‘Nobody is safe until we are all safe’: why the race for a coronavirus vaccine must include developing countries

In early 2009 when a strain of H1N1 flu, the same kind that caused the 1918 Spanish flu pandemic, emerged in Mexico, governments across the world feared the worst.

The initial outbreak had spread rapidly and, while it had not proved particularly fatal yet, scientists warned a repeat of 1918 and a second, far deadlier wave come the winter was entirely possible.

A scramble to develop and distribute a vaccine began but, despite experience from the 2004 bird flu scare, a coordinated global effort to ensure the whole world gained equal access to a vaccine failed to materialise. Wealthy countries were already well-served by “pre-production contracts” which gave them claims to the limited production that would be available, but poorer countries found themselves on the outside looking in.

Eventually, a number of rich nations pledged to donate 10 per cent of the doses they bought to the developing world, via the World Health Organisation (WHO). However, it soon became clear that for many donors this would happen only once they had fully served their own populations.   

The developing world eventually got access to vaccines in late 2009, but not before the rich world had taken care of itself. 

That pandemic turned out to be a mild one, but the fear of such a scenario repeating itself once again grips the scientific community.

“This terrifies me”, says Professor Peter Jay Hotez, a professor at Baylor College of Medicine in Texas who is working on a coronavirus vaccine deliberately aimed at low and middle-income countries, “it’s why our team has been in the lab night and day. It could be incredibly destabilising”. 

Developing a vaccine may well prove the easy part, says Prof Hotez, “it’s an old school problem in virology, the bar isn’t that high”. It’s the manufacture and distribution in an equitable manner that could prove by far the bigger challenge, he says.

There’s little the WHO can do to prevent wealthier countries from signing pre-production contracts and hoarding vaccines. “There is a risk of politicians wanting to put their own populations ahead of the global populations. I can understand politically why some politicians might do that. But nobody is safe until we are all safe”, says Dr Mike Turner, the head of major science investments at the Wellcome Trust. 

That phrase has become a mantra for those pushing for a coordinated global effort towards vaccination and its one that some world leaders appear, on the face of it at least, to be listening to. At a virtual vaccine summit hosted by the EU in early May, £6.5 billion to fund research of Covid-19 vaccines and therapies was pledged along with assurances that it would be used to ensure poor countries received equal access. 

But that summit was also indicative of the divisions already at play, with neither the US nor India taking part and China sending only minor representation. Since then, the UK and other rich countries, have signed bilateral pre-production contracts with pharmaceutical companies. 

The UK has signed four such deals, including one for the Oxford-AstraZeneca candidate vaccine, with the orders totalling 250 million doses. The European Union has its own scheme that is yet to announce any deals, but an alliance of Germany, France, the Netherlands and Italy has signed one with AstraZeneca for 400 million doses. The United States, meanwhile, is pushing ahead with its own “Operation Warp Speed” strategy.

The claim that nobody is safe until everybody is safe “clearly isn’t resonating with countries,” says Kate Elder, senior vaccines policy adviser at Doctors Without Borders. Even the UK, which has long been one of the world’s biggest donors towards vaccination programmes, is not immune. “There’s been a lot of doublespeak from the British Government,” says Ms Elder. 

Speaking to Parliament last month, Matt Hancock, the Health Secretary insisted that the UK was “working to ensure that whoever’s vaccine is approved first, the whole world can have access.” The following day, however, he offered a clarification: “Naturally I’m determined to ensure that there is enough vaccine for the whole UK population, first and foremost”

The issue is that wealthier governments may believe that it makes more sense both politically and economically to pursue their own interests. Were the United States to develop a vaccine first, it might decide that “rather than sharing it with Mexico’s or Canada’s elderly we’re going to keep it to ourselves and give it to school teachers or students to get the economy going again”, says Professor Naor Bar-Zeev, an infectious diseases physician and statistical epidemiologist at Johns Hopkins University’s International Vaccine Access Center, “That would be reasonable if America was the only country affected but it’s not.”

The WHO and its fellow institutions are acutely aware of the issue. Rather than rely on the beneficence of richer nations, they hope to engage their self-interest and harness the same methods to guarantee a global distribution of any vaccine.

WHO launches vaccine buying alliance

At the virtual Global Vaccine Summit hosted by the UK in early June, Gavi, the vaccine alliance, alongside the WHO and Coalition for Epidemic Preparedness Innovations (Cepi) launched the Covax facility.

A subset of the broader “Access to Covid-19 Tools (ACT) Accelerator”, Covax aims to act as vaccine buying alliance, signing the same kind of pre-production agreements as rich nations as well as investing directly in research, development, and manufacturing. It already has its own $750 million deal with AstraZeneca. Wealthy countries would self-fund their vaccine purchase while also donating to cover the costs for up to 90 poorer countries.

The case being sold to rich countries is two-fold. One, that the pandemic won’t be truly over and all countries safe until every nation has been vaccinated. And two, there’s no guarantee that in signing bilateral agreements countries will pick a winner, but if they pool their resources with Covax they can maximise their odds by backing a much larger number of candidate vaccines. 

For countries such as Britain, which already have multiple deals signed, it may be little more than an insurance policy. But for smaller countries, it might be their best chance at wielding significant purchasing power. 

So far, Covax has received 75 expressions of interest from potential self-funding countries but as yet no firm commitments. Gavi has set a deadline of August 31 for countries to make a binding commitment to purchase enough doses to cover 20 per cent of their population and provide an upfront payment in proportion to their commitment.

Gavi wants to act fast to ensure a vaccine is ready in 2021, but the short turn around and uncertain returns, given the nature of vaccine development, is causing some countries to hesitate, says Ms Elder. “It’s a big budget commitment for these countries and there’s concern they might not get anything for it”. 

Even if Covax is a success, there may still be a significant slice of the world left out. While poor countries might be covered by aid and rich countries take care of themselves, “it’s the middle-income countries that might be in a real pinch,” says Prof Bar-Zeev, “because they won’t be underperforming enough that they could get Gavi support but they wouldn’t be able to compete in the open market.”

That’s an issue that could be compounded by the high-tech nature of many potential vaccines, which could be either too expensive to buy or too complex to manufacture for middle-income countries says Prof Hotez. His team hopes that their vaccine, which uses well-established yeast-based technology, will be straightforward for countries such as Brazil, Bangladesh and Indonesia, which already make their own vaccines, to manufacture.

In the meantime, there is an acute need for a debate on how any vaccine is best distributed. “Let’s say I’m an Italy or a Japan and I have a relatively older population, or I’m a Malawi or a Sierra Leone and I have a relatively young population but I have a lot of immunocompromised people,” says Prof Bar-Zeev, “how should a limited supply be distributed? 

“How do we distribute justly? There has been a lot of words, good words, but what does that translate into? What are the decisions that will need to be taken? Under what frameworks? Who gets to decide?” 

Such debates need to be had now, says Prof Bar-Zeev so that “a year and a half from now or in three years when there’s a working vaccine then we’ll have thought through some of these things.”

Even with Covax in the mix, there is still immense uncertainty about how any successful vaccines would be distributed. The deals being signed with pharmaceutical companies are not public and there has been little indication of what order they might be fulfilled in.

While the Covax facility guarantees nations enough doses to inoculate 20 per cent of their population, the question of who gets priority is still being discussed. There is a general acceptance worldwide that health workers will come first, and Gavi has previously stated that Covax will follow that principle before moving on to its 20 per cent target. 

As Ms Elder puts it, however, “Who is going to be served first? Somebody has to be.”

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