SAN MARINO — On the ground floor of the only hospital in San Marino, a tiny, independent republic perched high above the surrounding Italian countryside, nurses prepared Covid-19 vaccine doses from glass vials labeled in Cyrillic script, flicked needles and sought to put nervous residents at ease.
“Have you started speaking Russian since you got your first shot?” one nurse asked, coaxing a smile from Erica Stranieri, 32, as he injected Russia’s Sputnik vaccine into her arm.
San Marino, an ancient enclave within northern Italy, topped with crenelated medieval battlements on a mountain near the Adriatic coast, is best known — to the extent it is known at all — as one of the smallest countries on Earth.
Just six weeks ago, San Marino risked becoming the last country in Europe to start inoculating its people. It had counted on an agreement with Italy to furnish it with vaccines, but they never materialized. With tensions rising and doctors threatening to stop working, the desperate government turned to Russia and found a warm embrace.
San Marino has long had close ties to Russia, and readily accepted more than 7,000 doses of the Sputnik vaccine, which has not been authorized by European or Italian drug regulators. For San Marino, it seemed like the natural thing to do.
Russians have been drawn for years to this nation of just 33,000 people, often flying directly from Moscow to the Italian beach town of Rimini only 10 miles away. More than 100,000 Russian tourists visit San Marino in a typical year, so many that most stores started hiring Russian-speaking salespeople.
“Pronto. Da,” the Ukrainian manager at one sunglass store answered the phone in Italian and Russian. She sold 15 pairs of designer sunglasses to a group of glamorous Russian regulars who browsed under Matryoshka dolls sent back from clients in Russia.
“San Marino is extremely convenient for taxes,” said Marina Skirnevskaya, 35, a customer who entered the shop with her pet Chihuahua. Ms. Skirnevskaya, who is from Siberia but lives outside Rimini and has an export company, said the arrival of Sputnik was a positive development, and she wished she could get it, but that it wasn’t needed to improve bilateral relations. “The relationship is good already.”
Signs of San Marino’s friendship with Russia dot the sloping stone streets of the historical town center. A few paces from the city walls is a 2006 statue of a terrified boy, dedicated to the hundreds of children killed by Chechen militants in the Beslan school siege of 2004. At the national university is a bust of the first person in space, the Soviet cosmonaut Yuri Gagarin.
San Marino did not back sanctions against Russia over the invasion of Crimea. In 2019, Sergey Lavrov, Russia’s foreign minister, visited San Marino without stopping in Italy.
“Politically there is a strong link,” said Sergio Rabini, 62, the director of the San Marino hospital, who was himself hospitalized with Covid in October. He walked past the Covid ward, still packed with patients intubated in intensive care, and down to the vaccination center.
“Here’s Sputnik,” he said, holding up one of the thawing vials. He said it wasn’t the first time his country hadn’t followed the lead of Italian or European regulatory agencies.
“Viagra,” he said with a grin. “We had it before the Europeans authorized it.”
Sputnik is just the latest tool Moscow has used to gain influence in Europe, exploiting rifts between the European Union, which has had a disastrously slow vaccine rollout, and some member states. This week, Slovakia’s prime minister resigned amid an uproar over his secretly arranging a delivery of Sputnik.
Roberto Ciavatta, San Marino’s health minister, said that he understood that many people saw geopolitics in Russia’s vaccine diplomacy, but that for his nation the issue was much simpler.
“The only vaccine in that moment available on the market was Sputnik,” he said in his office in the hospital complex.
Vaccine makers told San Marino that they would deal only with the European Union, Mr. Ciavatta said, and his government’s direct appeals to the Biden administration and the U.S. consulate in Italy went nowhere.
San Marino has been a political anomaly, its identity built on standing apart, ever since its founding, according to tradition, in 301 by its namesake, St. Marinus, a stonecutter who settled amid the craggy caves of Monte Titano in the Apennines.
What started as a haven for Christians escaping persecution by the Roman Empire eventually became an assiduously neutral microstate. One of the world’s oldest republics, it has a system of government more than seven centuries old, and a constitution codified in 1600.
After surviving feudal lords, Napoleon, the Austrian empire and Italian unification, it emerged in the 20th century as a wealthy haven for tax-averse Italians and a destination for tourism and duty-free shopping.
Just as San Marino is within Italy but not part of it, it is ensconced in the heart of the European Union but not a member of the club and its vaccine buying program. As Europe’s vaccination efforts stumbled badly, San Marino risked falling ever further behind.
With help from Russia, the positions are now reversed. San Marino has given at least one vaccine shot to 26 percent of its people, more than double the E.U. average. Officials say hundreds of Italians have tried to make vaccination appointments there, and some even showed up, hoping in vain to get vaccinated by the foreign state next door.
“We asked Italy for help and didn’t get any,” Denisa Grassi, a 42-year-old teacher, said after receiving her shot. “Now it’s the Italians who ask us.”
Some Italians see in San Marino’s embrace of Sputnik only its latest provocative pandemic behavior. In November, when Italy imposed a 6 p.m. curfew on eateries, San Marino kept its bars and restaurants open until midnight, luring Italians and their euros across the invisible border to what Italian officials worried was a hilltop viral breeding ground.
“It was mostly young people who took advantage to go out at night,” said Aldo Bacciocchi, 50, whose restaurant, Ristorante Bolognese, was recently featured on Russian television. Now, San Marino’s restaurants must close by 6 p.m., and Mr. Bacciocchi said that business was lousy and that he didn’t see a way back to normalcy unless people got vaccinated. His mother, 77, was scheduled to receive her second dose of Sputnik on Friday.
“It’s not that we prefer it,” he said. “It’s that it’s there.”
A shade of that normalcy returned to the center of San Marino on Thursday, for the biannual installation of the country’s two heads of state, known as Captains Regent.
Throughout the morning and early afternoon, military marching bands wearing helmets festooned with feathers snaked up and down the sloping stone streets, past luxury watch and jewelry shops, the “Torture Museum,” souvenir traps and a multitude of stores selling guns, crossbows and swords, a legacy of San Marino’s medieval armory industry and relaxed gun laws.
Dignitaries took advantage of pauses in the procession to sip aperitifs at sunlit cafes, until the cannons blasted again and the march resumed. Guards escorted the incoming and outgoing Captains Regent — wearing black velvet cloaks, blue-and-white ribbons, satin gloves, black tights, black velvet hats edged with white ermine fur, and lace scarves — into various grand marble and stone buildings.
Bishops and ambassadors and men in top hats joined the procession, and so did some local residents wearing ghost masks, silently protesting the coronavirus lockdown measures.
“San Marino is not Europe, and we’re not getting any help,” said Massimiliano Carlini, 58, the protest organizer, referring to the lack of funds directed to struggling businesses. Himself a vaccine skeptic, he wasn’t sure inoculations would help, though he welcomed Russia’s involvement. “Sputnik is the only one I think people should be taking.”
Among the protesters was Matteo Nardi, the nurse who had vaccinated Ms. Stranieri. An Italian by nationality, he wondered why Italy, struggling with vaccine shortages, didn’t offer Sputnik, too.
“I mean,” he said, “why not?”