Then Health Minister Hridayesh Tripathi receiving the first batch of 348,000 doses of Covishield AstraZeneca vaccines from the UN Resident Coordinator in Nepal Sara Beysolow Nyanti in March. The remaining 1.92 million doses promised by COVAX never arrived. Photo: UN
The realpolitik of vaccine nationalism and how it impacts on countries like Nepal
As a previously unknown mystery disease caused by the novel coronavirus struck Planet Earth in the winter of 2019-20, public health officials and the World Health Organization (WHO) recommended universal mask wearing, physical distancing, lockdowns and travel restrictions, while awaiting the arrival of preventive vaccines and effective therapies.
On two sides of the Atlantic, two contrasting approaches emerged to tackle what came to be known as the Covid-19 pandemic.
On the one hand, there was the erratic and eccentric Donald Trump (seconded by his Brazilian buddy Jair Bolsonaro) who denied the seriousness of the pandemic or peddled his “genius” discovery of miscellaneous medications and magical cures like injecting disinfectants into human body or irradiating patients’ bodies with UV light.
Blaming China and WHO was Trump’s fallback position to hide his own policy failures. But he also invested billions of dollars to bankroll several American pharmaceutical companies to speed up the production of Covid vaccines through his Operation Warp Speed.
Consistent with his ‘America First’ priority, the vaccines were meant primarily for Americans, of course, though any leftovers could be sold or given away to friendly countries abroad depending on the MAGA Leader’s mood and magnanimity.
On the other side of the Atlantic, at the urging of the WHO Director-General Tedros Adhanom, many European leaders took a seemingly more enlightened global approach. Recognising that “no one is safe until everyone is safe”, European Commission President Ursula von der Leyen, French President Emmanuel Macron, German Chancellor Angela Merkel and their fellow Nordic counterparts declared that they would eschew “vaccine nationalism” and embrace the concept of a Covid vaccine as a ‘global public good’ to be made available equitably to all countries. The United Nations, the developing world, civil society organisations and celebrities welcomed this enlightened approach.
Encouraged by this idealistic vision, WHO launched a clumsily worded but ambitious ‘Access to Covid-19 Tools (ACT) Accelerator’ that would speed up the development, production, and equitable access to Covid-19 tests, treatment, and vaccines. The ACT Accelerator brought together a grand alliance of governments, scientists, businesses, civil society, and philanthropists, including the Gates Foundation, GAVI, the Vaccine Alliance, the Global Fund, the Coalition for Epidemic Preparedness Innovations (CEPI), the World Bank, Unicef.
It was a who’s who of the global health partnership. The most important ‘pillar’ of the ACT Accelerator was the ‘COVID-19 Vaccines Global Access’, abbreviated as COVAX.
COVAX is hosted and administered by GAVI, and its main vaccine procurement and delivery partner is Unicef. A high-level COVAX Coordinating Mechanism with representation of a cross-section of its partners and multiple technical groups is responsible for ensuring equitable allocation and access to Covid-19 vaccines worldwide.
Participating in COVAX are two groups of countries: the fully self-financing high-income countries (HICs), and nearly 100 low and middle-income countries (LMICs) that generally rely on donor funding to receive some vaccines, but can also purchase some more with their own resources.
A mechanism called the Advance Market Commitment (AMC) through which GAVI guarantees the purchase of a large quantity of vaccines to incentivise manufacturers to produce doses and sell them at an affordable price. Initially, the donors were expected to capitalise on the COVAX facility with a contribution of $9 billion to purchase and distribute 2 billion doses of vaccines to meet the needs of some 20% of high-risk groups in participating countries, including frontline health workers and senior citizens.
Launched with much fanfare in April 2020, long before there were any viable vaccines, COVAX was hailed as a futuristic model of enlightened international cooperation to ensure that vaccine development and delivery would progress at ‘a speed, scale, and access never before seen in human history’.
Realpolitik of vaccine nationalism
While most poorer countries patiently waited for COVAX to be fully-functional, most richer countries, particularly the G-7 and EU members, decided to jump the queue and cut bilateral deals for their own citizens. Not to be left behind in the competition for public relations and profits, China, India and Russia, the three major vaccine producers outside Western Europe and the US, engaged in carefully orchestrated ‘vaccine diplomacy’ to bolster their image of solidarity with LMICs.
COVAX remained under-funded and unable to compete with the HICs that quickly reserved huge quantities of vaccines directly from the manufacturers, often exceeding their actual requirements. By August 2020, the Trump administration had signed seven bilateral deals with six companies for more than 800 million doses, enough to vaccinate 140% of its population.
The Biden administration substantially increased this. The EU was not far behind in reserving half a billion doses secured through two deals. The UK signed five bilateral deals for 270 million doses, equivalent to 225% of its population. Canada was at the head of the class reserving four times more vaccines than the total requirement for its population.
These bilateral deals severely undercut COVAX’s ambition of becoming the global coordinator of vaccine procurement, allocation and distribution. By the time it managed to secure the $8.3 billion it needed to procure and deliver the promised vaccines to 92 poorer countries in June 2021, manufacturers had no more vaccines to sell, as practically all their production was contractually committed to the HICs.
COVAX was caught in a Catch-22. Whereas initially it did not have enough money to buy the vaccines, now it has the money but there are no vaccines in the market. Besides HICs hoarding a huge cache of excess vaccines, two other problems are responsible for the global vaccine shortage.
The huge second wave of Covid infection in India in the Spring of 2021 led it to ban the export of the AstraZeneca Covishield vaccine manufactured by the Serum Institute of India (SII). This was a huge shock and disappointment for both COVAX and most lower-income countries like Nepal. They were counting on SII, the world’s largest vaccine producer, to be their main supplier.
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But an even bigger and more systemic problem is the unwillingness of a handful of Big Pharma to give up their exclusive patent rights to produce life-saving vaccines and medications. Although the World Trade Organization’s Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) provides for waiving patent rights in the case of life-saving medicines and vaccines, in public health emergencies like global pandemics, most HICs have refused to grant such waivers.
President Biden did express a willingness to consider waiving the intellectual property rights for Covid vaccines. But the same European leaders who loudly proclaimed Covid vaccines as ‘global public goods’, have stubbornly and hypocritically resisted waiving the IP rights of their pharmaceutical companies.
The hypocrisy is compounded because billions of dollars, euros and pounds of public funds were given to private Big Pharma companies to accelerate research and development of new vaccines for which they now claim exclusive patent rights to maximise profits for their private shareholders.
The G-7 charade
There were high hopes that the G-7 Summit of the world’s richest democratic countries in Cornwall in June 2021 would lead to a breakthrough in Covid response, revive COVAX and accelerate delivery of vaccines to developing countries. While the absence of an arrogant and unpredictable Trump created an atmosphere of congenial camaraderie at the G-7, its outcome was long in lofty rhetoric but woefully short in concrete and urgent action to tackle the global pandemic.
The IMF had estimated that an investment of $55 billion now would not only save the lives and protect the health of millions, but would help revive the world economy and yield a return of $9 trillion by 2025. Sadly, the G-7 accounting for 60% of the world’s economy did not pledge even 6% of the investment recommended by the IMF.
The G-7 commitment to donate less than one billion doses of the surplus vaccine they have hoarded, and that too over an extended period stretching well into mid-2022, was a huge disappointment in the face of a dramatic surge of newer and deadlier Covid variants ravaging countries like Nepal, much of Southeast Asia and the African continent.
COVAX estimates that it needs 2 billion doses in 2021 to reach the most vulnerable 20% of people in the developing world, and 11 billion doses to reach herd immunity by 2022. Alas, if current trends continue, if TRIPS patent waiver is not granted and technology transfer not facilitated to vastly increase and diversify vaccine production in many more countries, it might take decades before people in LMICs can expect to reach herd immunity.
The People’s Vaccine Alliance estimates that, at the current rate, low-income countries could take 57 years to fully vaccinate their populations, whereas G-7 countries are likely to reach that milestone in the next 6 months.
Contrary to the mantra of ‘vaccine equity’ chanted ad nauseum at the UN, at WHO, and at COVAX, the action and inaction of the G-7 actually promote vaccine nationalism. As the Secretary-General of the UN and Director-General of WHO have pointed out, vaccine nationalism in rich countries (and more recently in India) are perpetuating a two-tier world. Of the 2.1 billion Covid-19 vaccine doses administered worldwide so far, only 4% were provided to poorer countries by COVAX.
As UN Secretary-General António Guterres has noted poignantly, “Today, ten countries have administered 75% of all COVID-19 vaccines, but, in poor countries, health workers and people with underlying conditions cannot access them. This is not only manifestly unjust, it is also self-defeating.”
COVAX and an unequal world
COVAX has been criticised harshly for making tall promises but failing to deliver. As a bold and nascent initiative, it is going through teething problems, and has made some mistakes and miscalculations. GAVI that administers COVAX, made some early compromises on its egalitarian founding principles by agreeing to certain double standards applied to the HICs vs LMICs. For example, it allowed donor countries like the UK and Canada to pick and choose which vaccines they preferred to fund or purchase for themselves through COVAX rather than requiring their funding to be co-mingled as part of COVAX’s funding pool for all countries and products.
There was some consternation when the UK and Canada managed to purchase through COVAX fairly large quantities of their chosen vaccines, despite the fact that they had already procured plenty of vaccines through direct bilateral contracts with several vaccine manufacturers, even as COVAX was struggling to deliver minimal quantities of vaccines for LMICs.
Canada managed to procure through COVAX 1.6 million doses of the AstraZeneca vaccine while Nepal (a country of similar population size) only received 348,000 doses. An added irony is that some of those AZ vaccines in Canada remain unused and are on the verge of expiry, whereas 1.4 million senior citizens in Nepal are desperately waiting for their second jab of the AZ vaccine.
Some of these examples go to show that notwithstanding the lofty principles underlying the enlightened concept of COVAX, we still live in a world where, as the old saying goes, ‘one who pays the piper calls the tune’. On a larger scale, a similar situation prevails at the United Nations, where the principle of ‘sovereign equality of all member states’ is rendered meaningless by five veto-wielding permanent members of the Security Council, and a handful of other influential donors.
Despite such shortcomings, the UN, COVAX and other initiatives are important building blocks towards a fairer world of greater human solidarity. Imperfect as they are, humanity is better off with such organisations striving to harness the power of partnership and solidarity than a dog-it-dog world driven solely by narrow national or other parochial interests.
Some of the weaknesses and hypocrisy seen in the early functioning of COVAX are not the result of its model being wrong, but because some of its key sponsors not playing by agreed rules.
In a world of sovereign nation-states, leaders have a legitimate responsibility to protect their own populations first. Hence vaccine nationalism is understandable and should have been built into the design of initiatives like COVAX from the start — although pursuing vaccine equity must be its ultimate objective.
Without putting all our eggs in the COVAX basket, and while exploring all other options to meet our urgent vaccine needs, it is in the interest of countries like Nepal to help build a more robust COVAX to help the world better cope with future pandemics.
Kul Chandra Gautam, a Nepali diplomat, is a former Assistant Secretary-General of the UN and Deputy Executive Director of Unicef. He is also the author of Global Citizen from Gulmi: My Journey from the Hills of Nepal to the Halls of the United Nations. He was also a board member of GAVI.
Source: Nepali Times