On April 25, 2019, two gunmen opened fire on a group of vaccinators in a remote village in Chaman, Pakistan, near the border of Afghanistan. Nasreen Bibi, 35, was killed while another was critically wounded. This was one of many attacks against healthcare workers aiming to eradicate polio in Pakistan because of a growing distrust surrounding vaccines.
Distrust of vaccine workers in Pakistan has steadily grown since 2012 when it was revealed the CIA used vaccine programs as a cover for espionage, most infamously in attempts to discover the whereabouts of al-Qaeda leader Osama bin Laden. Since then, Taliban and hardline clerics have spread misinformation claiming vaccines are foreign plots to sterilize Muslim children. Though efforts by the CIA were unfruitful, they had detrimental effects on immunization programs geared toward eradicating polio in both Pakistan and Afghanistan.
Distrust and spread of misinformation around vaccines are one of many issues that have long haunted global immunization efforts and will need to be taken into consideration once (or if) a COVID-19 vaccine comes to market. People around the world have pinned their hopes on the development of a possible vaccine against coronavirus. Many are under the impression that an eventual vaccine will become our magical savior from the invisible killer. However, historically, the greatest challenge is what comes after we have a vaccine — navigating a broad spectrum of sociopolitical and economic barriers to immunization that often result in unequal vaccine access and global health disparities.
We must avoid what happened with the H1N1 pandemic in 2009, said Marian Wentworth, president and CEO of Management Sciences for Health, a nonprofit global health organization. H1N1 presented a situation where the short supply of vaccines was unable to meet the demands of the population. Three European companies make up the majority of the world’s influenza vaccine manufacturing capacity: GlaxoSmithKline, Sanofi-Aventis and Novartis. This existing manufacturing capacity was not enough to supply the world’s population. Instead, wealthier countries ordered and purchased the majority of the vaccine supply in advance. This “first-come, first served” model will likely be the case for a COVID-19 vaccine. “No matter how fast we scale up, it’s going to be true on day one, the total number of doses available is less than the need,” Wentworth said.
The main concern is that access to the COVID-19 vaccine will be another opportunity for price gouging — countries competing with one another to purchase limited supplies of vaccines driving up the price. High-income countries will come out winners, outbidding middle- and lower income-countries in the global economy.
These concerns are not unfounded despite some pharmaceutical companies, such as Johnson & Johnson, assuring the public the vaccine will be affordable. Gilead Sciences recently sought to privatize a promising antiviral drug against COVID-19 under the Orphan Drug Act. The “orphan drug” status, granted to Gilead Sciences by the Trump administration, would have allowed the company to profit exclusively from the drug for seven years and blocked manufacturers from developing affordable generic versions of the drug. Additionally, German officials reported that President Trump attempted to buy exclusive rights to a vaccine produced by German biopharmaceutical company CureVac. Though these accusations were later denied by the CEO of CureVac, fears of countries hoarding a vaccine for their own population remains a source of unease. One writer for The Guardian has gone as far as to suggest a hypothetical situation where India, known as the “pharmacy of the developing world,” may use its manufacturing capacity to create vaccines to protect its own population before exporting it to the rest of the world. This was seen last month when India banned the exportation of hydroxychloroquine to secure its own supply. After Trump threatened to retaliate, India announced last week it was lifting its blanket ban on exports. The drug’s treatment efficacy is unproven, but touting it as a life-saving drug could prove profitable for some close to Trump.
In partnership with organizations such the Bill and Melinda Gates Foundation and the World Bank, public-private global health group Gavi, a vaccine alliance, has been a huge player in introducing vaccines to low-income countries by sharing a portion of a country’s vaccine costs and building up advocacy programs. But even with an innovative financial model, it took 10 years with the help of Gavi funding for human papillomavirus or HPV vaccines to reach developing countries, according to Wentworth. To put that in perspective, prior to Gavi, it took Hepatitis B vaccines 25 years to reach developing countries. That’s an alarming time gap.
Gavi also does not support middle-income countries and therefore they run the risk of falling through the cracks, said Lois Privor-Dumm, director of policy, advocacy and communications at Johns Hopkins’ International Vaccine Access Center. “Middle-income countries are where the majority of the world’s poor live and often don’t have the political will or resources to address what needs to be done,” she said.
Depending on the status of the disease, least priority will be given to countries that have been most devastated by COVID-19 because their survivors will likely have built self-immunity, not requiring a vaccine as urgently, Wentworth said. This may include countries with fragile health care systems such as Iran, which is economically struggling under U.S. sanctions, and war-torn occupied lands such as Kashmir and Palestine, or possibly the U.S., which has now become the epicenter of the coronavirus pandemic. Although it is hard to imagine a scenario where the U.S. is last to receive vaccines, creating a potential situation where resources are diverted from places where the need is greater.
Even within countries, certain populations will be prioritized over others due to the limited supply. It is anticipated that front-line health care workers and emergency responders will be immunized first, but beyond that, it will vary based on local policies and priorities. In the U.S., for example, the Centers for Disease Control and Prevention will provide general recommendations, but there will be further input from each individual state and county public health agencies that will be making decisions for their particular jurisdiction in the absence of scientific evidence. “In this case, the information about the disease is rolling out as quickly as it can, but in small pieces. There is so much we don’t know,” Wentworth said.
Already we need to be questioning which communities will be prioritized above others in the U.S. As our current health care system operates, vulnerable communities such as undocumented immigrants and people of color will continue to be neglected, even as the coronavirus crisis brutally exposes the stark health inequalities, disproportionately killing along racial lines. These disparities are not biological, but entirely a result of explicit consciously made political and socioeconomic decisions around access, or rather the lack of — whether it be access to health insurance, housing, voting rights, stimulus checks or vaccines.
Looking toward the future, many countries are putting in place protective measures to ensure they have open access to any coronavirus-related data, patent rights, technologies, drugs and vaccines. Costa Rican President Carlos Alvarado sent a proposal requesting the World Health Organization (WHO) to pool “existing and future rights in patented interventions, designs, as well as rights in regulatory test data, know-how, cell lines, copyrights, blueprints for manufacturing diagnostic tests, devices, drugs, or vaccines.” The WHO approved the proposal last week.
The international scientific cooperation to find a vaccine has been extraordinary, Wentworth said. She credits China’s researchers for releasing the genetic sequence of SARS-CoV-2 early on in January, enabling scientists all over the world to start researching possible vaccines. “This is better than I have ever seen it,” she said.
The effectiveness of the voluntary pool remains to be seen. Their success on expanding access to treatments and vaccine data will depend entirely on pharmaceutical companies willingness to opt in and participate in the voluntary pooling.
Chile, Ecuador, Canada and Germany have each recently passed resolutions under the Trade-Related Aspects of Intellectual Property Rights agreement urging their governments to seek compulsory licensing for medicines and vaccines to combat the pandemic. Brazil is currently contemplating adopting a similar proposal. Compulsory licensing allows a government to tap a third party to produce a patented drug without the consent of the patent owner in the case of a national emergency in order to access much-needed medications.
Compulsory licensing was initially established as a means to balance intellectual property rights with global health priorities, particularly with developing countries in mind. However, in practice, many of these countries do not have the manufacturing infrastructure or expertise to produce these medications, and therefore compulsory licensing hasn’t improved access in the developing world. Furthermore, these measures will have little impact on prophylaxis vaccines because they are difficult to replicate, Wentworth said.
The U.S. has regulations that allow the government to intervene on private patents funded by taxpayer money during national crises under the Bayh-Dole Act. With the millions of taxpayer dollars poured into pharmaceutical companies promising vaccines through the National Institutes of Health and Department of Defense, the U.S. would hypothetically be able to use its authority under this law to make the vaccine affordable or provide a license to a third-party manufacturer to produce generic supplies. While there is some historical precedence of the government intervening to lower drug prices during the 2001 anthrax scare, it is unlikely the Trump administration will do, so as it has notably privatized its coronavirus response and seeks to profit off the protections afforded to pharmaceutical companies.
Beyond vaccine access and affordability at the structural level, grassroots efforts for immunization will require building trust between health care workers and vulnerable communities that in some cases do not exist and are often further impeded by the state.
Across the United States and Europe, anti-vaccine movements threaten to derail immunization efforts. The 2019 measles outbreak was partly attributed to their efforts and even now, they continue to spread conspiracy theories that diminish the seriousness of the pandemic. It certainly doesn’t help that, in the past, Trump validated claims linking vaccines to autism based on Andrew Wakefield’s scientifically unfounded Lancet paper published in 1998. Trump’s war on science has done irreparable damage to the credibility of vaccines in some pockets of the U.S. that cannot be undone even now as he calls for the fast-tracking of a COVID-19 vaccine. According to the WHO, vaccine hesitancy was one of the top 10 global health threats of 2019.
Culturally sensitive approaches to vaccines that are mindful of specific populations’ concerns could play an important role in rebuilding trust essential for tackling vaccine hesitancy. For example, in Indonesia, measles vaccinations have dropped after the state’s largest Islamic body, the Indonesian Ulama Council, issued a fatwa banning measles-rubella vaccines because they contained porcine gelatin. A similar trend was seen in ultra-Orthodox Jewish communities in Brooklyn, New York, leading Mayor Bill de Blasio to declare a public health emergency to contain the spread of measles last year. One suggestion has been to create vaccines with halal or kosher ingredients to improve vaccination among segments of Muslim and Jewish communities who believe vaccines contradict their religious mandates. “This is something that needs to be part of the target product profile from the beginning of development,” Privor-Dumm said. “These are opportunities to reimagine vaccine delivery in ways that are culturally sensitive and reach more people, benefiting everyone.”
COVID-19 vaccine distribution will be a political project that will require navigating the violent reaches of neoliberalism that seeks to limit access to vulnerable populations globally and pocket wealth in the hands of corporations. It will not be enough to have a COVID-19 vaccine if we are unable to get it to people in hard to reach places in a timely manner, where the need is equally (if not more) dire. This will be a grueling task if past global immunization programs are any indication. Nonetheless, this does not mitigate how important it is to build capacity and coordinate efforts so that when a vaccine is ready, it can be made equally accessible and affordable. This will be important for both reducing individual suffering and improving collective global public health to prevent a future pandemic, but more consequently, allowing countries to reopen their economies so people can return to work, ease financial burdens and resume a semblance of “normalcy” — equally critical for communal and individual health.
“We live in a global world that needs to be considering how well other countries are able to prevent and manage disease,” Privor-Dumm said. “What happens in one part of the world is not something we can [ignore].”
This is a lesson we are learning a tragically hard way.