How a Great Power Falls Apart
Decline Is Invisible From the Inside
It is now abundantly clear that the world cannot fully emerge from its current state of novel coronavirus lockdown until a vaccine is found. Never before have so many lives, livelihoods, and economies depended so much on a single health intervention. But as scientists race to develop potential vaccine candidates, the international community must remember that the ultimate goal is not only to produce a safe and effective inoculation but to bring the pandemic to an end. And that can happen only after billions of doses are produced affordably and made available to everyone, particularly those in low-income countries.
An enterprise on this scale requires a new perspective: vaccines must be recognized as global public goods. Neither domestic agendas nor profit can be allowed to drive the effort for the largest vaccine deployment in history. Governments, pharmaceutical companies, and multilateral organizations must work together to develop, produce, and deliver the vaccine. Producing and distributing billions of doses of a new vaccine would be challenging at the best of times. Doing so during a pandemic will require an unprecedented global effort.
Just consider the recent global shortages of personal protective equipment and test kits. A coordinated international effort is needed to avoid similar vaccine shortages and to prevent large numbers of people from going unvaccinated. Unfortunately, equitable vaccine distribution has frequently been a problem in the past. Increased demand for the HPV vaccine in developed countries, for example, has recently impeded access for vulnerable adolescent girls in developing countries. And during the 2009 H1N1 pandemic, a small number of countries placed large advance orders for the vaccine before it became available, effectively buying up most of the global supply and leaving little for the rest of the world.
Scientists should of course aim to develop more than one vaccine. But even the existence of several effective ones won’t guarantee that hoarding won’t take place, as supplies will initially be limited. It is the duty of every government to put its citizens first, but during a pandemic this duty also requires thinking and acting globally. If manufacturing agreements or export restrictions impede the deployment of vaccines and allow the virus to survive anywhere, nowhere can be safe from reinfection.
Even the existence of several effective vaccines won’t guarantee that hoarding won’t take place.
One way to ensure the adequate supply and equitable distribution of vaccines is to remove some of the barriers created by intellectual property and technology transfer laws and to encourage manufacturers and research groups to work together toward a common goal. That way, when the first safe and effective vaccines emerge, multiple manufacturers can immediately start producing them simultaneously. The pharmaceutical industry has already shown some willingness to allow this: the Serum Institute of India has announced that it will not retain the intellectual property on its COVID-19 vaccine candidate, the pharmaceutical giants GSK and Sanofi have formed an unprecedented partnership to pool their resources, and several manufacturers have agreed to not profit from COVID-19 vaccines. This bodes well for the new Access to COVID-19 Tools Accelerator (ACT) initiative launched by global leaders and the World Health Organization (WHO) to expedite the development, production, and equitable distribution of new COVID-19 diagnostics, therapeutics, and vaccines.
Ensuring that a vaccine can be manufactured quickly once it is developed also poses significant challenges. Many of the most promising COVID-19 vaccine candidates are being developed by organizations that lack large-scale manufacturing capabilities. Since some of these organizations will inevitably fail to discover a viable vaccine, mechanisms must be put in place to reduce the risks of investing in development and manufacturing capabilities. Doing so will mean that the best vaccine candidates can be rapidly produced at scale and made available to everyone who needs them regardless of where they live.
That may sound like a tall order, but there is actually a precedent: Gavi, a global health partnership dedicated to increasing immunization access where I serve as Board Chair, launched its Advance Market Commitment pilot in 2009. This innovative financing mechanism has already helped to accelerate the roll-out of vaccines. Prior to this it could take more than a decade for the price of new vaccines, like the pneumococcal conjugate vaccine (PCV), to come down enough for poorer countries to afford them. The AMC was a game changer, making vaccines affordable in these countries by providing incentives for manufacturers that effectively created a market where previously there was none. It worked on the principle of committing funds to guarantee the price of vaccines, once they had been licensed, thereby helping to remove some of the risk associated with investing in increasing manufacturing capacity, essentially ensuring that there will be a market if they do so. Gavi used a similar approach to accelerate Ebola vaccine production in time to help prevent the most recent epidemic in the Democratic Republic of the Congo from spiraling out of control. Although COVID-19 is a very different disease, similar financing mechanisms could help ensure that vaccines are made available in an accelerated fashion. And because such mechanisms would involve legally-binding agreements with manufacturers, they would also help to prevent hoarding and to promote equal access.
Then there is the challenge of delivering the vaccines. That will not be straightforward either. Even under normal conditions, transport and supply chain issues, regulatory regimes, civil unrest, conflict, and natural disasters can all potentially undermine vaccine delivery. But in the midst of a global crisis, the logistical hurdles are likely to be even more daunting, particularly in the world’s poorest countries.
Health systems in these countries were already weak before the coronavirus. Now they are under severe stress—and not only because of the pandemic. COVID-19 has increased the risk of outbreaks of other deadly diseases, such as measles, polio, and yellow fever. This is because even though the WHO recommends that routine immunization programs continue where possible during the pandemic, it has also had to recommend that vaccination campaigns against some diseases, which are used to fill immunization gaps, be suspended in many countries in order to reduce the risk of spreading COVID-19 and to preserve scarce public health resources.
Pandemic-related disruptions to routine immunization have caused millions to go unvaccinated.
This is extremely worrying. Not only could suspending other routine immunization programs lead to countless preventable deaths; doing so could impede the world’s ability to end the coronavirus pandemic. Major outbreaks, either during or immediately after lockdowns, will inevitably put more pressure on weak national health systems.
Coronavirus-related disruptions to immunization have already caused at least 13.5 million people in Gavi-supported countries to go unvaccinated. It is crucial that low- and middle-income countries resume vaccination campaigns as soon as possible and that they keep routine immunization programs going throughout the pandemic. The supply chains, cold chain equipment, trained health-care workers, data systems, and disease-surveillance efforts that make up these existing programs will ultimately form the backbone of the delivery network that brings COVID-19 vaccines to the people who need them.
To this end, Gavi is working with countries to bolster their health systems and keep routine immunization running. It has made a first tranche of $200 million available to protect health-care workers with personal protective equipment, perform vital surveillance and training, and fund diagnostic tests. But this sum is marginal compared to the billions of dollars that will be needed to develop and deliver a vaccine or vaccines that can end the pandemic. These are vaccines for all of humanity. That means they not only need to be made available to everyone but ideally, they also need to be tested and manufactured around the world.
A viable vaccine is still unlikely to be licensed for at least another 12 months. But some of the focus does now need to shift from the race to develop a vaccine to preparing for its arrival (including trying to find therapeutics until the vaccine is ready). In recent years, multilateralism and globalism have come under attack. The pandemic crisis is an opportunity to push societies to adapt and evolve from shareholder capitalism to stakeholder capitalism, mobilizing all contributors around a common goal: one world, protected. Because no one will be safe until everyone is safe.
Developing Countries Are Hurtling Toward Coronavirus Catastrophe