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Vaccine nationalism and vaccine diplomacy: Vaccine distribution and the global south

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The coronavirus pandemic represents a massive challenge for all states. In the first instance, it is a health crisis, with thousands of citizens infected and dying across the world. At the same time, the health crisis is accompanied by an economic crisis, as government measures to deal with the pandemic lead to severe contractions in economic activity. Finally, it represents a potential political crisis, with governments facing the massive challenge of addressing both the pandemic itself and its effects.

The ability of states to deal with the crisis varies greatly. While rich countries with strong institutions are well placed to handle it reasonably well, poorer countries with institutions that are less effective are severely constrained.

Poor countries’ access to Covid19 vaccines depends on the production capacity and the policies of the vaccine producing countries. The vaccines were first developed in the West and Western countries have the largest production capacity, at least in the short term. However, vaccines are also produced in China, India and Russia.

Although everyone realises that “nobody is safe until everybody is safe”, responses to the pandemic and to vaccination have been driven by national interests rather than global cooperation and solidarity. While Western countries’ policies can be described as “vaccine nationalism”, doing everything they can to get access to as many vaccines as possible to their own citizens, emerging powers such as China, India and Russia, have been practicing “vaccine diplomacy” and used the pandemic to improve their relations with other states.

Constraints on vaccine distribution: Politics and economics

In addition to the global constraints in terms of production capacity, three interrelated factors constrain poor countries’ access to vaccines at the moment: lack of purchasing power, vaccine nationalism in rich countries and intellectual property rights preventing the production of cheaper vaccines. The first is purchasing power. At the moment, global production capacity is still limited in relation to demand. So far, rich countries, with 14% of the world’s population have obtained 53% of the vaccines. Almost all of the Pfizer/BioNTech and Moderna vaccines have gone to rich countries. The US and the UK have banned vaccine exports, while the European Union (EU) has exported 34 million doses to Singapore, Saudi Arabia and Hong Kong – countries that have no problem paying for vaccines. The EU has also sent about 9 million doses to the UK. Meanwhile, African countries, such as Uganda and South Africa, have paid more than twice as much per dose for the AstraZeneca vaccine as the EU. This has led the World Health Organisation (WHO) to warn that the world is on the brink of a “catastrophic moral failure”.

The second constraint for developing countries is political. With production capacity limited and concentrated in rich countries, poor countries have received a very limited number of vaccines. Rich countries have prioritized securing vaccines for their own citizens and have ordered several times more vaccines than they need. Taken together with the shortage of supply and poor countries limited purchasing power, this “vaccine nationalism” has left poor countries with only a fraction of the vaccines they need.

The third constraint is the system of intellectual property rights, which gives those who develop a vaccine an exclusive right to produce it for a specified time period. The first medicines were developed by Western companies with funding from governments and in cooperation with public research institutions. After the first vaccines were developed, Chinese and Russian companies have developed their own vaccines, while India’s Serum Institute has made an agreement with AstraZeneca to produce their vaccine with a license. The Serum Institute has produced 60 million vaccine doses, which have been supplied to over 70 nations, on a bilateral-grant or commercial basis. While China, India, South Africa and Brazil have the ability to develop and produce copies of the patented vaccines – so-called generics – significantly cheaper than the big Western companies, they are only allowed to do so if agreements are made with the patent-owning companies. India and South Africa have proposed that patent rules should be wavered in the current emergency situation. However, this was flatly rejected by both Western governments and the pharmaceutical industry.

International cooperation and vaccine diplomacy

Meanwhile, there are two countervailing factors that to some extent compensate for these constraints. First, the Covax initiative – a collaboration between UNICEF, the WHO, the vaccine alliance Gavi and the Coalition for Epidemic Preparedness Innovations – uses purchases by wealthier nations to fund vaccine supplies to poorer and middle-income countries. The Serum Institute is contracted to supply 1 billion vaccine doses to Covax this year, and received $300 million in funding support from Gavi and the Gates Foundation to assist it in expanding its capacity. By 1 April, 33 million vaccine doses India have been distributed through the Covax facility.

However, funding for Covax remains insufficient. According to the WHO, Covax has only received a quarter of the funds needed. Moreover, because of an increase in infections in India, export of vaccines produced in the country were halted in late March. In addition, India is now facing constraints in supplies of filters and bags needed for its vaccine production, as a result of a US ban on exports of such equipment. These developments will cause delays in the distribution of vaccines, including distribution under the Covax programme.

The second countervailing factor is the vaccine supplies coming from non-western countries. While Western countries have scrambled to obtain as many vaccines as possible for their own population, other countries have used vaccines as a political resource. China, India and Russia have all distributed vaccines to other countries, sometimes for free. Such “vaccine diplomacy” lies behind the distribution of vaccines to countries in Asia, Africa and Latin America.

In Asia, it has become part of the competition between China and India for regional influence. India, with its formidable vaccine manufacturing capacity, and a licensing deal to produce the AstraZeneca vaccine, has distributed 60 million doses, mainly to Bangladesh, Nepal, Sri Lanka and the Maldives. Its pharmaceutical industry is also the largest contributor of vaccine to the global Covax facility.

China has sent its own manufacturers’ vaccines to a large number of countries in Africa, the Middle East and Latin America – partly as donations and partly as sales. This vaccine provision has been linked with the Belt and Road Initiative, distributing vaccines as part of deals related to ports, roads and rail projects. China has also decided to provide 10 million vaccine doses to the Covax alliance.

Meanwhile, Russia has capitalised on delays in the EU’s programme to promote its Sputnik vaccine to Hungary, Serbia, Austria, as well as to Middle Eastern and Latin American countries, albeit in much smaller volumes than China and India. Russian and Chinese companies have also been willing to strike licensing deals to allow manufacturers in places such as Indonesia and Malaysia to partly or fully produce Covid-19 vaccines themselves.

So what are the implications of these factors for poor countries’ ability to vaccinate their populations? Clearly, the constraints faced by poor countries (purchasing power, vaccine nationalism and patent rules) have so far been much more severe than the countervailing factors (Covax, supplies from emerging powers). The result is that poor countries, by and large, will have to wait until rich countries have vaccinated their own populations before they will receive anything like the amount of vaccines they need. Meanwhile, the pandemic will continue, and new mutants are likely to emerge which may be both more infectious and more resistant to the existing vaccines.

The Coldest Cold Chain: Chilling Effects of Covid-19 Vaccines

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This post first appeared on the International Health Policies (IHP) blog, and is re-posted here. You may access the original post by clicking this link.

Woman receiving an influenza vaccination at the Maternal and Child Hospital in Vientiane, Laos. Photo: CDC via Unsplash

After various stretches of lockdowns and the related dire political, social, and economic consequences, the world has welcomed the news that several companies – including ModernaAstraZeneca and Pfizer – are approaching an effective vaccine for Covid-19. Approximately 200 more are in the pipeline, of which 48 in clinical and 164 in pre-clinical stages of development. While there is thus hope on the horizon, for low and lower-middle income countries the roll-out of the vaccine will be enormously expensive, whatever option is eventually selected. As such, the life-saving vaccine may bring ramifications for future prioritization within domestic health budgets as well as allocations in foreign aid budgets.

In terms of ethics considerations, much of the debate so far has either focused on (1) criticizing high-income countries scrambling to secure vaccines for their citizens for lacking in solidarity and for inadequate support of equitable distribution schemes (COVAX) – or (2) on prioritization of population groups (see herehere and here). Contributing to the emergent analysis of the ethics of Covid-19 vaccination schemes while things are still ‘up in the air’ – the coordinated ‘mammoth operation’ led by UNICEF is in the midst of a vaccine tender process (running 6 weeks from November 12) – in this commentary, we suggest that attention must also be paid to the complex ethics challenges arising from the logistical challenges of distributing specific vaccines.

Taking the Pfizer vaccine, with a storage requirement of -70˚C (-94 F) or below, as our case example, we identify a preliminary list of challenges relating to the feasibility and societal impact of a successful roll-out of an ultra-cold chain dependent vaccine. The cost and the probability of logistics failure is extremely high – and even if a program can be successfully implemented, serious ethical issues with chilling effects on global health outcomes will likely arise. We also suggest that laying out some of the issues related to the Pfizer vaccine, if it were to be rolled out globally, can shed some light on medium and long-term ethics challenges for other vaccines as well, even if some probably present fewer challenges in this regard.

Feasibility

With respect to feasibility, ultra-cold chains require special cooling systems in facilities and during transportation. The tradeoffs involved in successful implementation must be carefully considered. Technical challenges greatly increasing risk include time constraints, freezing units, package sizes, and kitting:

  • The vaccine puts significant constraints on time: The proposed active plus passive cooling in containers will enable keeping vaccines in the required temperature range for 72 hours, after which the combination of power cells (active cooling) and dry ice (passive cooling) deteriorates. Such a short delivery time calls for air transportation; yet carrying dry ice on airplanes, especially passenger planes, is regulated as it consumes oxygen. The same solution has been used for ultra-cold chains before (e.g., STRIVE Ebola vaccine), but the scale of any Covid-19 vaccination programme will be constrained by the global availability of such containers, and the regulations constraining their use.
  • The unaffordability of freezing units is a possible spoiler: The estimated time that vaccines will stay usable after opening a package is 24 hours only. At facilities, including storage, customs, cross-docking, materials handling, and vaccination centers, freezing units will be required to store and appropriately handle the vaccines. In a bidding war, rural, small, and underfunded hospitals will lose out.
  • Proposed package sizes are for 5,000 vs 1,000 units. While optimal for transportation, these sizes do not consider usage patterns: the administration of 1,000 vaccines within 24 hours requires huge distribution facilities and massive manpower. Throwing away unused vaccines comes at an exuberant cost. Locations with lower population density may not be able to use such package sizes and de facto be excluded from the distribution of vaccines.
  • Vaccination programs have a host of material needs: syringes, gloves, PPE, tents for locations etc. Kitting will be of the essence; yet the other parts of these health kits will differ in their temperature control requirements. Inter-agency health kits have in the past been developed for vaccination programmes as well as emergencies, and include from cholera kits to entire field hospitals as a kit. They are composed in a way that regardless of the administering unit, any humanitarian organisation or health centre would know what to find in which box, and which items would need special processes (such as temperature control) in handling and storage. In the case of COVAX, UNICEF has started to procure and stock up on e.g. syringes and gloves, as to say, items that will for sure be needed to be able to administer vaccines.

Societal impact

In terms of societal impact, the following chilling effects of getting an effective vaccine program rolled out urgently need ethical consideration:

  • The Covid-19 response focuses on an increasingly narrow range of options for combatting the pandemic. We are now at a point where the solution – in the form of a vaccine (any of the vaccines) – is steering problem framing. However, even if cold chains can successfully be kept intact in hard-to-reach areas, and the vaccine can be distributed successfully, a vaccine program does not solve the structural problems in public health infrastructure that are greatly exacerbated by the pandemic. Food shortages, lack of access to clean water and basic hygiene, domestic violence and drop-outs will not be magically cured through a vaccine.
  • While the Covax Advanced Market Commitment (AMC) scheme will likely be a useful vehicle to secure health outcomes, it should be noted that GAVI explicitly mentions co-payments: “it is likely that the 92 ODA-eligible countries accessing vaccines through the AMC may also be required to share some of the costs of COVID-19 vaccines and delivery, up to US$ 1.60 – US$ 2 per dose – a mirror of the amount paid upfront by self-financing participants.” Taken together, the knock-on effects of the cost of vaccines and ultra-cold chains constrain future decisions about health budget allocations. Already overwhelmed health budgets in poorer regions will be additionally burdened by high-income countries demanding that vaccine coverage is prioritized to combat Covid-19 once and for all. In other words, the countries with the youngest populations and the highest child mortality will be asked to invest their health budgets to rescue the aging West.
  • Whichever vaccine or set of vaccines are procured for distribution through global mechanisms, this decision will likely determine pathways for foreign aid. For example, once effective ultra-cold chains have been financed and established, there is a likelihood that allocations for vaccines will tie up a significant portion of donor budgets for the short-to-medium time. We argue that the funding of vaccine initiatives –in particular the financing of the ACT-Accelerator through ODA budgets– needs to be subjected to careful ethics impact assessments.

In conclusion, while a vaccine requiring an ultra-cold chain may be the most daunting one logistically, all options come with their own requirements on temperature ranges, but also with differences in vaccine efficacy, and regimes to administer. Technically, if we can manage the Pfizer one, the other ones should follow. Regardless, the ethics of every single vaccine candidate, including its likely logistics pathways and distributive impact on public health, needs to be carefully mapped out.