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
天花是困扰人类三千多年的烈性传染病。据不完全统计，仅二十世纪，天花就导致了3亿人死亡。天花根除行动是一场在二十世纪五十至八十年代之间开展的，由世界卫生组织（以下简称“世卫组织”）牵头的、美苏等大国引领的、全球成千上万名卫生工作者参与的全人类疫苗合作。在各方的团结协作与努力下，近１０年里完成了５亿次疫苗接种，花费超过３亿美元，最终成功战胜天花，挽救了无数人生命，每年为全球减少近10亿美元的损失。1980年5月8日，第三十三届世界卫生大会（the World Health Assembly）正式宣布：“人类已经根除了天花，这是全人类的胜利。”
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
早在1948年首届世界卫生大会上，天花就被列为公共卫生重点问题之一。1953年，热衷于开展疾病根除运动的时任世卫组织总干事布鲁克·齐泽姆（Brock Chisholm）提议在世界范围内开展天花根除行动，然而却遭到了美国、英国、法国等国从技术到资金等各方面的质疑。1958年，重返世卫组织不久的苏联在第十一届世界卫生大会上，由苏联卫生部部长维克多·日丹诺夫（Viktor Zhdanov）提出了一项敦促全球根除天花的决议，苏联承诺提供疫苗。此次决议获得全票通过。次年，世卫组织正式为天花根除项目（smallpox eradication program, SEP)立项。然而，在之后的七年中，由于缺少经费与人手，SEP项目停滞不前。这一状况直到1965年才得以扭转。1967年，世卫组织终于配备了足够的资金和人力，开始在全球范围内集中消灭天花。此后的十年中，SEP项目在三大洲几十个国家开展，地区范围从巴西跨越至非洲撒哈拉沙漠西部、南亚次大陆，一直延伸至印度尼西亚群岛，以拱形辐射了整个南北半球。尽管根除天花过程中由于各方现实利益冲突，过程曲折反复，但最终守望相助、团结协作的公共卫生伦理精神发挥了作用。在世卫组织、美苏两国的积极带动与帮助下，不同国家、民族、社群与家庭、国际组织之间团结互助，将全人类的生存安全视为共同利益，在不到三十年间以极高的效率彻底根除了困扰人类三千多年的顽疾，对改善发展中国家特别是因疟疾导致的弱势群体的健康与生活状况意义重大。在此期间，我国为全球天花根除行动做出了巨大贡献。一方面，我国走在天花根除的前列。早在SEP提出前，我国便于1950年发起了全国范围的牛痘疫苗接种运动，1952年底便实现了全国88％的接种率，1961年最后一名天花患者治愈出院。然而，由于我国直到1972年才恢复世卫组织的合法席位，受制于漫长的天花根除认证流程等因素影响，我国于1979年12月最终获得世卫组织认证，可谓SEP“收官之作”；另一方面，新中国恢复合法席位后，加大了对世卫组织的经费支持，缴纳会费金额直逼欧美发达国家；此外，中国积极援助其他发展中国家根除天花。例如，我国加强了与缅甸、老挝、越南等国的疫苗接种合作，在国境线上开辟了一条长达4061千米的天花免疫地带；中国援外医疗队也帮助当地国家开展天花等烈性传染病防治工作，提高了民众的防疫意识。
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.
守望相助（solidarity）是全球卫生合作的重要伦理支撑，它基于standing up beside（站在其身边）的根本理念，包含standing up for（以支持和帮助他人为宗旨）、standing up with（行为体一致行动，改善受害者状况）以及standing up as（设身处地支持另一方），本质上是为了群体层面更大的利益，与受害者站在一起，承受一些成本。然而，国际格局演变、大国关系调整、国际力量对比直接影响守望相助的伦理价值实现程度。特别是超级大国间的国家利益冲突、意识形态对立往往导致全球卫生合作中产生“路线竞争”甚至“路线对立”，彼此猜忌、互不信任、奉行狭隘的国际权力观、忽视发展中国家利益，使得他们难以设身处地为全人类的群体利益考虑、难以积极提供全球卫生公共物品，从而冲击全球卫生合作。作为迄今为止最为成功的全球卫生合作案例———“天花根除行动”受到冷战格局影响，美苏竞争与对立贯穿合作全过程，深深烙上了美苏争霸的印记。在合作初期，美苏缓和与紧张态势并存，以紧张为主，两国意识形态斗争激烈。苏联认为美国的疟疾根除计划是为其全球化工厂商、制药厂商的资本家谋利，同时为在第三世界扩大影响力；而美国认为苏联提议开展天花根除行动的主要动机便是将应对天花的“苏联做法”推广至全球，扩大苏联阵营的全球影响力与权威。因为在1958年日丹诺夫交给世卫组织的根除天花提案中，他特别强调了苏联国内通过强制接种疫苗消灭天花的成功做法，提出应制定五年计划，几乎要求全人类强制接种疫苗（少数国家和地区人口除外）。为了表明决心，苏联及其盟友古巴分别承诺每年提供2500万、200万剂冻干疫苗用于根除天花。尽管美国对苏联这一扩大影响力的做法表示沉默，但美国认为，苏联若真心热衷于全球卫生，应加入美国的疟疾根除计划。二十世纪六十年代中期以来美苏紧张态势趋缓，美国逐渐采取“和平演变”战略与苏联在全球开展制度、意识形态等“软权力”领域竞争。从一定程度上看，1965年美国加入SEP正是这种“软权力”领域竞争与对立的结果。正如美国官员认为美国加入SEP的原因是“在与苏联开展天花合作的同时，也是传播美国软权力，帮助苏联‘自取灭亡’”。在实际操作中，从SEP项目负责官员背景调查、任职流程到合作文书用词定稿都充斥着美苏的意识形态交锋。在美苏争霸的大背景下，深受疟疾困扰的第三世界国家成为了超级大国间利益、制度、路线争夺的焦点，直接阻碍SEP项目真正站在受疟疾影响的国家身边，提供设身处地的支持。
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].
尽管美苏争霸的国际格局冲击守望相助的公共卫生合作伦理原则，但在卫生专家、流行病学专家之间，已经超越了国家利益、制度与意识形态对立，在专业领域达成了全球根除天花的共识，并将这些共识延伸至政策制定领域，为实现守望相助奠定了思想基础。这主要包括两类共识：天花是当时全球唯一能够被根除的疾病。相较于疟疾、黄热病、脊髓灰质炎、肺结核等传染病，天花在控制上具有更大的流行病学优势，例如天花传播不需要动物带菌体，因此并不需要过多干预生态，天花症状明显、疫苗效力更好、副作用更小等。因此，当二十世纪六十年代美国主导的疟疾根除计划失败之际，美国的卫生专家逐渐将视角转向天花。1962年以来，美国多名卫生专家多次致信美国公共卫生署国际健康办公室主任詹姆斯·瓦特（James Watt），表达天花是当前唯一能根除的全球性传染病。由于美国卫生领域官员多具有专业医学背景，便迅速与国内卫生专家达成共识。这些共识不久之后便直接影响到美国时任总统林登·约翰逊（Lyndon Baines Johnson）。对约翰逊政府而言，恰如卫生专家们的建议，天花根除不仅花费与争议都较小，还能扭转美国的国际形象。因此，二十世纪六十年代中后期，美国最终放弃了疟疾根除计划，政策制定者达成了天花根除的共识。虽然美苏争霸并开展“路线竞争”，但两国在面对第三世界发展中国家时达成了高度“现代性”或“科学”共识，即：通过科学战胜自然与落后。美苏的技术精英、中层的卫生官员等一致认同现代医疗和科技手段，并且都希望将其运用到广阔的第三世界中。这些共识多自下而上产生，先在中层的专业人士中形成，再逐步影响高层。随着大国关系的转变，当高层达成初步合作意向后，再由专业的中层人士执行推动，相似的科研背景、技术能力，以及所在组织为其保障的经济实力，使专业人士意见得以超越地缘政治与意识形态分歧。因此，即使冷战加剧，美苏高层政治家对立严重，但专业卫生官员与卫生人员仍能够站在发展中国家立场上开展密切合作，共同制定科学方案攻克疟疾。
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
尽管世卫组织内部对天花根除计划的伦理可行性看法不一，但在美苏主导国与广大新兴独立国家间，达成了根除天花的合作共识。各方团结协作以实际行动支持根除天花。一方面，美苏大力支持SEP。苏联作为主导者，遵守了1958年世界卫生大会上承诺的每年供应2500万剂疫苗。1958至1979年间，苏联共提供了14亿剂量的疫苗。此外，苏联还在1967至1984年间向世卫组织健康促进志愿基金会消灭天花特别账户（the voluntary fund for health promotion, special account for smallpox eradication) 捐赠超过2.9亿剂疫苗。美国则作为资金的主要提供者，为9800万美元的项目提供了近1/3的资金支持，同时直接向项目提供了1.9亿剂疫苗。1967至1977年，美国还派出了时任疾病控制与预防中心（Communicable Disease Center, CDC) 传染病监控主任唐纳德·亨德森（Donald A. Henderson) 赴世卫组织领导SEP项目。亨德森对SEP的成功做出了巨大的贡献；另一方面，恰逢二十世纪五十至六十年代新兴独立国家渴望抓住机遇，获得国际援助改善民生，巩固新生政权。因此，在苏联提出SEP后，就获得了饱受天花之苦的广大发展中国家的支持。1965年5月，在发展中国家的支持下，世界卫生大会最终将全球消灭天花列为组织主要目标；随着美国做出具体承诺后，越来越多的国家争相加入SEP。以西非国家上沃尔特（Upper Volta，现为布基纳法索）为例，其卫生部长听闻1965年美国在世界卫生大会的承诺后，趁着到访华盛顿之际，联络了美国国际开发署（United States Agency for International Development)，表达了加入SEP的强烈愿望。约翰逊根除天花的宣言点燃了许多发展中国家的热情，并在高层政治家之间达成了消灭天花的共识。1966年，当总干事坎多提交第二年关于天花“超额”的预算时，尽管部分发达国家有所抱怨，但在广大发展中国家的支持下，以2/3的赞成票获得了通过，成为世卫组织预算表决史上“最侥幸”的一次胜利。
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.
全球卫生合作深受国际政治形势影响，正如在美苏争霸的冷战格局下，SEP进程与美苏关系演变同频共振。当前，面对百年未有之大变局，世界加速进入动荡变革期，国际格局中的世界主要力量对比在既有轨道上加速演变。而在全球卫生领域，新冠疫情“未平”，而与天花同属正痘病毒科的猴痘“又起”，全球卫生与生物复合安全面临严峻挑战，同时有效的全球卫生治理协调机制缺位，全球卫生陷入“金德尔伯格陷阱”（the Kindleberger Trap)，主要体现为当占主导地位的大国无意或无力承担领导责任时，就会造成全球卫生公共产品赤字，导致全球卫生治理体系失序）。在此背景下，中国作为负责任大国，始终秉持人类命运共同体理念，积极推进和参与卫生健康领域国际合作，维护地区和世界公共卫生安全，推动构建人类卫生健康共同体，提出全球疫苗合作行动倡议，坚守“守望相助”的合作伦理原则，呼吁国际社会摒弃疫苗民族主义，开展广泛合作，积极为发展中国家提供疫苗等紧缺的公共物品。然而，西方部分政治家仍固守狭隘的国际权力与安全观、奉行国际政治的丛林逻辑，加剧全球卫生治理失灵。因此，可以吸取美苏疫苗合作中的经验，一方面，在合作弱化的背景下更需要加强与世卫组织以及大国间合作，遵守《国际卫生条例》（2005年），加强大国间疫情信息交流、防控协调的顶层机制设计，将天花根除的经验应用于当前应对新冠疫情以及猴痘疫情；另一方面更加重视卫生领域中层技术官员与专家的作用，通过在中层专业人员间达成共识，助力大国合作。因此，应利用多边机构平台或创造机会搭建平台，加强全球卫生、传染病学专家及官员、疫苗专家之间的学术与经验交流合作，扩大大国之间医学专家与官员的合作交流，形成疫苗合作领域的专业共识。同时加强疫苗合作中政策制定与执行过程中的卫生与传染病专家的参与，提升专业共识的政策转化程度；更重要的是，在交流合作以及国际医学教育中传递中国全球卫生合作的价值取向，建立人类命运共同体共识，以命运与共、守望相助的合作伦理取代弱肉强食、以邻为壑的国际政治丛林法则。
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.