‘America First’ vs. ‘The People’s Vaccine’ 

As the world races to develop a vaccine to end the still-raging coronavirus pandemic, “vaccine nationalism” threatens both the near-term fight against COVID-19 and the longer-term prospects of multilateral cooperation.

Major countries,  including the United States, China, France, Germany, and Italy, have been locking in agreements with pharmaceutical companies to develop and mass-produce vaccines for their own populations, raising concerns among smaller countries that they will be shut out of the market. A competing effort led by the World Health Organization and a coalition of global health organizations to secure what is being referred to as a “people’s vaccine” for poor and middle-income countries is struggling to line up sufficient funding among rich donors, who are reluctant to gamble billions of dollars on the development of vaccine candidates that may never succeed.

The effort to secure widespread distribution of effective vaccines is turning out to be a major test of multilateralism in an era when countries, or regions, are pursuing their own remedies. The United States, which during previous pandemics used its influence to galvanize international responses, has largely abdicated the role it played in fighting Ebola, HIV/AIDS, and malaria. It has announced plans to withdraw from the WHO, and it is reportedly snapping up much of the world’s supply of the antiviral COVID treatment Remdesivir. Even big European countries are locking in future vaccines first for themselves.

“If we continue on the path we are on currently then multilateralism will have failed,” said Thomas Bollyky, the director of the global health program at the Council on Foreign Relations.

There could be short-, medium-, and long-term consequences of hoarding vaccines, he said. “For the short and medium term, it will mean the pandemic rages unabated in countries without supplies. For the long term, there will be consequences for reaching global cooperation on other matters,” he said. “If we can’t cooperate in this context, it undermines the case for cooperating in other cases.”

Hoarding is a big concern, because even once successful vaccines are developed, health experts expect global supply shortages for the next 12 to 18 months. Rather than see wealthy countries snap up limited supplies of vaccines for their own countries, health experts say it would be more effective to ensure that vulnerable populations worldwide can get the vaccine to prevent future resurgences of the pandemic.

“We know for sure that there won’t be enough,” said Mariângela Simão, the WHO’s assistant director-general for access to medicines and health products. “One certainty we have is that if we have one or two or three candidates they are not enough to vaccinate the entire world at the same time. So we are aiming at priority populations to be vaccinated by the end of next year.”

Concern about the availability of vaccines comes as the coronavirus pandemic continues to rage, especially in the United States. Worldwide, more than 10 million people have been infected and over 500,000 have died; in the United States, around 3 million have been infected and more than 130,000 have died. The United States marked its biggest-ever one-day total of new cases at more than 55,000 last week.

“The worst is yet to come,” Tedros Adhanom Ghebreyesus, the head of the WHO, said in a virtual briefing on Monday. “We all want to get on with our lives. But the hard reality is this is not even close to being over.”

A cooperative approach to developing vaccines is important because developing vaccines is an inherently risky undertaking, with only a tiny fraction of preliminary vaccine candidates eventually proving successful in human trials.  Only about 7 percent of vaccines in the early stages of development are successful, and only 17 percent of those that reach trials on humans end up being successful, according to figures compiled by Gavi, the Vaccine Alliance.

Those figures give an edge to wealthy countries like the United States, which has hedged its bets by  signing lucrative vaccine development and manufacturing deals with several companies. But it is filled with peril for poor countries, which lack the resources to sign multibillion-dollar deals with pharmaceutical companies, or middle-income states that risk gambling on a small number of loser vaccines.

In April, the WHO, working closely with the European Commission, the Bill and Melinda Gates Foundation, and others, launched the Access to COVID-19 Tools Accelerator to coordinate a global campaign to develop diagnostic tests, medicines, or therapeutics to alleviate the severity of the disease, and vaccines to prevent transmission.

It aims to raise $31.3 billion, including $18.1 billion for the development of vaccines, from governments and private donors, to produce 500 million tests and 245 million therapeutic courses by mid-2021, and 2 billion vaccine doses by the end of 2021. But it has raised only $3.4 billion for vaccines, tests, and treatment so far, leaving an urgent funding gap. Neither China nor the United States has contributed; the White House point person on COVID-19 response, Jared Kushner, sees the multilateral effort as a competitor in the race for a vaccine.

The initiative’s vaccine pillar, known as the COVID-19 Vaccine Global Access Facility, or COVAX, seeks to pool resources among different countries, nonprofits, and international organizations to develop enough vaccines to cover the most vulnerable in each population, and thus keep future outbreaks under control.

COVAX is a grouping of several different global efforts to accelerate the search for new vaccines. It includes the WHO, Gavi—created in 2000 and funded by the Gates Foundation, the United States, Britain, and Norway—and the Coalition for Epidemic Preparedness Innovations (CEPI), which is funded by the Gates Foundation, the Wellcome Trust, Germany, Japan, and Norway.

“COVID-19 is the biggest threat to global health security in a century, and the pandemic has shown that disease has no borders,” according to an internal June 11 “discussion document” detailing the COVAX technical plan. “Without a global effort that focuses on vaccinating the world’s key priority populations across all countries and quickly tackling disease outbreaks, the pandemic will continue to spread.”

“The competition for vaccine candidates would lead to a global bidding frenzy, driving up pricing as countries ‘panic buy,’” the document added.

“The substantial gaps in immunity to COVID-19 globally will result in continued & substantial waves of disease through at least end-2021, straining health systems and further disrupting societies and economies,” other global health experts warned.

COVAX is championed by Singapore and Switzerland, which formed a so-called Friends of the Facility group to promote the multilateral approach. Britain, Iceland, Japan, Norway, South Korea, the European Union, and New Zealand have joined the group, and others, including Australia and Canada, are expected to sign on. The United States has not opposed the initiative, and there is some hope that it might provide some support in the future. But so far, the United States has not contributed any funding to the COVAX initiative.

“The COVID-19 pandemic demands a united and concerted response by all nations,” Singapore’s Prime Minister Lee Hsien Loong said in a virtual summit on COVID-19  in early June. “I hope that this summit will help focus our minds and resources, and forge partnerships to promote ‘vaccine multilateralism.’”

The initiative—which is still being negotiated with interested governments—is meant to forestall mass shortages of vaccines as during the H1N1, or swine flu, pandemic, which resulted in the death of as many as 575,000 people in 2009. Manufacturers would be asked to seek minimal financial returns in the initial phase of the vaccine response, ensuring that priority populations would receive affordable doses. In exchange, the companies would secure future commitments to sell additional doses. The more countries invest in the project, the larger number of vaccine candidates it can afford to develop, increasing the odds of finding one or more successful vaccines.

So far, CEPI has reached agreements with pharmaceutical companies to develop more than a dozen potential vaccines for COVID-19, and efforts are underway to secure funding from governments, the private sector, and private health charities to fund an expansion of those efforts. Earlier this month, the pharmaceutical giant AstraZeneca reached a $750 million agreement with CEPI and Gavi to support the manufacturing and distribution of 300 million doses of a vaccine, starting at the beginning of the year. But more funding is needed to secure agreements with major manufacturers to produce vaccines.

“The global vaccine requirements to control the pandemic are vast, and achieving the scale of vaccine production needed, as quickly as possible, requires providing manufacturers with certainty of future financing and procurement,” according to the COVAX paper.

The task of funding and distributing vaccines to the poorest countries will be left to Gavi, which has already built an extensive distribution network in more than 75 lower- and middle-income countries, but which has never tackled a crisis of this magnitude.

Meanwhile, the United States, in addition to seeking to stockpile antiviral treatments that could crimp availability for the rest of the world, has signed contracts with several pharmaceutical companies for vaccines, including Johnson & Johnson, Moderna Inc., and AstraZeneca to purchase and manufacture billions of doses of vaccine.

“There is not much discussion of world partnership,” said Michael Collins, a research associate at  the Council on Foreign Relations. “If I had to guess, the ‘America First’ approach is going to prevail with the vaccine procurement process.”

Under the White House’s Operation Warp Speed, led by Kushner, the United States is seeking to acquire 300 million doses by January 2021, suggesting it would seek to offer vaccines to low-risk individuals—not the approach that health experts say would be most effective at tamping down the global pandemic.

“There is going to be scarcity, during that period of scarcity how much of those supplies are you going to use domestically? If you use them all, scarcity is going to last longer,” said Bollyky, the global health expert. “If you focus on priority needs and share the rest, there will be more available.”

China, for its part, seems to be charting a different course, potentially using vaccine development to boost its influence among developing countries. In May, China’s President Xi Jinping said any vaccines his country produced would be a “global public good” and shared with poor countries. “This will be China’s contribution to ensuring vaccine accessibility and affordability in developing countries,” Xi told the World Health Assembly at its virtual gathering. China watchers say it would likely share the vaccine with countries participating in Xi’s signature Belt and Road Initiative.

Even Europe, for all its talk of broad multilateralism, is looking out for itself. Germany, France, Italy, and the Netherlands struck out early to form their own purchasing alliance, called the Inclusive Vaccine Alliance. The move rankled other European powers, including Belgium, which complained it was undermining EU efforts to purchase vaccines on behalf of all its member states.

French government officials, meanwhile, moved to quash an effort by the United States to line up an exclusive agreement to purchase the first potential vaccine produced by the French drugmaker Sanofi, calling it “unacceptable.” And Britain’s health minister protested that vaccines produced in Britain, where a University of Oxford lab has produced one of the more promising vaccine candidates, should be used to protect Britons.

“The Europeans talk the rhetoric of multilateralism, but it remains to be  seen if they are committed to it,” said one senior diplomat.

Following criticism, France and Germany have since sought to assure countries that they will support broad distribution of any future vaccine. In April, French President Emmanuel Macron and German Chancellor Angela Merkel, along with the WHO, backed an $8 billion virtual fundraising event to raise money to produce vaccines for all countries.

“We are talking here about global public property, about producing this vaccine and then distributing it all around the world,” Merkel said.

The United States declined to participate in the fundraiser.