When smaller is better: Microstates, island nations and overseas territories speed ahead in global vaccination race

Last week, British Health Secretary Matt Hancock described Gibraltar, a British-administered territory on the tip of the Iberian Peninsula home to around 30,000 people, as “the first nation in the world to complete its entire adult vaccination program.”

Vatican City, a city-state considered the least-populated sovereign nation in the world with just 450 full-time residents, is just this week completing the first doses of the Pfizer-BioNTech vaccine and beginning the second doses, according to the Holy See press office.

And not far behind are the Seychelles, an archipelago of over 100 islands in the Indian Ocean with a population of 97,000, where enough doses have been administered for 9 out of 10 people.

Other high-performing countries include Bermuda, another British overseas territory with a population of over 71,000; Monaco, a sovereign city-state with a population of under 39,000; and the Maldives, another archipelagic state in the Indian Ocean with a population of over 500,000.

One major factor in these place’s vaccination success is not hard to guess: Because they are smaller, they simply have fewer people to vaccinate. The United States is currently vaccinating well over 2 million people a day, far more than the entire population of all of these nations.

But even so, there are many small places that have struggled to vaccinate their population. Those that have succeeded are generally those able to secure vaccine doses through strong relations with larger countries. Some have even been able to play multiple states against each other for their own benefit.

Many of the top vaccinators are British overseas territories like Gibraltar and the Falkland Islands, which have benefited from the government’s large scale despite their distant location (Gibraltar, at the southern tip of Spain, is almost 7,000 miles away from the Falklands).

British overseas territories are self-governing, but exist under the sovereignty of Britain and have Queen Elizabeth II as their head of state. They are distinct, though similar, to crown dependencies like Jersey. Their status as independent countries is a matter of often heated debate.

In the Pacific, some small island nations like Palau and the Marshall Islands have benefited from their close relationship with the United States. Though both are independent nations, they have historical ties to the U.S. through pacts of free association.

These countries have received vaccine doses from the United States. “The U.S. government has been outstanding during this entire COVID crisis,” Jack Niedenthal, Secretary of Health & Human Services for the Marshall Islands, wrote in an email.

The Marshall Islands expects to be able to vaccinate all of its adult population by June if not earlier, Niedenthal said. The entirety of the country’s doses had come from the United States, he noted, and are mostly made up of the U.S.-backed Moderna vaccine.

Even countries that don’t have strong formal relations like these have been able to use bilateral relations in a way to get doses. “We have a lot of good friends that love us,” Vanessa Lesperance, a medical officer in the tourist-friendly Seychelles, told the Associated Press in February.

India and the United Arab Emirates have each donated more than 50,000 vaccine doses to the island nation, reflecting long-standing ties forged through trade and immigration. That’s put the Seychelles on track to become one of the first sovereign nations with herd immunity, and the government expects to lift quarantine requirements for virtually all travelers by the end of March.

Barbados, currently leading the Caribbean’s vaccine race, is another benefit of India’s vaccine diplomacy. Tourism officials in the island nation of roughly 301,000 people have indicated that they might soon begin offering jabs to foreign visitors, a surefire way to boost the struggling travel industry and reduce the risks associated with reopening resorts.

Barbados’ health ministry did not immediately respond to a request for further details, such as how many vaccine doses would be set aside for tourists.

There are many small countries that have not begun vaccinations, or expect the process to take years rather than months. Vanuatu, a Pacific Island with a population of 307,000, recently estimated that it may take until the end of 2023 to vaccinate the majority of its adult population.

Health officials in the Bahamas have similarly indicated that they do not expect to be able to get vaccines from major manufacturers like Johnson & Johnson until 2022, leaving the country to rely on donations and doses distributed through the global Covax initiative.

While Covax aims to ensure that poorer and less-powerful countries have access to vaccines, small countries that depend on the initiative have gotten a late start as orders went out to larger, wealthier nations.

Cape Verde, an Atlantic island archipelago with under 600,000 inhabitants, hadn’t vaccinated any residents until Thursday, when six health-care workers received the first doses from a shipment distributed by Covax.

There are practical problems with vaccinations, too. Smaller nations often do not have the equipment necessary to store and transport vaccines, especially those that require extra-cold storage.

Niedenthal said that in the Marshall Islands, they were saving doses of the Johnson & Johnson vaccine, which is comparatively simple to store, for those that lived in some of the more remote parts of the nation.

“You have to understand, while most of the outer islands have airstrips on the main island, there are still people who live on the outer islands of the outer atolls, and they have to be reached by boat,” he said. “Most of them have no electricity.”