eopolitics, i.e. the geographical, territorial and spatial dimensions of power, is changing. A tectonic shift occurred during the Covid-19 pandemic when two great powers, China and the United States, made geopolitical strides in an unconventional arena, i.e., global health. The World Health Organisation became collateral damage when one power, the US, pulled out because the WHO did not censure its rival, China. WHO’s flagship response to Covid-19, the COVAX initiative, a multilateral mechanism for equitable global access to Covid-19 vaccines, closed at the end of 2023, having delivered nearly two billion doses of vaccines to 146 economies. It was also undermined by subtle power levers of geopolitics, i.e. vaccine diplomacy and vaccine nationalism. The WHO tried to balance the stakes with uneven effectiveness. Will the same happen with the MPox and the like? The jury is still out.

Global health diplomacy (GHD) is about “the multi-level and multi-actor negotiation processes that shape and manage the global policy environment for health.”

The global health crisis of Covid-19 highlighted its significance as countries negotiated vaccine distribution to better respond to the pandemic. Resultantly, GHD has emerged as a critical instrument in the diplomatic toolbox. Established powers such as the US-led Western bloc and the China-affiliated emerging powers can manifest GHD differently. GHD can help them advance their foreign policy objectives, improve global health security and protect their national and global economies. Cooperation between the old and the new powers can help achieve these objectives.

The Brazil-Russia-India-China-South Africa group, now joined by other countries, is emerging as a coalition with substantial geopolitical and economic clout. Among other fronts, it is challenging the US-led Western bloc in the global health sphere. The latter has remained a dominant force with a long-standing leadership role in global health governance, but the scales may be shifting now. By examining these rival blocks through the GHD lens, we endeavour to see how global health goals can be harmed by their negative competition or positively affected by their cooperation.

The “multilateral and multi-stakeholder” nature of GHD is manifested in the US-led Western bloc’s approaches to global health. For instance, they effectively leverage the Group of Seven, the World Economic Forum and entities such as the Global Fund to shape health policies and set global health priorities. Their substantial assessed funding to WHO enables the latter to function and but their withholding of voluntary funds can cause its dysfunction. Furthermore, their commitment to combat diseases through PEPFAR and the Global Fund promotes GHD. Still, it can potentially undermine the primary GH entity, i.e., the WHO and the one nation, one vote principle of the World Health Assembly.

Similarly, their control of rules making at the World Trade Organisation and enforcing the Trade-Related Aspects of Intellectual Property Rights Agreement can promote innovation, encourage investment in research and enable the pipeline of life-saving medicines and vaccines. Yet, the same agreement can block developing countries from equally benefiting from the life-saving products by establishing pricing monopolies.

Individual countries in the group can sometimes break ranks to promote GH and universal health coverage (UHC). This was seen under the G7 presidency of Japan.

The mantle of global health leadership is up for grabs. We will see whether it results in a shared win for both blocs or if one cedes the space to the other.

Despite lacking formal institutions like the Global Fund and G7, the BRICS countries have shown their potential to reshape the global health landscape through unified South-South cooperation. China’s Health Silk Road under the Belt and Road Initiative distributed approximately 1.5 billion doses of Covid-19 vaccines to over 100 countries. Russia’s Sputnik V vaccine was distributed to over 70 countries, with around 1.5 million doses delivered by mid-2021. The Serum Institute of India, leveraging its status as the “pharmacy of the world,” engaged through its Vaccine Maitri initiative and initially promised significant vaccine exports, distributing around 66 million doses before halting exports due to domestic needs.

Vaccine diplomacy refers to leveraging vaccine distribution to achieve broader diplomatic goals. Vaccines are donated by economically and technologically advanced nations or coalitions to countries with fewer resources. This fosters goodwill, improves global health security and sometimes advances the donor country’s strategic interests. In the early phases of the Covid-19 pandemic, China, India and Russia used vaccine diplomacy to achieve one or more of these objectives. Vaccine nationalism was mostly manifested by the G7 economies. Vaccine nationalism is governments’ prioritising securing vaccines for their citizens, often at the cost of global equity in vaccine access. Wealthier nations can build stockpiles at the expense of global solidarity through advance purchase agreements and outpricing economically developing countries. By September 2020, wealthy nations, comprising 13 per cent of the global population, had acquired 51 per cent of the vaccine doses. The COVAX initiative aimed to provide equitable access but fell short, delivering only 200 million doses instead of the planned 600 million due to vaccine nationalism, highlighting stark inequities in vaccine access.

GHD could have played a vital role in this matter. It could have engaged with the producers to better negotiate prices and secure negotiated licensed production in developing countries. It could also have helped developing countries navigate the technical and political challenges in issuing compulsory licences and efforts for voluntary waivers.

GHD at the 2024 WHA was, nonetheless, a failure. Certain nations, on the pretext of sovereignty, reneged from supporting the global pandemic treaty. The treaty would have enabled the WHO to effectively prevent, detect and respond to global health threats. The pact intended to create legally binding commitments for countries for global health security. This collective failure highlighted the missed opportunity to balance national sovereignty with global responsibility.

The recent Mpox declaration of a public emergency of international concern may open a new front between BRICS and the US-led Western blocs. In case of cooperation, the research capabilities of the US-led bloc and the massive production capacities of the BRICS bloc can promote global health security. Their competition and blame shifting can lead to infructuous global responses, as was witnessed during the Covid-19 pandemic.

Both these groups should leverage their economic and political influence in global health governance to negotiate the pandemic treaty effectively based on the notion of greater collective good. How these powers react to this MPox and align with the next effort at the pandemic treaty will shape global health and the balance of soft power. The Global South might have internalised Dr Tedros’s historical words before the Global North when he said, “No one is safe until everyone is safe.” The mantle of global health leadership is up for grabs. We will see whether it results in a shared win for both blocs or if one cedes the space to the other. The Global South will watch closely for vaccine nationalists and the spoilers of the pandemic treaty.

Dr Sheraz Ahmad Khan holds PhD, MPH and MBBS degrees. He is an associate professor of global health at Health Services Academy, Islamabad.

Dr Maidah is a lecturer at Shaikh Khalifa Bin Zayed Al Nahyan Medical and Dental College, Lahore.