World’s poor need action, not Covid ‘vaccine nationalism’, say experts

Pharmaceutical companies should do more to transfer vaccine technology to prevent the poorest countries falling behind in the distribution of Covid 19 vaccines, according to an expert.

The warning came from Dag-Inge Ulstein, the co-chair of the global council trying to speed up access to Covid vaccines for the world’s poor, known as the Act (Access to Covid-19 Tools) Accelerator. Ulstein, Norway’s international development minister, oversees the drive to ensure vaccines reach the poor – the Covax programme.

His remarks were amplified by his global health ambassador, John-Arne Røttingen, who told the Guardian that the battle to create equal access to vaccines was “at a very important turning point”. Other diplomats fear that if the issue of vaccine distribution is not resolved, it will result in years of resentment between the rich north and the poor south.

Samantha Power, the new USAid director, has also admitted the scheme is not on track, and the WHO director general, Tedros Adhanom Ghebreyesus, pointed out that only 25 people had been vaccinated in Africa compared with 39 million in rich countries, and said the world was on the “brink of a catastrophic moral failure”.

The Act Accelerator is aiming to distribute 2bn doses of vaccines by the end of 2021 to world’s 92 poorer countries. Those countries can buy from elsewhere if they wish, but are unlikely to have the cash, and outside the scheme the price is likely to be higher.

It is now forecast that only 27% of those living in poor and medium income countries will be vaccinated this year, but there are fears that something deeper may be going wrong. Detailed forecasts issued by the global vaccine alliance Gavi this week show Africa, a continent of 1.3 billion people, will only receive 140m doses by June through Covax.

As of mid-January, according to the Duke Global Health Institute, more than 7bn vaccine doses had been purchased globally and the lion’s share – 4.2bn – have gone to high-income countries. While high-income countries represent only 16% of the world’s population, they currently hold 60% of the Covid vaccines purchased so far. Canada topped the list, having purchased enough vaccines to cover more than five times their population. Most other high-income countries have more than 100% coverage, and some can cover their populations several times over.

Røttingen complained about vaccine nationalism. “The world’s efforts to create cheap vaccines for the world’s poorest countries has become very insular and out of proportion,” he said. “There are disputes over what are really minor differences over timing and scale of roll outs in different countries that all have started vaccination.”

He also warned that unexpected challenges were delaying the drive to distribute vaccines being overseen by Covax.

He said: “The difficulty is that we only really have widespread international approval for the marketing of two vaccines – the two mRNA vaccines. The challenge is that one, the Moderna vaccine, is very expensive, and the other, the Pfizer/BioNTech vaccine, that one was first available and is now being rolled out in Europe [and] is moderately expensive in comparison with others, and requires a super-cold chain.

He added: “The price and the cold chain makes them not the ideal vaccines for a global vaccine.”

He said: “We had hoped the other vaccines would be ready to go, but currently they are not. We are still waiting for general market approval of the AstraZeneca vaccine and even more importantly we are waiting for WHO pre-qualifications, particularly for the AstraZeneca vaccine, that are produced at the Serum Institute in India [SII] for Covax”.

Covax initially ordered 200m doses from SII, the world’s largest vaccine manufacturer, with options for up to 900m doses more of either the AstraZeneca/Oxford or Novavax candidates. It also signed a statement of intent for 200m doses of the Sanofi/GSK vaccine. In December it signed of a further purchase agreement with AstraZeneca for an additional 170m doses, and a memorandum of understanding with Johnson & Johnson for 500m doses of the Janssen candidate.

But Covax can only distribute vaccines approved by the WHO, and neither the AstraZeneca nor the Johnson & Johnson vaccine have that approval (although AstraZeneca has approval in the UK).

The degree to which these advance purchase agreements are binding legally is also contested. Serum, a privately owned company, has said a key priority is to provide for the domestic Indian market.

Faced by approval delays, Covax may announce later this week a small additional order from Pfizer and Moderna. But the costs of its vaccines were at one point treble the price per dose for which Covax has budgeted.

The delays and the clamour for a vaccine from voters are now pushing some countries to try to secure bilateral deals with pharmaceutical companies outside the Covax mechanism. South Africa, for instance, has ordered from AstraZeneca at reportedly double the price paid in Europe. It would form part of a portfolio of 20m doses. The South African president, Cyril Ramaphosa, has said he may have to raise taxes to fund this.

Røttingen said: “We had wanted a parallel rollout of the Covid vaccines globally, with the Covax mechanism ensuring rollout in the poorest countries. It has been made complex because the vaccines that had originally been chosen to be frontrunners, due to their price and logistical issues, are not yet ready.

“So now we are seeing middle-income countries understandably pressurised to make bilateral deals by their constituents, because vaccination programmes have started elsewhere, especially in Europe and the US.

“The danger is that we are going to see an increasing number of bilateral deals struck by these middle-income countries that may not be in their best long-term interests. They may be costly and some of the pharmaceutical companies can potentially use this political pressure to increase their profits and encourage countries to go with bilateral deals, instead of the joint procurement Covax facility. That is highly problematic.”

He said Norway was now trying to promote three principles to protect the scheme:

He said: “We need transparency and openness on these deals. WHO has the means, capacity, willingness to monitor the market, but they are not being given the data since these deals are not transparent. We need to shift that.”

Echoing the WHO’s Tedros, Ulstein also warned: “If all countries try to outbid each other in the fight for vaccines, we create an immoral race towards the abyss. We have a unique opportunity now to ensure that enough people in all countries are vaccinated, but then we must stick to the global approach and not fall for a vaccine nationalism that we have so long warned against” .

One bottleneck appears to be slowness with which data on the Oxford/AstraZeneca vaccine being manufactured in India is being sent to the WHO. It is possible that manufacturers have prioritised market approval in countries where profit is highest.

On the plus side, the arrival in office of Joe Biden, and Power, means that the US this week joined the funding of Covax, something the Chinese have yet to do, although Beijing is willing to supply its vaccines through Covax. The arrival of the US should help with the budget shortfall.

Power is appraised of the problem, saying immediately before her appointment: “Right now developing countries are not on track to get significant shares of the vaccine. The pool of money and the fundraising that has been attempted by the WHO and Covax Act, this vaccine initiative, has not produced the resources that are needed.” She also understands the need to explain to voters in, say, Pittsburgh, why it is in their self-interest for a Rwandan to be vaccinated, and so for the whole of the world to come out of the economic and health crisis.

The difficulty is that voters in the rich north judge their governments largely against the benchmark of the fastest-vaccinating countries, such as Israel, and hardly spare a thought for a country such as Nigeria, where a population of 200 million is waiting for its first vaccine. The incredibly insular media lens of most countries, including the UK, hardly helps.

Norway is trying to overcome this by showing a moral lead, saying it is likely to have three times as many vaccines as it needs for its population, and it will make this surplus available to the Covax. The EU has also promised to do the same, even if the detail is unclear.