We are experiencing two very different pandemic realities between low-income and high-income countries. Unfortunately, instead of seeking a solidarity-based response, the international community has once again demonstrated its disunity in this health crisis. The task now is to regain credibility and rebuild trust.
“(…) There is a sense of sadness and frustration with a system that is failing humanity, and the political leaders who seem unable to grasp that which is blindingly obvious” –Ayoade Alakija.
How very true this observation by the Nigerian World Health Organisation (WHO) Special Envoy for the Access to the Covid-19 Tools Accelerator is! Despite the fastest-ever vaccine development in history and a global vaccination campaign, we have by no means got on top of the global public health crisis. There has been no real solidarity-based response to the pandemic, in terms of sharing out either the vaccine or the economic burden. The socio-economic consequences of the lockdowns and measures to fight the pandemic have hit the poorest sections of society everywhere in the world, particularly in the Global South. It has had the effect of widening the gap between rich and poor all over the world.
There are two very different realities of the pandemic between low- and high-income countries: industrial countries such as the United Kingdom, Germany, the USA and Israel are already giving their populations their third and fourth doses. The vaccination rate is also very high in many emerging nations, particularly in Latin America.
In the other reality, we are seeing that in many countries, citizens have not yet had even their first dose of vaccine. As of January 2022, just 5% of the population of the low-income countries had been fully vaccinated and just 11% had received at least one dose of vaccine. In Yemen, where civil war has been raging for years, less than 2% of the population are fully vaccinated against the coronavirus, while in Haiti, plagued by natural disasters and sociopolitical maladministration, the figure is not even 1%.
Vaccination programmes are making very slow headway on the African continent, with the exception of countries like South Africa: 10% of the 1.3 billion people who live in Africa have been fully vaccinated. The vaccination rate in Senegal, for instance, is 6%, while it is barely 4% in Burkina Faso and just 0.2% in the Democratic Republic of the Congo. Every day around the world, six times more people are given a booster than people in low-income countries receive their first dose.
The enormous divide in vaccination distribution between the African countries and the EU has seriously damaged the standing and credibility of the EU. In mid-December last year, Ghana’s President, Nana Akufo-Addo, warned EU legislators that vaccine nationalism and hoarding vaccines to give booster shots could hamper vaccination efforts in Africa.
The Secretary General of the UN, António Guterres, has also repeatedly addressed the global imbalance in the distribution of vaccines since the pandemic broke out two years ago. He rightly describes the fact that vaccination rates in high-income countries are seven times higher than in African countries as “shameful”.
This is negligent and irresponsible, as we are still a long way from achieving global herd immunity: only around 50% of people around the world have been fully vaccinated.
Global inequality grows during the pandemic
The longer the global vaccination campaign takes, the longer the pandemic will last and the more serious the global socio-economic consequences will be.
The latest reports by organisations such as Oxfam and the World Bank revealed the potential scale of the socio-economic consequences of the pandemic and the measures to tackle it. People living in poverty or in danger of poverty have been particularly hard hit. Around the world, more than 160 million people have been driven into poverty by the pandemic. This number will only rise: by 2030, there could be a further 207 million people living in extreme poverty, according to the UNDP. People with low education, limited assets, people working under precarious employment conditions and the entire groups of the population who lack access to essential resources are particularly feeling the fallout. Economic recovery from the pandemic could take more than a decade for all these people.
Women have been more adversely affected than men by the economic impact of the pandemic. According to the International Labour Organisation, the employment rates of men returned to 2019 levels in 2021, while there are 13 million fewer women in work than two years ago. The shocking socio-economic inequality and the breaking of the global pledge of justice, which can be observed in practically all spheres of life, are unfortunately central characteristics of this global public health crisis.
Ever since the pandemic began to take hold, the International Monetary Fund (IMF) has stressed the absolute importance of acting and vaccinating globally, if global economic recovery is not to be hampered. Should Covid-19 have longer-term effects, worldwide GDP losses could grow to 5.3 billion USD within five years and cost several million human lives. According to the IMF experts, this means that by the middle of this year, 70% of the world population will need to have been vaccinated.
All necessary steps must therefore be discussed and the existing barriers taken down if efforts to bring the pandemic under control – which must, by definition, take place at a global level – can ultimately succeed.
Tackling the uneven distribution of vaccines
The vaccines needed to do it are available. Access to them, however, is difficult and uneven for several reasons – high prices, lack of infrastructure and awareness as well as vaccination scepticism.
The high and excessive prices for vaccines have been an enormous barrier from the outset and are preventing a fair global distribution of vaccines.
In August, the Financial Times reported that a dose of Pfizer/BioNTech vaccine from the EU costs 19.50 euros and that Moderna is charging 25.50 USD (21.60 euros) for a dose. However, British researchers from Imperial College London presented a study calculating that in mass production conditions, a dose of mRNA vaccine can be made for just 1.18 to 2.85 USD. The petition “No Profit on Pandemic” – a European citizens’ initiative – is therefore calling for contracts with vaccine manufacturers to be made public. There should be more efforts at political level to bring prices down: the vaccines were ultimately developed with billions of dollars of public money, yet there has been no political involvement in price-setting.
COVAX is not enough
To support the roll-out of vaccines to all countries, not just the wealthy ones, the platform Covid-19 Vaccines Global Access (COVAX) was set up in April 2020. Its aim is to support the development and production of Covid-19 vaccines and to negotiate their prices. The head of the vaccine alliance, Gavi Seth Berkley, has announced that COVAX has already supplied a billion doses of vaccine, in a shipment to Rwanda in mid-January. This, he stresses, marks a milestone in the biggest and fastest global vaccine distribution campaign in history, benefiting 144 countries (article in German only).
But this is too little, too late, according to the President of the German trade union Erziehung und Wissenschaft, Maike Finnern, in her letter of 6 January 2022 to four German federal ministers (article in German only). Out of 1.8 billion doses of vaccine pledged by the EU, Norway, Switzerland and the G7 states, just 261 million doses have so far been delivered.
And even worse: far too often, donated vaccine comes with a very short expiry date. Nigeria, for instance, was forced to destroy more than 1 million expired doses of AstraZeneca vaccine at the end of December 2021. Not only is this cynical, it feeds into vaccine scepticism and undermines the credibility of the industrial countries even further.
Bolstering production capacity in the Global South
The speedy delivery of vaccines is a useful interim measure, but is neither reliable nor sustainable. Instead, the countries of the Global South should be supported in setting up their own production capacities for vaccines, tests and drugs to combat the virus. Critically, this would give them the resources to prevent the spread of infectious diseases in the event of future pandemics.
It all comes down to local vaccine production. In October 2021, Rwanda and Senegal signed an agreement with BioNTech to set up facilities to produce mRNA vaccines under licence. Moderna has also announced plans to build a production facility for mRNA medicines and vaccines on the African continent. Precisely where and when the project will get underway, however, is not yet known.
Temporary patent release
Well over a year ago, the WTO received a proposal by India and South Africa to waive patent protection for vaccines, at least temporarily, under acute pandemic conditions, so as to expand production capacities. More than 100 WTO member countries have so far lent their support to the proposal. In May 2021, the USA announced its agreement, but reportedly told a virtual WTO meeting in December that it would only support an exemption covering vaccines. This will keep the equally essential treatment drugs, diagnostic equipment and medical devices out of the scope of the regulation.
Contrary to the demands of the European Parliament, the European Commission and the new German Federal Minister for Economic Cooperation and Development, Svenja Schulze, are still completely opposed to any temporary patent waiver (article in German only). Their preferred option is to concentrate on business partnerships to produce mRNA vaccines under licence. The German Federal Minister for the Economy and Climate Action, Robert Habeck, has also taken the Greens’ position 180°, telling a press conference (video in German only) at the end of January 2022 that a temporary lifting of patent provisions would be a pointless move. He makes the case instead for deals to be struck with manufacturers to supply poorer countries with vaccine at cost price.
The calls made by the new German Federal government and its predecessor for vaccine supplies, licence issuance and company partnerships between the industrialised and developing countries are well known. As far as the countries of the Global South are concerned, this exacerbates their dependence on Western pharmaceuticals groups, their controls and their prices.
Critics of the patent waiver approach point out that the production of new vaccines is far too expensive and at least in the short term, unrealistic in the developing and emerging countries. This argument simply does not hold water. The South African biotech company, Afrigen Biologics and Vaccines, is currently working on the development of Africa’s own first coronavirus vaccine, which imitates mRNA technology and will not be patented (article in German only). And according to reports by Human Rights Watch (HRW), there are more than 120 Pharma companies in Asia, Africa and Latin America that are capable of producing an mRNA vaccine if provided with the corresponding technology by their counterparts in Germany and the USA.
At the beginning of March 2022, the WTO Ministerial Conference will return again to the issue of the TRIPS waiver. It is high time that the EU and the UK stop blocking the way for negotiations and acting against the majority of WTO countries, against expert opinion and against growing voices from civil society and economic circles: international pressure has been piled on by healthcare unions and Nobel prizewinners, plus more than 20 Olympic and Paralympic athletes and 65 major investors, managing assets in excess of 3.5 billion USD. In a letter to a group of non-executive Presidents of EU countries in early January of this year, the Irish President, Michael D. Higgins, also urged support for the TRIPS agreement waiver.
Last year, encouragingly, the pharmaceutical company Merck announced a voluntary licensing agreement with the UN-backed Medicines Patent Pool (MPP). Under the agreement, Merck gave the MPP permission to grant sub-licences for the production of the new oral Covid-19 medicine Molnupiravir to manufacturers in other countries. It has since been reported that the MPP has signed agreements with more than two dozen generics manufacturers in 11 countries, including Bangladesh, Vietnam and South Africa, for the production of versions of Merck’s Covid-19 tablet medication to supply 105 developing countries. This will allow the drug to be produced and sold cheaply in the poorest countries, in which coronavirus vaccines are hard to come by, thereby mitigating the most serious consequences for the populations.
In October, however, the organisation Médecins sans Frontières spoke out against the fact that the licensing structure will leave important countries such as Brazil out of its scope of application and contains several restrictive clauses. On the plus side, neither Merck nor Ridgeback Biotherapeutics and Emory University, which invented the drug, will receive licence fees on the generics manufacturers’ sales of Molnupiravir as long as Covid-19 continues to be a global public health emergency. To date, not a single Covid-19 vaccine manufacturer has agreed to a similar arrangement.
Public health infrastructure
Since it broke out, the pandemic has laid bare the weaknesses of the public health systems in every country of the world. A podcast by Medico International (available in German only) highlights how the increasing global commercialisation and commoditisation of health care has led to massive weaknesses in the system. The conclusions that are drawn from this are more important than ever.
The urban-rural gap in health care provision is startling. “We are not going to have shortages of vaccines any more, but our main concern and focus now is getting these vaccines to all corners of the country, including the remote mountain areas”, says Nepal’s Minister of Health.
To mitigate shortcomings in the infrastructure, the pandemic has prompted a number of creative approaches. In Ghana and Rwanda, for instance, drones are used to reach isolated communities. In Kenya, the young engineer Norah Magero has invented a solar-powered fridge, the Vaccibox, which can be used in conjunction with a bicycle, motorbike or small boat to transport vaccines to rural areas with no electricity supply. 70% of the population of Kenya live rurally.
African states have many other logistical challenges to overcome. According to the WHO, Africa is 1.3 billion USD short for operating costs, including the costs of refrigerated logistical chains and data recording software. There is also a lack of vaccination syringes and freezers, training and wages for vaccination and support staff.
The current pandemic has once again highlighted the lamentable state of the healthcare infrastructure in African countries. The Global Health Security Index (GHSI) of 2019 put the countries of sub-Saharan Africa into the category of countries least prepared for a pandemic.
If a lack of staff in the healthcare sector is a major problem even in the wealthier countries, by way of comparison and in proportion to the population, the poorer countries have an almost 10 times greater shortfall of nursing staff. This is compounded by the fact that several industrial countries, including Germany, recruit healthcare staff from the Global South, including Mexico, India, sub-Saharan Africa and parts of the Caribbean, making their shortages even greater.
Besides the lack of healthcare staff, the industrialised and developing countries share another common problem, that is hampering the vaccination campaigns: vaccine scepticism. “There’s no doubt that the delay in the provision of vaccines is a factor”, adds Dr Matshidiso Moeti, the Regional Director for Africa of the World Health Organisation. Just as is the case in Germany, healthcare staff in India not infrequently come across fierce resistance from individuals who believe that vaccines can cause serious adverse effects, even death.
As well as infrastructure and staff, therefore, more awareness and information are needed. “In low-income countries, little or nothing has been invested in information and advertising for vaccines. Why do we expect to just drop vaccines off at airports and arrange a photo shoot, then people will flock to the airport and pick up a vaccine?” Dr Omer, epidemiologist at Yale University, asks wryly.
International cooperation: staking credibility
Instead of putting all efforts into a solidarity-based response, the international community has unfortunately once again demonstrated its own imbalance in this public health crisis. Most states have focused predominantly on themselves.
What we are also seeing, again and again, is a competition as to who can supply vaccines the quickest. It has also been a race for political spheres of influence between Europe, the US, China and Russia. China and Russia have supplied the countries of the Global South with their vaccines in great style, Russia principally in Latin America (including Argentina, Mexico, Venezuela, Nicaragua and Guatemala) and parts of Africa (Algeria, Namibia). China has focused on its neighbours, such as Afghanistan, Bangladesh, Nepal, Pakistan and Sri Lanka, most countries of Latin America and, so far, fifty countries in Africa (article in German only). The Chinese government delivered its second vaccination donation to Nicaraguan at the end of December 2021, after the central-American country resumed relations with the Asian giant and broke them off with Taiwan.
For the Big Pharma companies of the industrialised world, it is mainly about securing their markets and the fat profits they will make by setting prices and not waiving their patents.
This means that vaccines will continue to be used in countries’ own geopolitical and geo-economic interests to establish long-term political dependence in countries that produce no vaccines themselves and cannot afford to pay market prices for them.
A lot more credibility was lost when South Africa gave an early warning of the discovery of the Omicron variant. African heads of state or government have reacted furiously to the travel bans put in place against several African countries due to the new variant. Wealthy countries were criticised on social media for their hypocrisy in slapping new restrictions on Africa rather than supplying them with vaccines.
This reality is at odds with the EU’s stated intention of breathing new life into cooperation with Africa at the joint summit with the African Union in February.
Rebuilding trust, creating for solutions for all
Regaining credibility and rebuilding trust would be a possibility in the near future if patents on vaccines and drugs were temporarily lifted.
In a study in “The Lancet”, the authors reached the conclusion that access to vaccines can also be a valuable tool to fight vaccination scepticism. They point out that the introduction of Ebola viruses in West Africa showed that the physical presence of vaccines strengthened the commitment of the national political leadership, extending as far as the local communities.
It is very positive that the EU and the German Federal government are actively donating vaccines, including to COVAX. Germany is now the world’s second-largest vaccine donor. However, the logistical framework conditions in the countries of the Global South and potentially long delivery times within these countries need to be taken into account.
These measures must be expanded to include testing kits and drugs and be accompanied by support to create sustainable healthcare infrastructures in the Global South.
In the medium-and long terms, we need to address structural questions of global healthcare and global (in)justice, so that the whole world, rather than just small parts of it, is better prepared for future challenges. According to the UN Secretary General, this is within reach, as long as investments are made in monitoring, early identification and rapid reaction in every country, as well as bolstering the capacity for action of the WHO.
This may sound like a Herculean task, but in the opinion of WHO Special Envoy, Dr. Ayoade Alakija, it is entirely possible, “but only if a life in Mumbai matters as much as a life in Brussels, if a life in São Paulo matters as much as a life in Geneva, and if a life in Harare matters as much as a life in Washington DC”.
*I would like to thank Dr. Alexandra Sitenko for her assistance with this article.