Who will get the coronavirus vaccine first? All the lofty rhetoric aside, geopolitics and money talk.
It’s not purely about protecting a population’s health. As many experts see it, a vaccine is also a vital in getting economies back on track.
World leaders know this, and it’s causing wealthy countries to snap up hundreds of millions of doses of pre-ordered potential vaccines, hedging their bets that one of the front-runners they’ve chosen will be successful.
Suerie Moon, co-director of the Graduate Institute Geneva’s Global Health Centre, calls these candidates “strategic assets” on par with “military weapons.” Having access to a vaccine is a chance to strengthen a country’s allegiances, political standing and prestige, she noted.
Even before a single vaccine has been produced, deals worth hundreds of millions or even billions of euros have already been done.
The U.K. has secured up to 30 million doses of a potential vaccine created by BioNTech and Pfizer, has a separate deal with AstraZeneca for 100 million doses of its vaccine, and another deal with GSK and Sanofi Pasteur for 60 million doses. AstraZeneca also has a contract with four EU countries — the Netherlands, Germany, France and Italy — to buy 400 million doses.
Not one to be outdone, the U.S. has three deals agreed, one with BioNTech and Pfizer (worth nearly $2 billion) for 600 million doses, another with AstraZeneca for 300 million doses and a third with Novavax for 100 million doses.
But this rich-country scramble is “disastrous at the international level,” said Moon.
“It means that there will be very, very little vaccine available for the rest of the world and for countries that either don’t have the money or the production capacity within their own borders to access the vaccine,” she said.
In the first year after a vaccine is found, there just won’t be enough doses to go around, said Charlie Weller, head of the Wellcome Trust’s vaccine program.
“Therefore the mechanisms to allocate scarce resources fairly are going to become absolutely critical,” she said.
The vehicle to organize this effort is the Covid-19 Global Vaccine Access Facility — known as COVAX — which serves as a purchasing pool. The idea is to prevent a repeat of the mad dash in 2009 to secure the swine flu vaccine, which resulted in high-income countries commandeering the lion’s share, leaving poorer countries far down the queue.
Pharma in the middle
Big Pharma is hyper-aware that the world could see this happen again.
Thomas Cueni, director general of the International Federation of Pharmaceutical Manufacturers and Associations (IFPMA), warned that industry might be caught in the middle between governments wanting their country to receive the vaccine first and global access initiatives attempting to ensure equitable distribution.
“We do not want to run that risk,” he said at a Chatham House event on July 22. “That’s why we are fully committed to the COVAX Facility.”
“But in terms of getting support for the facility, you need solidarity from richer countries willing to subsidize the poorer countries,” he added.
However, Doctors Without Borders’ senior vaccines policy adviser, Kate Elder, thinks that industry shouldn’t be automatically released from responsibility.
“Industry definitely should not just be making deals with the first high-income country that has a lot of money to come in and negotiate with them,” she said. Elder conceded, however, that Big Pharma seems to have shifted its stance in the pandemic, with some vaccine-makers promising “not for profit” vaccines.
For now, promises of so-called solidarity from richer countries have been forthcoming. German Chancellor Angela Merkel has described a future vaccine as a “public health good for all humanity,” while European Commission President Ursula von der Leyen says the vaccine must be deployed at an affordable price to “every single corner of the world.”
French President Emmanuel Macron has made similar declarations, saying at the Global Vaccine Summit that when a vaccine is discovered, it must benefit everyone “because it will be a global public good.”
Elder said these messages are unprecedented.
“We have never seen so many heads of state, standing up and saying these are going to be global public goods … [that] this is going to be the people’s vaccine,” she said.
James Love, director of Knowledge Ecology International, is more skeptical.
The follow-through from these warm words “has been a lack of transparency and a lot of secret deals,” he warned. “[In a] lot of cases this is considered a national security issue by some countries, and so it’s very hard to get transparency.”
The U.K., for example, has agreed several bilateral deals with drugmakers in which the precise terms are secret.
However, Health Secretary Matt Hancock insisted to the U.K. parliament on July 20 that the U.K. is “working to ensure that whoever’s vaccine is approved first, the whole world can have access.”
“We reject narrow nationalism,” he said. “We support a global effort, because this virus respects no borders, and we are all on the same side.”
But there is one caveat: The U.K. is covered first.
“Naturally I’m determined to ensure that there is enough vaccine for the whole U.K. population, first and foremost,” Hancock told MPs the next day. “I am after all the U.K. secretary of state for health and social care.”
For Elder, this kind of talk is “almost like trying to have your cake and eat it too.”
At the moment, she noted, it’s unclear whether serving your own population and participating in a global solution are mutually exclusive.
“But … in a global context of scarcity of supply of future medical tools and vaccines that everybody needs, there might be some elements that indeed are mutually exclusive,” she said. “You can’t do both things sufficiently.”
In fact, it may prove surprisingly easy to keep a British-made vaccine in the country — simply by implementing an export restriction.
Europe’s fondness for banning exports of goods that are considered necessary for public health was illustrated at the beginning of the pandemic, when Germany and France scrambled to keep vital personal protective equipment within their borders, while the EU banned exports outside the bloc.
For his part, Hancock hasn’t yet threatened an export ban. Instead, he has justified keeping a vaccine in the U.K. by claiming that once a vaccine is found, it can be manufactured and distributed to anyone.
“The point of a vaccine is that once you’ve got the blueprint, lots of people around the world can manufacture it, and we don’t want to stand in the way of that,” he claimed on July 21.
Except Hancock seems to have forgotten about one small issue — intellectual property, something fiercely guarded by Big Pharma.
It’s the issue that Love has been battling Big Pharma over for more than 25 years.
Love believes that if anyone has a vaccine that could work, “they should start the technology transfer right now to other companies that have the capacity to manufacture that vaccine.”
The more manufacturers have capacity, the more quickly the vaccines can be made, which in turn makes it easier to get large quantities cheaply to more people, explained Love. “But that has not been the path that governments have really embraced adequately,” he said.
What’s the alternative?
The problem, explained Moon, is that there isn’t a global entity that has both the power and authority to enforce a workable system to equitably distribute a vaccine.
The COVAX facility is attempting to do this, but participation is voluntary. Designed by Gavi, the Vaccines Alliance, CEPI, and the World Health Organization, the facility aims to ensure quick and equitable access to 2 billion doses of a future vaccine by agreeing advance purchase deals with drugmakers. Wealthy countries would pay for any future doses through their own coffers while donating to the facility to ensure that up to 90 lower-income countries also receive doses.
However, soon after launching, the facility’s draft design was sharply criticized by civil society groups as it would have seen wealthy countries covering up to 20 percent of their populations, with no similar arrangement for donor-funded countries.
The feedback appears to have been taken on. According to a Gavi spokesperson, under the latest iteration, “allocation will initially prioritize health and social care workers but will then expand to cover 20 percent of the population of participating countries.”
“Further doses will then be made available based on country need, vulnerability and Covid-19 threat,” the spokesperson said.
Weller believes that limits like these on supply is “the best way we’ve got to ensure that there’s enough vaccine for those who need it in the rest of the world.”
Belt and braces
This trade-off isn’t lost on wealthy nations, which are beginning to express interest in COVAX. However, some countries have continued to agree bilateral deals, leading to concern that countries could be negotiating twice for the same vaccines.
How exactly a vaccine would be distributed if a government has both a bilateral deal with a manufacturer and is part of COVAX is unclear.
“In principle, we are asking manufacturers to supply us as soon as their vaccine doses become available – ‘equal access,’” said the Gavi spokesperson when asked about this dilemma. “Some manufacturers may have obligations to supply their domestic government first. To mitigate that, we are aiming to sign contracts with manufacturers that don’t have such obligations as well.”
There’s broader agreement on who should get the vaccine first: Health care workers, the elderly and those with co-morbidities are already on the WHO’s allocation plan.
Where it gets trickier is whether particular ethnic groups that have died disproportionately from Covid-19 — such as Black Britons — should be higher up in the queue. There are also questions over which professions should be prioritized over others.
And then there’s the question of whether “governments will give priority access to well-connected people, to cronies, as political favors,” warned Moon, adding that there needs to be “a level of vision and leadership” that sees beyond this.
In the end, equitable distribution is a win-win, according to the Wellcome Trust’s Weller.
“It’s the right thing to do. But it’s also the fastest way to end the pandemic,” said Weller. “Until all people in all countries are protected from Covid, then we’re still all at risk.”
This article has been updated to reflect the number of doses the U.K. has secured from BioNTech and Pfizer. It is 30 million doses.