VACCINE INEQUITY, Inside the cut-throat race to secure doses

Inequity is everywhere: Inoculations go begging in the United States while Haiti, a short plane ride away, received its first delivery July 15 after months of promises — 500,000 doses for a population over 11 million. Canada has procured more than 10 doses for every resident; Sierra Leone’s vaccination rate just cracked 1% on June 20.

It’s like a famine in which “the richest guys grab the baker,” said Strive Masiyiwa, the African Union’s envoy for vaccine acquisition. In fact, European and American officials deeply involved in bankrolling and distributing the vaccines against coronavirus have told The Associated Press there was no thought of how to handle the situation globally. Instead, they jostled for their own domestic use. But there are more specific reasons why vaccines have and have not reached the haves and have-nots. COVID-19 unexpectedly devastated wealthy countries first — and some of them were among the few places that make the vaccines. Export restrictions kept the doses within their borders. There was a global purchase plan to provide vaccines for poorer countries, but it was so flawed and underfunded that it couldn’t compete in the cut-throat competition to buy. Intellectual property rights vied with global public health for priority. Rich countries expanded vaccinations to younger and younger people, ignored the repeated pleas of health officials to donate their doses instead and debated booster shots – even as poor countries couldn’t vaccinate the most susceptible.

The disparity was in some ways inevitable; wealthy nations expected a return on their investment of taxpayer money. But the scale of the inequity, the stockpiling of unused vaccines, the lack of a viable global plan to solve a global problem has shocked health officials, though it wasn’t the first time.

“This was a deliberate global architecture of unfairness,” Masiyiwa told a Milkin Institute conference. “It’s simple math,” he said. “We have no access. We have no vaccine miracle.” The World Health Organization has duly updated its epidemic playbook after every outbreak, most recently with Ebola in mind. Then, as often in the decades before, an emerging illness was largely contained to countries lacking robust public health services, with poor sanitation and crowded living conditions and limited travel connections. For years, the WHO assessed countries’ readiness for a flu pandemic: The United States, European countries and even India ranked near the top. The U.S. readiness was 96%, and Britain at 93%.

On Jan. 30, 2020, WHO declared the coronavirus outbreak in China to be a global emergency. It would be months before the word “pandemic” became official. But that same day, the Coalition for Epidemic Preparedness and Innovations, or CEPI, was planning for the worst. CEPI announced “a call for proven vaccine technologies applicable for large scale manufacturing,” according to minutes from its scientific advisory group. CEPI said it would be critical “to support the strategy for global access” early in the game.

CEPI quickly invested in two promising coronavirus vaccines being developed by Moderna and CureVac. “We said very early on that it would be important to have a platform where all countries could draw vaccines from, where there’s accountability and transparency,” said Christian Happi, a professor at Nigeria’s Redeemer’s University and a member of CEPI’s scientific advisory committee. “But the whole idea was that we thought rich countries would fund it for the developing world.” Happi said officials never expected the pandemic would strike first and hardest in Europe and the U.S. Or that their assessment of preparedness in the world’s most advanced economies would prove horrifically optimistic. Global health experts would soon come to realise that rich countries “could sign a piece of paper saying they believe in equity, but as soon as the chips are down, they will do whatever they want,” he said. On March 16, five days after the global pandemic was declared, the novel mRNA vaccine developed by Moderna was injected into a trial participant for the first time. By then, the disease was tearing through the elderly populations of Europe and the United States.

Moderna and Pfizer/BioNTech were the first companies to come out with an mRNA vaccine, devising methods of mass production almost on the fly. Scientists at Britain’s Oxford University also came up with a vaccine with a more traditional platform, and Bill Gates brokered a deal for them to partner with AstraZeneca, a pharmaceutical company with global reach but no experience in vaccine production. On April 30, the deal was confirmed: AstraZeneca took sole responsibility for the global production and distribution of the Oxford vaccine and pledged to sell it for “a few dollars a dose.” Over the next few weeks, the U.S. and Britain secured agreements totalling 400 million doses from AstraZeneca.

The race to make and secure vaccines was on, and the United States and Britain were leagues in front of the rest of the world — a lead they wouldn’t lose. Still, both countries would see life expectancy decline by at least a year in 2020, the biggest drop since World War II. In the European Union, 22 countries saw their average lifespans cut short, with Italy leading the list. But as grim as the situation was, all those countries had a major advantage: They were home to the pharmaceutical companies with the most promising vaccine candidates, the world’s most advanced production facilities, and the money to fund both.

The U.S. repeatedly invoked the Defense Production Act — 18 times under the Trump Administration and at least once under Biden. The moves barred exports of crucial raw materials as factories were ramping up production of the as-yet-unapproved vaccines — and eventually, of the vaccines themselves. But it also meant those materials would run low in much of the rest of the world. The U.S. stranglehold would lift only in spring 2021, and only partially. Operation Warp Speed supercharged the global race to secure vaccines, but it would still take another two weeks until COVAX — the COVID-19 Vaccines Global Access Facility — was formally announced as the entity to ensure equity, with the Serum Institute of India as the core supplier for the developing world.

COVAX had the backing of the World Health Organization, CEPI, vaccines alliance Gavi and the powerful Gates Foundation. What it did not have was cash, and without cash it could secure no contracts. “Operation Warp Speed signed the first public deals and that started a chain reaction,” said Gian Gandhi, UNICEF’s COVAX coordinator for supply. “It was a like a rush on the banks, but to buy up the expected supply.” Some involved in the COVAX project flagged India as a potential problem early on, according to minutes of meetings in late spring and early summer of 2020.

Dr. Clemence Auer, the EU’s lead negotiator for vaccine contracts last summer, said the question of compelling pharmaceutical companies to suspend their vaccine intellectual property rights to increase the worldwide supply of coronavirus vaccines never even came up. “We had a mandate to buy vaccines, not to talk about intellectual property, ” Auer said. “The global community should have had this discussion back in 2020 but that didn’t happen,” he said. “Maybe we should have done it last year, but now it’s too late. It is spilled milk.”