Covid-19 vaccines – inequality and the politics of health

Leslie London and Lauren Paremoer

Covid-19 has exposed the faultlines of egregious inequality, both between and within countries. It’s time the world woke up, assert the writers.

This inequality will kill people on a global scale, as it did with HIV, until civil society forces Big Pharma to cede power. That’s the scenario we are looking at again. Hopefully, we have learnt something from the past, before too many of our people die.

Covid-19 increases inequality

The recent Corona Virus Rapid Mobile Survey showed that socio-economic inequality has increased six-fold in South Africa under Covid-19. Working class women have been especially hard hit by job losses, loss of income, higher levels of hunger, and an increased burden of care for children and the sick during lockdowns. Covid-19 mortality rates were twice as high in the impoverished black townships of Cape Town as in wealthier suburbs. Much of this has to do with longstanding gross maldistribution of health care resources between the public and private health sectors, exacerbated by the epidemic.

Globally, the enormous inequalities in power and resources are most starkly illustrated by unequal access to Covid-19 vaccines. Less than 20% of the world’s population lives in high income countries (HICs), but HICs have secured more than 50% of all Covid-19 vaccines. Canada, the UK, Australia, USA and the EU have secured between two and five times the doses needed by their populations. In contrast, it is estimated that most African countries can only hope for full vaccination coverage by early 2023. 

Protection of profit is the problem

Covax is a public-private partnership (PPP) established to encourage global solidarity towards equitable access to Covid-19 vaccines. It is the vaccine pillar of the ACT accelerator, a multilateral structure comprising the World Health Organisation (WHO) and two global vaccine partnership organisations.

Covax assumes that voluntary deals with vaccine producers and subsidies from middle- and high-income countries (MICs and HICs) can be used to procure and subsidise Covid-19 vaccines for low income countries (LICs). So far, this has not been the case. This system was set up to “ensure vaccine access to the world’s most vulnerable”. But Covax has failed to avoid what the World Health Organisation (WHO) Director General calls a looming “catastrophic moral failure”?

This is because Covax accepts existing intellectual property (IP) regimes that protect vaccine manufacturers’ profits but undermine the right to health.

First, Covax consolidates market logic: patented, life-saving vaccines remain privately owned commodities. Companies have total discretion in determining vaccine prices and prioritisation of customers.

Second, Covax expects countries to pay up front, without knowing which vaccines they will get, at what price, when they will be delivered, or whether the vaccines they receive will work for their health system (e.g. some vaccines require very low temperature freezing). Additionally, only LICs qualify to purchase vaccines at subsidised prices through Covax. Despite the devastating economic impact of Covid-19 on MICs like South Africa, they must pay full price.

Third, Covax is struggling to secure vaccine supplies because many HICs have already pre-purchased most available supplies. There are 56 such bilateral deals at last count, while Covax remains in the doldrums. Currently it is only providing about 15% of the world’s vaccines, yet is meant to reach all LICs who are unable to pay market rates.

Governance outsourced

Finally, Covax is not subject to democratic oversight by WHO member states. A small elite group make key decisions, while elected officials representing their governments at WHO watch from the sidelines. This kind of unaccountable multistakeholder platform is often heavily influenced by private sector interests, private philanthropists and donors. Its ascendance underlies the weaknesses of global Covid-19 vaccine governance and the decline in authority of the WHO.

Meanwhile the WHO itself has been deliberately underfunded over the past decades to weaken its global stewardship role. As a result, it has had to rely on these multistakeholder platforms to promote global health goals.

Another voluntary mechanism, the Covid Technology Access Pool (C-TAP), aimed at sharing Covid-related IP is also a dismal failure. Not one vaccine producer has donated their IP to C-TAP. Most vaccine producers have not provided WHO with full data for regulatory review in real time to accelerate approvals. They have chosen rather to market their vaccines bilaterally to countries that can pay, at profit-boosting prices.

Covax and C-TAP have failed to solve the underlying power that patents and the rule of the market afford private corporations. They clearly demonstrate that voluntarist agreements in multilateral forums are woefully insufficient in ensuring equitable and universal access to Covid-19 vaccines. Without changes to existing patent rules, LICs and MICs will struggle to vaccinate their populations.

SA and India propose waiver

Serum Institute of India, which claims to be the world’s largest vaccine manufacturer. We know that local production is already advanced in Asia and advancing in Latin America but not in Africa.

For this reason, the proposal by South Africa and India at the World Trade Organisation (WTO) for a waiver of intellectual property protections for all Covid-19 related health technologies is critical to vaccine equity. The proposal seeks the waiver for all Covid-19 vaccines, diagnostics and treatments for the duration of the epidemic or until widespread immunity is achieved. Implementation of the waiver would not be mandatory but would open the door to greater competition amongst vaccine manufacturers. This will increase supply, decrease prices, promote information-sharing regarding production costs, and enable technology transfer aimed at encouraging local vaccine production in MICs and LICs.

It is widely recognised there are relatively few vaccine producers, almost all concentrated in HICs. Already they cannot cope with the urgent global need for vaccines. Diversifying the production base will expand capacity and also introduce competition, currently absent from the global vaccine scenario. The experience of antiretroviral (ARV) access showed that when the stranglehold of patents was broken, competition radically decreased prices.

HICs with biotechnology industries have steadfastly opposed the waiver while using their economic and political power to preferentially achieve full vaccination coverage. HICs claim existing flexibilities in the Trips agreement (Trade-Related Aspects of Intellectual Property Rights), which were extracted from the WTO with great effort during the ARV treatment access campaign, are sufficient and there is no need for a waiver. This argument is spurious. Trips flexibilities are cumbersome, lengthy, require technology-by-technology applications and put countries at risk of economic retaliation. For example, compulsory licences issued by Brazil, India and Thailand for ARVs elicited harsh responses from the USA and the EU. This has discouraged MICs and LICs from using TRIPS flexibilities to access essential medicines. The shrinking policy space under TRIPS-plus provisions included in trade agreements further restrict these flexibilities.

Tide turning?

Yet, despite the initial hardline opposition in the WTO from developed economies, the tide appears to be turning. From a resolution of a handful of WTO members, current supporters of the waiver include the WHO, the Vatican, the African Union and more than 100 countries, including China. The greed with which developing countries helped themselves to a global public good appears to be finally causing some indigestion amongst world leaders.

Moreover, most vaccines have been produced, in part, as a result of public funding, and through participation of developing country populations in vaccine trials. This gives the lie to the notion that vaccines can be anything other than a public good.

Build local vaccine production

For sustainable solutions we need local productions in LMICs. South Africa and Senegal are countries with vaccine institutions and considerable work is being directed at how local capacity could be built to produce vaccines. This is important because what we have now is a two-tier system in which rich and powerful countries can access sufficient vaccine for their own populations. This is both morally bereft and short-sighted: failure to protect everyone at the same pace increases the likelihood of new virus variants developing in low coverage countries. These will spread globally and potentially threaten the health of populations that have only been vaccinated against earlier variants.

We know that local production is already advanced in Asia and advancing in Latin America but not in Africa. For Africa to play its part, there must be real regional cooperation in logistical, legal and institutional capacities. We already have regulatory authorities in the region that have been cooperating on access to medicines. We can build on this this to ensure safety and cross-border equity in access, given the movement of people amongst countries on the continent.

The waiver is the one proposal that does change the rules because it challenges the fundamental problem – that the global political economy has centralised power in the hands of the vaccine producers and their states. At the moment, WHO DG Tedros has to plead with vaccine producers to “allow” states to share doses and with countries to “work together in solidarity”. This emphasises that the bigger issue of corporate power is still being sidestepped.

Leslie London and Lauren Paremoer are activists in the People’s Health Movement and the C19 People’s Coalition, South Africa.

(This article first appeared in Amandla 75 | March 2021)