Vaccine Diplomacy and Political Diversification in Mexico’s Science and Technology Stakeholders

COVID-19 has acutely affected countries in the Global South, putting pressure on healthcare systems and worsening inequalities in access to scientific and technological (S&T) resources. Particularly, in Latin American countries, the pandemic has revealed the weaknesses in national S&T capacity for research, development, and distribution of vaccines, treatments, and medical devices. But the pandemic has also raised awareness of the importance of vaccination and elevated the profile of science in global and local public agendas. This article documents important examples of vaccine policies and diplomacy in Mexican history, some of them developed by new stakeholders as part of an emergent science diplomacy discourse.

Currently in Mexico, the urgent need for effective health policies and vaccines has prompted new alliances between scientists among policy makers. The reconfiguration of political alliances has become evident through institutional initiatives connecting distinct levels of governance and incorporating science awareness into a range of political discourse. As described below, the Government of Mexico City, the State of Hidalgo, the Federal Ministry of Foreign Affairs (SRE), and universities are among the stakeholders now coming together towards vaccine diplomacy. Vaccine diplomacy is the display of international cooperation for global access to vaccines and support for their research and development, strengthening nations’ soft power and influence in the multilateral system.1

This paper also explores the diversification of stakeholders in the Mexican S&T ecosystem. These stakeholders have participated in global negotiations towards universal access to vaccines and other mechanisms of scientific cooperation in response to COVID-19.

Vaccination in Mexico 

Historically, Mexico has made important contributions to global vaccination efforts. From 1803 to 1806, the Mexican territory was part of the first global vaccination campaign, namely the Royal Philanthropic Vaccine Expedition against smallpox which covered the whole of the Spanish Empire and was led by Dr. Xavier Balmis and the nurse Isabel Zendall. This has been also interpreted as an example of Bourbon dynasty’s illustrated policy of public health, colonial security, and foreign policy, as a measure to contain the advent of independence wars across the continent.2

Just over eighty years later, in 1888, Mexican physician Eduardo Liceaga brought from Paris the first anti-rabies vaccines, incubated in the brain of rabbits, launching the modern era of vaccination in Mexico. In 1905, President Porfirio Díaz ordered the creation of the National Bacteriological Institute, to be devoted to vaccine production. During the first years of the Mexican Revolution (1910–1917), the Institute’s budget was cancelled, but in 1918, its Director General, Angel Gaviño, convinced the government to maintain the Institute. By then, World War I had drastically increased the cost of importing vaccines from Europe, and imports from the United States were unlikely, due to weakened diplomatic relations. After the Mexican Revolution war, governments soon realized that a lack of vaccines could increase political instability, as was the case during the so-called Spanish influenza pandemic that started in 1918.3 By 1921, this pandemic had accounted for more than half a million deaths in Mexico. As a matter of national security, therefore, the Institute was upgraded to the National Institute of Hygiene and began supporting the local production of vaccines.

In 1960, the National Institute of Virology was created, and recognized as Regional Center of Reference for Vaccines, supporting the World Health Organization (WHO) thanks to its technical capacity and the high quality of vaccines it produced. Of particular importance was its production of the oral trivalent polio vaccine for the mass inoculation of newborns and toddlers. During the 1980s, Mexico advanced national capacities in vaccination and consolidated vaccine production efforts by the National Institutes of Hygiene and Virology under a new decentralized entity, the General Management of Biologicals and Reagents. By 1990, thanks to the management of former health minister and scholar Jesús Kumate and direct public investments in the Expanded Immunization Program (PAI), Mexico was one of just seven countries in the world that was self-sufficient regarding the manufacture of vaccines necessary for its residents.4 Under Kumate’s leadership, Mexico strengthened cooperation for development in the Global South and developed political influence in multilateral health bodies, promoting national and regional vaccination programs against measles, dengue, cholera, polio, malaria, smallpox, Ornithobacterium rhinotracheale (ORT), and tuberculosis.5 Some of these vaccination programs and policies have been successfully replicated in Latin America and the Caribbean. Specifically, PAI was adopted by the Pan American Health Organization (PAHO) in 1977.6

By 1998, the PAI fostered by Kumate was expanded nationally to include rubella and mumps, and later hepatitis B and Haemophilus influenzae type B as well. By 2013, the scheme grew to include fifteen different diseases, including seasonal influenza, invasive pneumococcus, rotavirus, human papilloma virus (HPV), and hepatitis A. This project was designed with the collaboration of international immunization experts and became a universal access program through the National Health System.7 The Mexican vaccination policy is further enforced by the deployment of National Health Weeks three times a year, focused on the eradication of polio, measles, rubella, and congenital rubella syndrome. In children, vaccination is enforced by the compulsory presentation of personal vaccination records before registration in public schools. The success of this scheme has resulted in some of the lowest rates for infectious diseases worldwide.8

Despite this legacy, in recent history, the production and distribution of vaccines has been drastically reduced in Mexico.9 In the 1970s, vaccine production facilities were systematically dismantled and investment in public health institutions was reduced, based on recommendations of the World Trade Organization. After signing the North American Free Trade Agreement (NAFTA) in 1994, Mexico further reduced its control of health care and regulation.10 By 1998, Mexico ceased to be self-sufficient in vaccination, with consequences that became evident during the 2009 H1N1 influenza pandemic. In 1999, the remaining vaccine facilities were concentrated in a new company called Birmex, a state-owned company with a mandate of vaccine production and distribution. However, Birmex has ceased to produce vaccines directly, but rather facilitate public-private associations for their import. In 2020, Birmex imported 77 million doses of vaccines with a commercial value of 137 million dollars.11 The purchase of 30 million doses of the H1N1 influenza vaccine in 2009 has been criticized as obeying economic interests more than public health priorities, and the justification for the purchase—that the country lacks the capacity to develop its own vaccines—is refuted by Mexico’s recent history.12,13,14

Broadly, prevention campaigns had been a core aspect of Mexico’s health policy, stemming from the first smallpox inoculations in 1804 up until 1942. From 1943 to 1945 the government abandoned preventive medicine, causing a significant increase of smallpox cases.15 Prevention campaigns were resumed in 1990, during Kumate’s administration, again becoming a pivotal part of health policies. A key lesson of this experience was the low cost of disease prevention compared to the cost of treatments.

Additionally, a lack of long-term funding for S&T has also affected research and development in biotechnology and next-generation vaccines. Despite its growing number of biotechnology professionals, Mexico has not been able to develop and scale up new vaccines, due to the absence of effective collaboration between universities, the private sector, and state-owned facilities.

The thorough degradation of social insurance and public health care system over the last 30 years has undermined the prevention of emerging and re-emerging infectious diseases such as tuberculosis, and measles. Although they had previously been controlled, these diseases are again increasingly causing outbreaks. Over the last 30 years, compulsory vaccination has diminished among children because the oversight of vaccination records as a requirement to enter school has become less strict.

COVID-19 vaccine diplomacy has become an opportunity to revive or ignore Mexico’s legacy of success. Today, Mexico is confronting its weakened capacity within new, complex global realities.

Global production and distribution of COVID-19 vaccines in Mexico

According to the World Health Organization (WHO), as of May 10, 2021, there have been over 150 million (157,973,438) confirmed COVID-19 cases globally, with 2.3 million cases (2,364,617) in Mexico.16 Despite the timely recommendations of the WHO, the Mexican government reacted late, and the National Campaign of Healthy Distance (Jornada Nacional de Sana Distancia) was declared only on March 23, 2020, when more than 1,000 cases had already been confirmed in the country. But controlling the spread of the virus requires strict public health measures and efficient management of its many dimensions. Public investment is also necessary, for the development and deployment of diagnostic methods, vaccines, and other medical countermeasures. Finally, the greatest challenge may be the implementation of a universal vaccination scheme against SARS-CoV-2.

A major challenge for the prompt elimination of the virus is vaccine refusal. Personal hesitation to submit to a compulsory vaccination campaign for COVID-19 ranges from 3% to 76.4% of the adult population in 33 different countries. The highest rates of hesitation are in Kuwait, Jordan, Italy, Russia, Poland, the United States, and France, with 41.7 to 76.4% refusal rate;17 the lowest are in Ecuador, Malaysia, Indonesia, and China, from 8.7 to 3%. In Mexico, the refusal rate for the vaccine is relatively low (23.7%). The refusal rate of vaccination generally has increased dramatically over the last decades, matching with new outbreaks of diseases such as tuberculosis and measles, which were previously controlled. With this projected level of refusal, a vaccine against SARS-CoV-2 will cover only 70% to 75% of the population. Although this is the estimated herd immunity threshold for SARS-CoV-2, population heterogeneity and the advent of new variants could mean that even higher coverage is required to eliminate viral transmission, given current vaccine efficacy.18 Another challenge for government and academics is therefore building a strategy for informing citizens on global health.

As soon as the SARS-CoV-2 virus was isolated and its genome sequenced, the race for the vaccine started, with more than one hundred different prototypes currently under investigation. The cost of the accelerated development of each vaccine will be over $750 million. Amid the economic crisis imposed by public health restrictions, not all countries will be able to invest in research and development at these levels. Some of the original projects have already been abandoned.19 However, close to a dozen COVID-19 vaccines are already being used across the world. As of April 2021, WHO has issued Emergency Use Listings for three different vaccines, with decisions anticipated on three more before June.20

In Mexico, six vaccines have been approved by COFEPRIS, the federal regulator, for emergency use: Bharat Biotech’s Covaxin (India), Pfizer/BioNTech’s BNT162b2 (USA/Germany), CanSino’s Ad5-nCoV (China), Gamaleya’s Sputnik V (Russia), Oxford-AstraZeneca’s AZD1222 (UK/Sweden), and Sinovac’s CoronaVac (China).21 These vaccines can only be administered by the federal government.

New stakeholders in vaccine diplomacy 

While some examples of vaccine diplomacy can be considered science diplomacy, they also intersect with global health diplomacy. In other words, vaccine diplomacy may not necessarily impact science and technology capacity building in the long term. Science and vaccine diplomacy are examples of so-called para-diplomacy, which describes a diversity of international actions from non-traditional stakeholders that, in the Global South, can temporarily enrich or substitute for official diplomatic relations.22 By contrast, science diplomacy in the Global North largely refers to the wider universe of scientific activities that contribute to improving global policies and generate soft power, e.g., a multinational mechanism for developing a vaccine against COVID-19, but also benefit scientific and technological development over time.23 Now, the emergent nature of science diplomacy in the Global South implies that international vaccine development and COVID-19 policies of Mexico would be better understood as vaccine diplomacy or paradiplomacy than as science diplomacy. The following examples meet these conditions.

Diplomacy at the federal and diplomatic level

The consequences of the potentially uneven distribution of COVID-19 diagnostic capacity, treatments, and vaccines prompted the WHO to develop a mechanism to coordinate equitable access and distribution to all nations, the Access to COVID-19 Tools (ACT) Accelerator (launched by the G20 and WHO in April 2020). One of its pillars is focused on vaccines, through the COVID-19 Vaccines Global Access initiative (COVAX). COVAX is a collaborative platform that supports research, development, and manufacturing of a wide range of COVID-19 vaccine candidates and helps countries to negotiate purchases. Mexico joined COVAX on August 31, 2020, under the modality of optional purchase, for almost $160 million, of 24 million doses of one of the participating vaccines as soon as its safety and effectiveness had been established. The negotiation was overseen by the Ministry of Foreign Affairs (SRE).

In the past, a strong engagement of Mexico in global health diplomacy was carried out by the Ministry of Health under the leadership of experts as Jesús Kumate. Today, a form of this engagement is evident in the work of SRE, which in 2019 created a scientific advisory council called Consejo Técnico del Conocimiento y la Innovación (COTECI). This council, hosted at the Mexican Agency of Cooperation for Development (AMEXCID), gathers the main scientific institutions in Mexico and Mexican experts abroad to support diplomatic agendas and negotiations. Examples of the Mexican engagement include the UN resolution on “International cooperation to ensure global access to medicines, vaccines and medical equipment to face COVID-19,” and the recent Mexican cooperation with Argentina, UK, Russia, the United States, and China for local COVID-19 vaccine access. These measures show how Mexico’s foreign policy is diversifying partners through science and vaccine diplomacy.24

In addition to the commitment to COVAX, for example, the government of Mexico negotiated directly with Pfizer to secure 7 million doses, the first of which were delivered to Mexico on December 24, 2020. Mexico was one of the first five countries in the world to receive COVID-19 vaccines, and the first in Latin America to begin vaccinations.

On January 25, 2021, Mexico signed contracts with the Russian government to purchase 33 million doses of the Sputnik V vaccine. This decision was made public after the announcement of the regulatory approval of the vaccine by Argentina in December 2020. Mexico’s decision, however, was received with skepticism in academic circles since, despite emergency use approvals in countries such as Hungary and the United Arab Emirates, the results of the Phase III clinical trial of the vaccine have not been peer reviewed. From a diplomatic perspective, there were concerns that this agreement might be perceived as an alignment of Mexico with Russia, less than one week after the inauguration of President Joe Biden, which might strain the U.S.-Mexico relationship. However, on March 18, 2021, the U.S. agreed to send Mexico 2.5 million doses of the Oxford-AstraZeneca vaccine, suggesting that fears of potential tension were unfounded, and indeed, this action was regarded by the international press as a forward step in vaccine diplomacy between these countries. As of March 3, 2021, 1.2 million doses of Sputnik V had been received in Mexico.

An initial agreement with the Chinese government for 10 million doses of the Sinovac vaccine was ratified on March 9, 2021. In a more complex collaboration scheme, the Chinese company CanSino sent biological products equivalent to 2 million doses of their Ad5-nCoV vaccine for local fill-and-finish in a factory in the state of Queretaro on February 11, 2021. These doses are the first batch of an overall agreement for 35 million doses.

In sum, by May 20, 2021, SRE was able to import over 30 million doses of vaccines from diverse origins and, in cooperation with Birmex, distribute them to the national and subnational health authorities.25

Vaccines are not the only means by which Mexico has engaged in global diplomacy during the crisis. Italy’s experience during the first wave triggered concern over the potential collapse of health systems due to the extraordinary demand of intensive care units and ventilators. These medical devices are sophisticated and produced only in the most technologically advanced countries. Their scarcity led Mexico to promote a G20 agreement to ensure that countries in the Global South that do not produce ventilators locally would not be subjected to rigged processes or speculation preventing their acquisition. This initiative was subsequently developed under the leadership of the Mexican Mission to the United Nations with the support of 179 countries. It materialized in resolution 74/274, approved on April 20, 2020 with the following agreement:

Member States are encouraged to work in collaboration with other relevant stakeholders in order to increase financing for research and development activities on vaccines and drugs, to appropriate digital technologies, and to strengthen international scientific cooperation to combat COVID-19 and to promote coordination, including the private sector, for the rapid development, manufacture and distribution of diagnostics, antiviral drugs, personal protective equipment, adhering to the objectives of efficacy, safety, equity, availability and fair price.26

Private venture and domestic research and development

On June 29, 2020, the Mexican Ministers of Foreign Affairs and Health gave a presentation to the Coalition for Epidemic Preparedness Innovations (CEPI), a global, multi-stakeholder coalition specializing in responding to epidemics. The topic was four research projects where Mexican scientists had participated in the international search for a COVID-19 vaccine. Three of them were based on the production of recombinant non-infective viral particles, with participation of: the National Autonomous University of Mexico (UNAM), the private firm Avimex, the Mexican Social Security Institute (IMSS), the Autonomous University of Baja California, and the Monterrey Technological Institute. More recently, the University of Queretaro and the National Polytechnic Institute (IPN) developed a fourth project to produce synthetic peptides. These collaborations are examples of how the Mexican government is engaging international multilateral partners with respect to advancing domestic research and development initiatives. Unfortunately, none of these projects received funding from CEPI or the federal government, and all are currently looking for private funding.

Mexico will actively participate in the production of one of the frontrunner vaccine projects through a joint venture of mABxcience, Liomont, and the Carlos Slim Foundation. This effort started when the University of Oxford-AstraZeneca vaccine launched Phase III clinical trials in Argentina and its subsequent packing and distribution in Mexico. The aim of the collaboration is the rapid production of 250 million doses in 2021. Other Latin American countries involved include Panama, Colombia, and Ecuador. The first round of production started in January 2021 and is expected to continue through 2022.

Subnational level

In May 2020, Mexico City faced the largest outbreak in the country with 606,039 confirmed cases of COVID-19 and 30,141 deaths.27 COVID-19 research and diagnostics became a priority for its government. The local Ministry of Education, Science, Technology, and Innovation created a mechanism grouping more than twenty universities and research centers to provide science advice and lead strategic projects between researchers and government officers. This mechanism, called “red ECOs,” or the ECOs network, has been a space for participation and channeling government demands to the academic community.

These sorts of bidirectional science policy and science diplomacy initiatives were enhanced at the local level when the Mexico City municipal government and UNESCO raised a common call to research institutions and government agencies to work together in the pandemic. As a result of these channels of cooperation, the City has been able to build up temporary capacity for diagnostic tests (more than 5 million), spur the development of rapid tests, and foster innovation of physical face shields.28 However, the local government’s potential to be a new stakeholder in science and technology is challenged, as the ECOs network has not been consolidated as a long-term institution and lacks critical evaluation and planning mechanisms.

A second emergent example of vaccine diplomacy at the subnational level is in the State of Hidalgo. In response to COVID-19, its Ministry for Planning and Foresight launched the only call for research projects related to the development of novel diagnostics, treatments, and vaccines against COVID-19. The State of Hidalgo partnered with the Swiss synchrotron SLS in May 2020. This allowed it to build up partnerships supporting the State’s main regional development project, the Mexican Synchrotron. All these COVID-19 research projects received funding from Hidalgo’s government and experiments on protein structure of the SARS-CoV-2 for drug and vaccine design were performed at the SLS.29 These initiatives served as a mechanism of economic promotion abroad, as part of a six-year plan to convert the state into a scientific and technological destination through science diplomacy. The Government of Hidalgo, in an effort to recover the historical legacy of Mexican vaccination, has constituted a group of experts in biotechnology (some of the authors included) to design an International Vaccine Facility which would be in charge of the Biotechnology Institute of the National University of Mexico in Hidalgo’s capital, Pachuca, to ensure vaccine production in the long term. This facility is already under construction.30

Understanding vaccine diplomacy in Mexico

Two key factors that facilitated the collaboration of the scientific community with decision-makers during this pandemic were political junctures and strategic alliances, which played a role in the work of both the SRE and the government of Hidalgo. In the case of the SRE, a history of ideological affinity among scientists working on COVID-19 research today precedes the pandemic, serving as political capital. Marcelo Ebrard, as Minister of Foreign Relations and second political figure nationwide, was able to assemble a group of today’s leading academics who became the perfect allies to generate institutional cohesion and advance leadership, together enriching Mexico’s agenda on vaccines, climate change, and multilateralism. This team of experts includes Esther Orozco, who is responsible for the CEPI initiative, and the former Minister of Science during Ebrard’s administration who is a former mayor of Mexico City. Another example is Ambassador Juan Ramón de la Fuente, former president of UNAM, former Minister of Health, and, just like Ebrard, a former member in the Party of Democratic Revolution since the 1990s. Also worthy of mention is Ebrard’s Undersecretary for Multilateral Affairs and Human Rights, Martha Delgado, who leads foreign policy regarding climate change and commercial vaccine negotiations, using strong alliances with the academic community.

In the case of Hidalgo, the effective relationship with the academic community has neither long-term precedents nor ideological affinity. It is related to the creation of a local Ministry of Planning and Foresight that, since the beginning of Governor Omar Fayad’s administration, has put science and technology as the core of the state policy and built local diplomacy upon it. Hidalgo presides over the Mexican Synchrotron project, the global network of the Mexican diaspora (Red Global), and the network of local authorities in science and technology (REDNACECYT). In this case, strategic connections are being built de novo. Interestingly, the academic community related to Hidalgo is composed not only of traditional leaders from academia but also figures from the Mexican diaspora and young local scientists.

Conclusion

While current sanitary and scientific capacity is insufficient and poorly coordinated, awareness regarding the need for S&T measures has increased and vaccines have once again become an element of political strategy for local and federal stakeholders, including new actors. Many of these political reconfigurations are contributing to vaccine diplomacy, but may not impact science diplomacy and policy in the long term. Some critical lessons can be drawn in this sense.

First, the history of vaccination in Mexico is an example of an important scientific tradition coupled to policies promoting vaccine diplomacy, independent of political and ideological changes. It also shows the creation, reorganization, and dissolution of the institutions charged with distributing vaccines over the past two hundred years. Vaccine self-sufficiency has eroded in the last thirty years, due to a lack of medium-term policies connecting these initiatives at distinct levels of governance, as consequences of neoliberal economic policy and non-collaborative working practices within academic institutions. As described above, vaccination has always been a state matter of public concern in Mexico, with strategic political importance in foreign and internal affairs.31

Second, SRE became a relevant stakeholder in vaccine diplomacy for Mexico with novel institutional mechanisms aimed at filling gaps and bridging the scientific community, industrial partners, and international initiatives with government science and health policy leaders such as the National Council of Science and Technology, the Federal Health Ministry, and the sanitary regulator COFEPRIS.32

Locally, the urgent need for a coordinated national response puts Mexico far from controlling COVID-19 and demonstrates the government’s negligence in recovering its vaccine sovereignty. It also emphasizes the importance of using science for prevention against future pandemics. For example, Mexico is still one of the countries with the fewest diagnostic tests. Despite international recommendations, the average number of tests in Mexico in 2020 remained below three tests per confirmed case, in contrast to other countries with similar rates of transmission, such as the U (which averaged 15 tests per confirmed case).33 Accurate data on the actual numbers of positive diagnostic tests are not available, negatively impacting prevention measures. Mexico has also refused to implement mandatory isolation for ideological reasons, despite rising deaths. This problem is outside the constitutional mandate of SRE, but may compromise the potential of its leaders to effectively enter and improve the science and technology ecosystem and gain support from an already oppositional scientific community in the long term.

At the global level, SRE’s most important challenge is to ensure that vaccine supply agreements are realized in the shortest timeframe possible. However, the global arena presents a scenario quite different from the examples of successful vaccine diplomacy against polio and smallpox during the Cold War. On February 17, 2021, Mexico denounced the inequality of vaccine distribution at the UN Security Council, on behalf of the Community of Latin American and Caribbean States. This should be considered an important position in today’s multilateralism. First, it signals a protest against the multilateral system’s reduced capacity to enforce global access to vaccines through mechanisms such as COVAX. Additionally, it serves as a warning that the United States and the European Union, despite rhetorically framing COVID-19 as a global problem, have in fact prioritized their national or regional vaccine supplies, letting China and Russia strengthen their geopolitical influence in the Global South through bilateral vaccine diplomacy and cooperation.

Finally, subnational level engagements are of interest because they are taking place alongside the announcement of important changes in Mexican S&T policy. A new general law on science, technology, and innovation is currently being prepared by Congress and may centralize the institutional framework in S&T, with local governments losing participation in this sector. In response, the scientific community is claiming spaces of debate around the new law. Scientists have publicly argued against changes in the National System of Researchers (SNI), such as the elimination of biotechnology as focus discipline during the COVID-19 emergency. We think that the discussion of the new law in Congress will be an excellent opportunity for the emergence of new federal, subnational, and academic stakeholders. It will be interesting to see how new stakeholders influence the national science agenda, or alternatively diversify existing science diplomacy mechanisms into other arenas, such as COVID-19 health policy, energy, and sustainable development.

COVID-19 positively affected science diplomacy in Mexico, illuminating the social function of scientific knowledge and scientists in the public agenda. The diversification of stakeholders enriches the ecosystem for science diplomacy by reaching new audiences at different political levels. Among the new stakeholders, SRE and subnational governments have become new leaders in science that can extend to the rest of the Latin American region via science-based cooperation initiatives, not exclusively towards a COVID-19 vaccine, but integrating a range of pressing issues into a common regional science diplomacy agenda.

Acknowledgments

The authors acknowledge the support of the Universidad Nacional Autónoma de México UNAM, host institution of the Chair in Science Diplomacy and Scientific Heritage, for its institutional support. Additionally, the authors recognize the Ministry of Education, Science, Technology and Innovation of Mexico City; the Ministry of Planning and Foresight of the state of Hidalgo; and the Mexican Agency of International Cooperation for Development, AMEXCID for its valuable support during this research as well as CONACyT: YT has received fellowship 263119.

Endnotes

1. Peter J. Hotez, “‘Vaccine Diplomacy’: Historical Perspectives and Future Directions,” PLoS Neglected Tropical Diseases 8, no. 6 (2014): 1–7.
2. Sherbune Friend Cook, “Francisco Xavier Balmis and the Introduction of Vaccination to Latin America,” Bulletin of the History of Medicine 11, no. 5 (1942): 543–560.
3. Ana María Carrillo, “Vaccine Production, National Security Anxieties and the Unstable State in Nineteenth- and Twentieth-Century Mexico,” The Politics of Vaccination: A Global History, 2017, 121–47.
4. Claudia A. Hurtado Ochoterena and Norma A. Matías Juan, “Historia de La Vacunación En México,” Revista Mexicana de Puericultura y Pediatría 13, no. 74 (2005): 47–52.
5. Jesús Kumate and Armando Isibasi, “Las Infecciones Prevenibles Por Vacunación | Salud Pública de México,” Salud Pública De México 30, no. 3 (1988): 349–61, https://saludpublica.mx/index.php/spm/article/view/175.
6. Andrus Jon Kim et al., “The Past, Present, and Future of Immunization in the Americas,” Revista Panamericana de Salud Pública 41 (2018): 121, https://www.scielosp.org/article/rpsp/2017.v41/e121/.
7. GSK, “México: País Pionero En La Producción Local de Vacunas. Historia y Avance de La Vacunación En México,” 2015, 1–8, https://www.gob.mx/cms/uploads/attachment/file/400159/Varios_-_Historia_....
8. Ibid.
9. José Ignacio Santos, "La Vacunación en México en el Marco de las ‘Décadas de las Vacunas’: Logros y Desafíos," Gaceta Médica de México 150, no. 2 (2014): 180–188.
10. Ellen R. Shaffer, Howard Waitzkin, Joseph Brenner, and Rebecca Jasso-Aguilar, "Global Trade and Public Health," American Journal of Public Health 95, no. 1 (2005): 23–34. 
11. Santos, "La Vacunación en México en el Marco de las ‘Décadas de las Vacunas’: Logros y Desafíos."
12. Gustavo Leal Fernández, "Calidad del Desempeño del Sector Salud Frente a la Influenza A (H1N1)," Casa del Tiempo 29 (March 2010): 68–79.
13. Eduardo Menéndez, “Las Instituciones y Sus Críticos o La Costumbre de Polarizar La Realidad: El Caso de La Influenza A (H1N1),” Salud Colectiva 10, no. 1 (2014): 15–40.
14. Silvia Tamez et al., “La Articulación Público-Privada En La Producción de Vacunas En México,” Saúde Em Debate 40, no. 111 (2016): 9–21.
15. Carrillo, “Vaccine Production, National Security Anxieties and the Unstable State in Nineteenth- and Twentieth-Century Mexico.”
16. World Health Organization (WHO), “WHO Coronavirus Disease (COVID-19) Dashboard,” n.d., https://covid19.who.int.
17. Malik Sallam, “Covid-19 Vaccine Hesitancy Worldwide: A Concise Systematic Review of Vaccine Acceptance Rates,” Vaccines 9, no. 2 (2021): 1–15.
18. Bruce Y. Lee, "How effective does a COVID-19 coronavirus vaccine need to be to stop the pandemic? A new study has answers," The Conversation, https://theconversation.com/how-effective-does-a-covid-19-coronavirus-va...
19. David E. Bloom, Daniel Cadarette, and Daniel L. Tortorice, “An Ounce of Prevention,” Finance and Development 57, no. 3 (2020).  
20.  WHO, “Coronavirus Disease (COVID-19): Vaccines,” n.d., https://www.who.int/news-room/q-a-detail/coronavirus-disease-(covid-19)-vaccines.
21. COVID-19 Vaccine Tracker, “Mexico,” 2021, https://covid19.trackvaccines.org/country/mexico/.
22. Jorge Schiavon, Comparative Paradiplomacy (New York: Routledge, 2019).
23. Pierre-Bruno Ruffini, Science and Diplomacy (Cham, Switzerland: Springer International Publishing, 2017).
24. Cecilia Bañuelos and Esther Orozco, "La Biotecnología en la Diplomacia Científica Mexicana y la Lucha contra la COVID-19," BioTecnología 24, no. 3 (2020): 11–28.
25. Federal Government of Mexico, “México Supera 30 Millones de Dosis de Vacunas Contra COVID-19,” May 19, 2021, www.gob.mx/sre/prensa/mexico-supera-30-millones-de-dosis-de-vacunas-cont....
26. United Nations, “74th Session, ‘International Cooperation to Ensure Global Access to Medicines, Vaccines and Medical Equipment to Face COVID-19’, (Resolution A/RES/74/274), April 20, 2020,” 2020, https://undocs.org/es/A/RES/74/274.
27. Federal Health Ministry, “Open Source of General Directorate of Epidemiology,” n.d., https://www.gob.mx/salud/documentos/datos-abiertos-152127.
28. Secretaría de Educación Ciencia Tecnología e Innovación de la Ciudad de México, “La UNESCO y La SECTEI Promueven la Vía Científica Para Hacer Frente a La Pandemia Por COVID-19,” 2020, https://www.sectei.cdmx.gob.mx/comunicacion/nota/la-unesco-y-la-sectei-p....
29. NotiCyTI, “Investigadores Mexicanos Viajan a Sincrotrón Suizo Para Combatir Covid-19,” May 20, 2020, https://invdes.com.mx/ciencia-ms/investigadores-mexicanos-viajan-a-sincr....
30. Brenda Valderrrama and Parsifal Islas, “Personal Communication,” n.d.
31. Carrillo, “Vaccine Production, National Security Anxieties and the Unstable State in Nineteenth- and Twentieth-Century Mexico.”
32. Bañuelos and Orozco, "La Biotecnología en la Diplomacia Científica Mexicana y la Lucha contra la COVID-19."
33. COVID-19 Vaccine Tracker, “Mexico.”