expand cooperation and communication between medical experts and officials among major countries to form a professional consensus in the realm of vaccine cooperation. At the same time, it is also necessary to further involve health and infectious disease experts in policy formulation and implementation in vaccine cooperation, so that the professional consensus can be more effectively transformed into policy. More importantly, we must convey the values of China’s global health cooperation in exchanges and international medical education, which means raising awareness about humanity sharing a community of common destiny and replacing the law of the jungle in international politics with an ethos of cooperation based on solidarity and shared destiny.

4.2 Partner with developing countries to join forces in global vaccine cooperation

Developing countries are an important force in the multipolar international order. They play an indispensable role in global health cooperation and in the fight against the pandemic, just as the success of smallpox eradication was attributable to the enthusiasm and initiative of developing countries. The SEP dovetailed with the priorities of many developing countries—namely, improving their citizens’ lives and consolidating their regimes—and thus succeeded in bringing them together. Channeling the power of the developing countries through multilateral platforms such as the World Health Assembly, the United States and the Soviet Union finally overcame the ethical controversies surrounding smallpox eradication within the WHO, which subsequently approved a series of major policies. Today, developing countries bear the brunt of global health issues. The Covid-19 pandemic has caused disruptions to the global supply chain, shortages of funds, high unemployment, and widespread human suffering, exacerbating the vulnerability of the dependent development model followed by most developing countries and further widening the gap between the global North and South. In this context, it is important that vaccine cooperation involve developing countries. Building on China’s 60-plus years of experience in foreign medical assistance and the Belt and Road Initiative, we should put forward appropriate, feasible, attractive, and comprehensive vaccine cooperation plans specific to a country’s situation, which should include prompt supply of Covid-19, influenza, and monkeypox vaccine doses and fast-track mutual recognition of vaccines. At the same time, we should assist countries along the Belt and Road in strengthening epidemic prevention mechanisms, promote vaccination against Covid-19 and monkeypox in neighboring regions, and build up a “wall of immunity” along the border. We should, furthermore, commit to supporting developing countries in areas like trade, finance, technology, employment. On the international stage, it is important to bring together the strength of developing countries, promote the leading role of the “Belt and Road” countries, and speak up in unison for prioritizing smooth vaccine cooperation and sustainable development in organizations such as the United Nations, the WHO, and the G20 as well as in multilateral forums such as the Belt and Road Forum for International Cooperation, the China-ASEAN Summit, the Forum on China–Africa Cooperation, and the Forum of China and Community of Latin American and Caribbean States.

4.3 Engage with local communities and oppose the politicization of vaccines

Finding a way to properly dispel vaccine hesitancy is key to achieving proportionality between the three ethical principles of efficacy, freedom, and equality. Although different national conditions, social systems, and social cultures have led to different approaches to tackling the pandemic, a high vaccination rate is essential to building population immunity. Currently, more than 11 billion vaccine doses have been administered globally, but more than 80 percent of the population in Africa has not received a single dose, and about 20 African countries have a vaccination rate of less than 10 percent. It is an urgent task to ensure fair and accessible vaccine distribution and eliminate the “immunity gap,”²² which was mainly caused by factors such as vaccine nationalism and vaccine hesitancy. In addition to increasing the supply of vaccines to developing countries, therefore, dispelling local vaccine hesitancy is also crucial to fighting the pandemic. An important reason for the success of smallpox eradication lay in the deep engagement of local health workers, who were able to combine modern medicine with local cultures, thereby reducing the ethical conflict between tradition and modernity. At present, vaccine acceptance rates in developing countries and regions are uneven. A complex mix of factors gives rise to vaccine hesitancy, including differences in individual health, doubts about vaccine safety, blind confidence in one’s own immunity, lack of convenient access to vaccination, and political distrust.²³ Apart from the influence of traditional culture, the politicization of vaccines also contributed to the above factors. While Western media and some politicians celebrate the United States’ Pfizer and Moderna vaccines, they have a completely different attitude toward some vaccines developed by other countries, which has directly affected the trust in vaccine safety among the population of some countries. To promote smooth global cooperation on vaccines, therefore, we may firstly draw on the experience of smallpox eradication. This not only means helping other countries put in place an efficient system of vaccination on the basis of respect for their approaches to tackling the pandemic. It is also important to take advantage of the rich experience of China’s medical aid teams and engage in close cooperation with local health workers, paying attention to the needs of individuals, families, and communities while respecting local culture. In this way, it is possible to foster a sense of common destiny between doctors and patients, which may make the problem of vaccine hesitancy easier to solve. Secondly, in the realm of international opinion, it is necessary to oppose the narrow view of international power and the politicization of vaccines and to demand fair treatment and mutual recognition of different types of vaccines, as well as up-to-date and transparent information on vaccine safety. This will help enhance the confidence in and uptake of vaccines in recipient countries, facilitating the effort to eliminate hesitancy.