Reflections and learning from Covid-19 crisis must cover all aspects of global and national responses. Here, I try to focus on some lessons that must be learnt from vaccine development and delivery.
1. Me first ?
Even while the vaccines were in clinical trials, rich governments showered pharmaceutical companies with millions of dollars and in return by November 2020, they bought 3.8 billion doses for their 16% of the world population.
It is predicted that while most rich countries can reach herd immunity by the end of 2021, most African countries would reach this state from early 2023 onwards. In fact, more than 85 poor countries will not have widespread access to coronavirus vaccines before 2023.
Rich countries and global institutions seem to put all their eggs into Covax basket. However, how can Covax deliver vaccines to Low and Middle Income Countries (LMICs) at the same time people are vaccinated in the north when the actual doses are not available? Moreover, Covax was designed to provide doses for at risk groups in LMICs –20% of the population. It is estimated that vaccination of 60-90% of a population is essential to reach herd immunity.
The Africa Union has a plan to reach 60% of Africa and has started negotiation with some companies to buy 270 million of doses. Yet not one single dose has reached Africa yet. Companies hold the power to decide what and when to allocate doses. Pfizer forced countries in Latin America to provide sovereign assets as a guarantee for indemnity from any civil claims of side effects even if resulting from a company’s fault.
In order to secure vaccination, many LMICs accepted donations and bought vaccines made by Chinese and Russian companies even without WHO emergency authorisation.
The WHO has warned against vaccine nationalism. Moreover, the virus has showed its ability for dangerous mutations that appeared in South Africa and Brazil. Yet these alerts did not change the grabbing behaviour of rich countries.
2. The elephant in the room: inadequate global supply
The fundamental problem facing the world is the inadequate supply due to the limited number and hence capacity of companies to supply doses for the whole world.
World leaders say that “nobody is safe until everyone is safe”. For example, in April 2020, the president of the European Commission stated that “We need to develop a vaccine. We need to produce it and to deploy it to every single corner of the world. And make it available at affordable prices. This vaccine will be our universal, common good.”
These words of global solidarity ring hollow in reality. Instead of global solutions for a global problem, the response has been bitty and nationalistic. There is no global plan of how, when and at what cost the world can reach global herd immunity.
I always imagine the situation as a bunch of strong individuals fighting for a bigger share of a small pizza leaving crumbs to the rest. This grabbing ignores the obvious solution of getting multiple big pizzas to feed all.
Yet the WHO and 40 countries launched a mechanism to facilitate maximum supply by enabling potential producers in all countries to manufacture million more doses. The Covid-19 Technology Access Pool (CTAP) is a one stop shop that facilitates the sharing of technology, knowhow and intellectual property (IP) so that other companies can produce the vaccines. However, rich countries ignore C-TAP -despite always talking about voluntary mechanisms especially in the face of proposals of IP waiver. Pharmaceutical companies rubbish it calling it “nonsense”. It is not surprising that not one single company has joined the pool especially when it has no support from international institutions like Covax, which would be a beneficial of increased supply.
It seems that rich countries are content to leave vital decisions of production, supply (who gets what doses and when), and price in the hands of pharmaceutical companies. Perhaps afraid not to get the millions of doses for their own population, governments are keeping off from trying to influence companies to share the technology that the very governments paid for.
3. Long term sustained and adequate investment in Biomedical research.
Sometimes it seems that the vaccines were quickly developed in 10 months by the pharmaceutical industry as if by magic. The reality is different.
The Oxford vaccine was based on research that started in 2002 with the emergence of SARS. More work was developed for MERS, another corona virus. Universities have been working on understanding corona viruses and developing vaccines since SARS. Universities such as Oxford that invented the vaccine that Astra Zeneca developed, are normally funded by taxpayer money.
Last year, governments invested more money in the research and development (R&D) of vaccines. For example, the UK government provided a grant of £65.5 million of new funding to Oxford university.
Similarly, research on mRNA started decades ago through the US National Institute of Health (NIH) and the University of Pennsylvania in addition to the knowledge generated on understanding corona virus. “When the pandemic started, we were on a strong footing both in terms of the science”. The NIH spends $ 41.7 billion annually on medical research. Since 2020, the US government poured money onto research institutions and companies to develop Covid-19 vaccines.
Clearly without sustained funding of university medical research, the world would have had to start from scratch taking years to produce a vaccine.
4. Change global system of biomedical research
The current biomedical R&D system relies on IP as the stimulus for innovation, which are fiercely protected by pharmaceutical companies and their supportive governments. Companies succeeded in implanting the believe that “no IP =no innovation” not only in politicians, academics but even in the public psyche ignoring that public funding is the fuel of the innovation engine.
Despite repeated failure of this system in producing medicines that are needed for public health such as the so called neglected diseases like sleeping sickness or antimicrobial resistance, the model is still protected.
Regarding pandemics, Dr. Tedros summarised the situation by saying that “Traditional market models will not deliver at the scale needed to cover the entire globe”.
Pharmaceutical companies claim that IP and high prices are critical to finance R&D. However, the industry keeps the cost of R&D of medicines and vaccines as a commercial/trade secret, and society has to accept a continually rising cost figure provided by one university funded by the pharmaceutical industry.
Many civil society organisations, academics and the WHO called for -at least exploring- a model of de-linking financing R&D from the price of resulting products. The delinking model can be a progressive reforming of R&D to enable universal access to knowledge and medical technologies responsive to public health and patients’ needs.
The financing of Covid-19 vaccines clearly illustrates the critical value of public funding not only for R&D but also -at least in time of pandemics- in manufacturing. Yet pricing is not delinked as companies told their investors of their intention to raise the prices in the near future to maximise their profit from the pandemic.
Yet still governments are not intervening to ensure supply of the vaccines or sharing the technology that they funded. The South African trade representative in Geneva summarised what should happen saying: “I don’t think governments should be outsourcing their responsibility for public health to private companies who are responsible to shareholders only.”
5. Sustained adequate investment in Public health system
Vaccine delivery is a critical part of dealing with pandemics. Outbreaks require a public health system ready to respond to these emergencies as well to run normal services.
After the Ebola outbreak, I personally wrote that “Resilient health systems, free at the point of use, are evidently a global public good. They are essential for the provision of universal health coverage and for a prompt response to outbreaks of disease”.
As illustrated by Covid-19, health systems are a foundation for national security as well as a basis for economic growth and social development. The vision that health care is a commodity to be chosen and paid for by the consumers with governments helping those who cannot is a short-sighted ineffective policy. Access to healthcare must be seen as a right and a public good that should be available to all and that users are citizens with rights not consumers of a luxury product that people have the choice of buying it or not.
The vision that investment in public health system is a public good means that national budgetary allocation must prioritise healthcare by adequate funding that matches health needs and advancement of technologies.
In summary, we must learn from the chaos and inequality of the global response to Covid-19. Every nation must prioritise investment in medical research and health systems as a right and as a public good. The world needs a different system of biomedical research that is based on sharing knowledge and technology. Pandemics require global plans for dealing with them and for maximising supply and fair sharing of vaccines.