The ability of wealthy countries like the United States and the United Kingdom to place huge orders for vaccines before companies had even proved their efficacy has attracted critics since the earliest months of the pandemic ― and the results they warned about are playing out now.
Wealthy countries are at the front of the vaccine supply line and have essentially cleared the shelves: High-income and upper-middle-income countries have secured more than 6 billion vaccine doses, according to data provided to the journal Nature by the Duke University Global Health Innovation Center. Two major manufacturers, Pfizer and Moderna, are also American companies, giving the U.S. a leg up.
As of March 30, 86% of the shots that have gone into arms worldwide have been administered to people in high-income and upper-middle-income countries, according to UNICEF data analyzed by The New York Times. Just 0.1% of doses were given out in low-income countries as of that date. In India, a country where the coronavirus is currently ravaging the population, only 10% have received a single dose.
To get the pandemic under control ― a universal goal, to be sure ― a growing number of voices in public health and global politics are demanding greater consideration of vaccine equity.
One proposal making the rounds would temporarily remove intellectual property barriers to producing vaccines and coronavirus-related treatments. Not surprisingly, it has garnered stiff opposition from pharmaceutical companies and the trade organizations (and politicians) that they fund. Supporters say it is essential to the timely and cost-effective production of drugs needed in every corner of the world.
The answer may not be so simple. Here’s what to know.
Global vaccine equity affects everyone, even if you’ve already been vaccinated.
“The only way to control this pandemic is vaccination. So until we have global coverage, we won’t have control,” said Dr. Thomas Kenyon, chief health officer for Project HOPE and former director of global health for the Centers for Disease Control and Prevention.
Uncontrolled spread of the virus allows it more opportunity to mutate, creating variants like the ones first seen in South Africa, the U.K. and Brazil that have since spread to America. Some have proved to be more contagious or deadly. New variants could also be more resistant to the vaccines we’ve developed so far. Researchers believe drugs like the ones made by Pfizer with BioNTech and by Moderna can be altered relatively easily to target such variants ― meaning people could get booster shots for them ― but production is still limited.
“Everyone’s been saying, ‘Oh, just wait, just wait.’ Like, we’ll let the rich countries fill their plates and then we’ll start sharing out. But now, you know, if actually high-income countries need boosters annually, then we’re sort of back at the starting point,” said Andrea Taylor, assistant program director for the Duke Global Health Institute who is studying vaccine distribution.
Taylor explained there are two reasons people may need booster shots: “One is that the immunity might wear off over time, and we don’t know if that’s a one-year thing or a five-year thing. We just don’t know yet.”
“And then the second reason is if we need to be targeting variants of concern,” she said. “So we need to be tweaking the vaccine and then rolling out boosters that target specific variants. And if other countries aren’t getting vaccinated, then variants are more likely to spread, and it’s just a whack-a-mole.”
Essentially, the longer it takes for people around the world to get vaccinated, the longer the pandemic will disrupt lives and livelihoods.
“The economic losses are staggering and the longer this continues the more those will occur,” Kenyon said, adding: “And it’s a real, real threat to sustainable development goals.”
Honest estimates as to when the developing world will reach herd immunity ― taking into account likely supply chain breakdowns and other delays ― range from 2023 to 2024 to even longer.
The TRIPS agreement protects intellectual property between countries — including vital medicines like coronavirus vaccines.
The World Trade Organization, with its 164 member nations, exists to make sure trade flows smoothly and follows the rules. One set of rules is called the Trade-Related Aspects of Intellectual Property Rights (TRIPS) agreement, which protects patent holders such as pharmaceutical companies manufacturing COVID-19 vaccines.
If a foreign government decided to try to make Pfizer and BioNTech’s exact vaccine without permission, for example, that would violate the TRIPS agreement, exposing that other country to possible sanctions.
A growing number of public health experts and politicians are joining a coalition of low- and middle-income nations to support waiving TRIPS protections.
India and South Africa first requested a waiver for certain sections of the TRIPS agreement in October, arguing that patents are getting in the way of global access to vaccines along with equipment and treatments that could help save lives.
Since then, the proposal won the support of about 100 countries, but a handful of wealthy nations are blocking it ― namely the U.K., the U.S., the European Union, Canada, Norway, Switzerland, Australia, Japan and Brazil. The pharmaceutical industry is, to put it mildly, not a fan of the proposal.
Among the organizations calling on WTO members to negotiate a TRIPS waiver is Doctors Without Borders (Médecins Sans Frontières, or MSF).
“Countries must stop obstructing and show the leadership required to deliver on the ‘global solidarity’ they have so often declared during this pandemic,” MSF International President Dr. Christos Christou said in a March statement. “It’s time to champion access to medical tools for everyone, wherever they live.”
Some 400 European lawmakers have signed onto a letter of support for the waiver alongside a group of more than 100 Nobel laureates and heads of state. Several U.S. senators, led by Sen. Bernie Sanders (I-Vt.) are also in favor of waiving patent rights in the name of vaccine equity.
As HuffPost previously reported, however, certain House Democrats who have received pharma industry funding have urged President Joe Biden to continue to oppose it.
The pharmaceutical industry says there’s no need to waive their patents, and doing so could hurt public health care. Proponents say otherwise.
India, South Africa and several other nations addressed many of the concerns brought up by wealthy opposing nations in writing back in January. The wealthy nations’ concerns echo many of the points brought up by the pharmaceutical industry, which is currently lobbying hard in favor of shielding their intellectual property.
One concern is that intellectual property protections are essential to create incentives for innovation ― that is, without TRIPS protections, companies will be less interested in putting up the money for coronavirus-related research and development.
In their written response, the group argues that when exclusive rights are enforced, pharmaceutical companies actually “slow down research and innovation.” Sharing technology and know-how encourages innovation by generic competitors and lowers prices for lifesaving drugs, they argue.
Proponents of the waiver also point out that the companies that developed these drugs received huge sums of public money for research and development ― they didn’t shoulder all of the financial risk themselves.
“[W]e fail to see the logic of maintaining IP monopolies that limit global supply and competition, and require taxpayers to repeatedly bear the cost of these IP monopolies,” the document states.
Later, it reads: “For COVID-19, the search for an effective treatment or vaccine is a global effort involving multiple actors ― it is not the result of the pharmaceutical industry’s efforts alone. Governments and public funding agencies around the world have poured billions of U.S. dollars of public money to support COVID-19 R&D, especially for drugs and vaccines. However, by and large no conditions for access or affordability have been included as a precondition to any of that funding.”
Opponents of the waiver point out that the TRIPS agreement already has built-in “flexibilities” around IP ― the world can work within the system as it exists, no waiver necessary. Companies already have the option of voluntarily sharing technology and know-how or entering into licensing agreements. Both AstraZeneca and Novavax, for example, have partnered with the Serum Institute of India to produce 1 billion doses of each company’s vaccine.
The governments of India, South Africa and other nations say the idea that the pharmaceutical industry will voluntarily solve the problem of global vaccine equity is “completely divorced from reality.”
Raw materials shortages, however, could undermine the anti-patent movement where it concerns vaccines. (At least in the short term.)
Producing COVID-19 vaccines is a complicated task. According to the journal Nature, vaccine production can require more than 200 individual components that are sourced from a variety of countries.
The heftiest argument the pharmaceutical industry has going for it is that waiving the protections may be counterproductive to inoculation efforts. The trade group PhRMA, which receives funding from the industry, argued in a March 5 letter to Biden that there is “no evidence” eliminating IP barriers would speed up production to provide vaccines to developing countries sooner. Shortages of certain raw materials can easily cause bottlenecks in production, and having more pharmaceutical plants in the mix could make things more difficult for existing facilities.
“The problem doesn’t seem to be in terms of not having enough production capacity online,” Taylor said. “The problem seems to be that we aren’t able even to use all the production capacity we currently have, because we can’t source the sort of materials that they need to produce vaccine quickly enough.”
“It’s not clear that patents are the bottleneck right now,” she said, adding that it could be the case in the future. With the coronavirus currently raging in parts of the world like India, time is of the essence.
“We are in a position now where we can’t afford to be inefficient, we can’t afford to miss any number of doses,” Taylor said.
Yet it’s nearly impossible to get a clear picture of where all of the shortages are, due to a lack of data and lack of transparency on the part of the pharmaceutical industry.
“There are just these anecdotal reports, like the Novavax CEO said this, Moderna CEO said this, Pfizer CEO said this. They’re saying, ‘Oh, we can’t get enough filters,’” Taylor said. “They’re saying it in interviews, and there’s no clarity. I’m sure they have clarity, but there isn’t any sort in the public domain.”
A coalition is working to supply vaccines to low-income countries, but its reach is limited.
COVAX is the vaccine arm of the Access to COVID-19 Tools Accelerator, a World Health Organization initiative funded by the U.S. and other wealthy nations. Public health experts believe it can help solve the problem of vaccine equity, but it will not solve it alone.
“COVAX at best provides very short-term, limited access to vaccines. Its approach is not sustainable in the medium and long term,” the governments of India and South Africa wrote. “The global needs are massive and can only be addressed with global sharing of technology, knowledge and related IP.”
It’s worth noting this whole debate over patents on lifesaving medicines is nothing new.
In 1955, when journalist Edward Murrow asked Dr. Jonas Salk who owned the patent to the newly developed polio vaccine, Salk famously responded, “Well, the people, I would say. There is no patent.”
He added: “Could you patent the sun?” The doctor’s comments have been used for years to fuel criticism of applying intellectual property law to public health.
The WTO has also been embroiled in controversy between drugmakers and the developing world over the past couple of decades. Patented HIV and AIDS drugs, for example, sparked public backlash in the late 1990s. American drug companies and other patent holders eventually bowed to pressure to allow less expensive generic versions of some medications to be manufactured and distributed in low-income countries.
Since then, the problem has been ongoing.
The big takeaway is that vaccine equity is both a short-term and a long-term problem.
In the short term, people in countries around the world need to get their first doses of COVID-19 vaccine. While a growing chorus of voices is calling for patent protections to be waived, it isn’t clear whether that will help get more shots into arms as soon as possible, although it could be more helpful in providing desperately needed treatments to alleviate symptoms.
The long view, however, is different. Public health experts warn that the world is at risk for another pandemic. One of the biggest lessons to be learned from COVID-19 is the importance of timely regional manufacturing ability ― the ability to produce the necessary medical equipment and medications as they are needed, where they are needed. Patent protections will undoubtedly create some hurdles in the process.
“I think in the long term, we’re going to see efforts by countries, by regions, to manufacture their own vaccine, because they see they can’t rely on the global market,” Kenyon said.
“I think we’re going to see that play out in Africa,” he added, noting the region is almost entirely dependent on vaccine imports.
Taylor also emphasized the need for regional manufacturing hubs in South America and Southeast Asia.
“But that’s not a 2021 fix, unfortunately,” she said.