The great vaccine rollout and the global pecking order

by Rajan Philips

Last Tuesday Britain became the first country to administer the first multi-nationally developed Pfizer-BioNTech coronavirus vaccine. Eight hundred thousand doses of the vaccine are being distributed among the Isle’s four nations in the first stage of the British rollout. Canada is starting its Covid-19 vaccination this week with 250,000 doses of the same vaccine; another 20 million doses are arriving next year along with over 350 million other vaccines. While welcoming the arrival of the Pfizer vaccine as “the beginning of the end of the epidemic in the UK,” Prof. Stephen Powis, medical director of the National Health Services England, has also cautioned that getting to the end itself is going to be a “marathon [and] not a sprint.” Britain has ordered 40 million doses so far and it will cover 20 million people with two shots each, 21 days apart. There are still 47 million to account for. It is a long haul.

In the US, Donald Trump is not happy that Britain got the vaccine before the US and he is even madder that he will not be able to claim credit for vaccination in America as much of it will happen after he leaves office. In any event, many of his supporters may refuse to take the vaccine because it is not mentioned in the US Constitution! Under its military “Operation Warp Speed” vaccination program, the US has issued purchase orders for 800 million doses from the world’s six leading vaccine contenders, although there is some controversy about the timing of vaccine deliveries. Last Tuesday, Trump issued a meaningless executive order that all vaccines procured by the US must be delivered to the US first before vaccines are supplied to other countries.

Russia meanwhile got ahead of both the UK and the US, launching three days before UK its nostalgically named Sputnik V vaccine in Moscow which accounts for about a quarter of Russia’s infections. For several months, China has been conducting mass trials involving millions of recipients for two of its five vaccines in development, Sinovac and Sinopharm. Beijing is yet to announce its internal vaccination program proper, but has already shipped 1.2 million doses of Sinovac to Indonesia, a nation of 274 million people. India has the world’s single largest vaccine manufacturer in the Serum Institute established in 1966, in Pune. The Institute has an annual production capacity of 500 million doses, and has production contracts with the Oxford-AstraZeneca vaccine as well as the Novavax vaccine. The first 100 million doses of Serum’s production are earmarked for use in India, while the rest will be open for distribution among developing countries.

The vaccine rollout I have described here is hardly global in that it is tilted entirely in favour of wealthy countries, and excludes much of the rest of the world, with the exception of the two giant outliers – China and India. This global vaccine anomaly is being exposed and criticized by the People’s Vaccine Alliance that includes well known civil society organizations such as Amnesty International, Frontline AIDS, and Global Justice Now. The Alliance has pointed out that wealthy countries representing only 14 per cent of the world’s population have so far reserved 53 per cent of the most promising vaccines, and thereby limited the ability of the world’s nearly 70 poor countries to vaccinate only 10% of their populations for all of 2021.

A majority of the developing countries are consigned to getting their supply from the pool of vaccines provided by the COVID-19 Vaccine Global Access (COVAX) facility, the global organization set up by the WHO to ensure “rapid, fair and equitable access to COVID-19 vaccines worldwide.” It is partnership of high-income countries and lower-income countries involving 60% of the world’s population, with the former providing for the supply of vaccines to the latter. The expectations are that the WHO will supply 20% of a developing country’s population at no cost. But the reserved quantities for COVAX, according to the People’s Vaccine Alliance, now amount to a single dose for about three people in developing countries, or 16% of the population. Even that may not be fully available in 2021. The root of the problem is too much reliance on donor charity and too little desire to tackle the structural aspects of anomaly.

The Pecking Order

The world’s ten leading Covid-19 vaccine contenders, including the Chinese (Sinovac) and Russian (Gamaleya) manufacturers, have a total capacity to produce eight to nine billion doses a year. The chart below illustrates the current capacity and pre-order of each vaccine candidate. Of the ten contenders, excluding the Chinese and Russian contenders, only three vaccines – Pfizer/BioNTech, Moderna and Oxford/AstraZeneca, are at the point of getting public health authorization in multiple countries. The three have a combined annual capacity under four billion doses. Novavax and Johnson & Johnson are expected to join them in 2021, and raise the capacity to six billion doses. In other words, even in any best-case scenario, it will easily take at least three to four years before a majority of the world’s peoples can receive their two shots of the Covid-19 vaccine.

Add to this what might be called the tragedy of the aggregate – in that while the combined global Covid-19 vaccine production capacity might exceed the world’s total demand, not every country, or not individuals within countries, would be equally positioned to receive the new vaccine without too much delay. Within the so-called high-income countries (HICs), the priority for vaccination is being given to the elderly, frontline healthcare workers, people with medical conditions, and those who are in essential services. But there is no reason-based system for distributing vaccines between different countries. The global pecking order privileges those in HICs far above the people in lesser income countries. The two charts below provide a snapshot of the per capita procurement levels (Calling the Shots); and the bulk vaccine orders placed by individual and groups of countries with different vaccine manufacturers.

As shown in the chart, Canada leads the pack with confirmed orders for just under 10 doses for each of its 37.7 million people. Australia and Britain are procuring just over five doses per head, while every other country or region is under three doses per head. At the bottom of the chart is COVAX, with a single dose for about three people. The bulk order chart shows 2.4 billion doses reserved for developing countries, whose estimated population, excluding China, is 3.6 billion people. Almost all of the reserved developing country supply will come from India’s Serum Institute and the Oxford/AstraZeneca and Novavax vaccines, which are considerably cheaper than Pfizer/BioNTech and Moderna.

On the supply side, “all of Moderna’s doses and 96 percent of Pfizer/BioNTech’s doses are contracted to HICs. In contrast, 64 % of Oxford/AstraZeneca’s doses are pledged to people in developing countries. But their supply can “only reach 18 per cent of the world’s population next year at most.” As well, Oxford/AstraZeneca’s deals are mostly with big developing countries like China and India, while the majority of developing countries are left to depend entirely on the COVAX facility.

Vaccines as global Public Good

This global pecking order and the disparity between countries are inevitable to some extent, but the question is what efforts are being made by national and international leaders to mitigate this seemingly natural gap. The signs of mitigation are not as encouraging as the rhetoric of global reset and assertions of global solidarity. The same wealthy countries that have ratcheted up vaccine procurement, are also opposing the waiver of the World Trade Organization’s rules for protecting intellectual-property rights, that is required to facilitate the production of Covid-19 vaccines in developing countries.

Led by South Africa and India, ninety-nine WTO members have called for a temporary waiver of WTO rules. The People’s Vaccine Alliance supports the waiver request, but it is being flatly rejected by the HICs, including the UK, the USA, Canada, Norway, and the EU. The HICs, which are under pressure by the pharmaceutical industry, are not supportive of structural changes, and would rather prefer a charitable avenue like COVAX. The UK is the largest funder of COVAX, and is keener about urging for more donations than supporting any rules waiver. WTO decisions are normally reached through consensus, and so a majority vote will be meaningless if the HICs are not willing to compromise.

To address, these disparities, the People’s Vaccine Alliance “is calling on all pharmaceutical corporations working on COVID-19 vaccines to openly share their technology and  intellectual property through the World Health Organization COVID-19 Technology Access Pool, so that billions more doses can be manufactured and safe and effective vaccines can be available to all who need them.” In addition, the Alliance is calling for Covid-19 vaccines to be made as “a global public good—free of charge to the public, fairly distributed and based on need.” A first step would be “to support South Africa and India’s proposal to the World Trade Organization Council to waive intellectual property rights for COVID-19 vaccines, tests and treatments until everyone is protected.”

It is indeed a pity that there should be so much global disparity in the production and distribution of Covid-19 vaccines, when all the scientific work and breakthroughs that created them have involved unprecedented international collaboration at every level. In 1955, when Dr. Jonas Salk at the University of Pittsburgh developed his successful vaccine against polio, the then generational scourge in the US and elsewhere, he was hailed as a “miracle worker,” but he declined to patent the polio vaccine, or to profit from it. He would rather let it be free for maximum global distribution. When asked, “Who owns this patent?”, Dr. Salk famously replied, “Well, the people I would say. There is no patent. Could you patent the sun?” Dr. Jonas Salk chose to walk away from a $7 billion worth patent and let his vaccine be a global public good. Why cannot Covid-19 vaccines be similarly another global public good?