In laboratories around the world, hundreds of scientists are racing to develop a vaccine for the coronavirus and end the pandemic that has brought global commerce, travel and much of everyday life to a screeching halt.
But while the eyes of private business, civil society and the news media are fixated on which vaccine candidates look the most promising and how soon a cure could be available for widespread use, comparatively less attention is being paid to the toxic chain of events that could unfold internationally once a vaccine is ready and national governments compete over access to it.
If the global race over the past few weeks and months to procure coronavirus-related medical equipment is anything to go by — the one that has seen national, state and local governments, the private sector and multilateral institutions compete with one another to outbid, scoop up and hoard scant quantities of diagnostic tests, personal protective equipment and ventilators — then the competition to acquire precious quantities of a new vaccine will be something the likes of which the world has never seen.
Unnerved by that possibility, some European powers, including France and Germany, are now attempting to build a broad international coalition that will jointly finance, develop and share in any vaccine. However, it is not clear how successful their efforts will be, absent buy-in from the United States and China, which are both using their considerable economic and scientific resources to go all-in on the hunt for a vaccine.
“We will only halt COVID-19 through solidarity,” the head of the World Health Organization, Tedros Adhanom Ghebreyesus, said on Friday at a virtual kickoff event with the heads of states of 10 countries supporting the collaborative work and sharing of a vaccine. “Countries, health partners, manufacturers, and the private sector must act together and ensure that the fruits of science and research can benefit everybody.”
Past experiences with HIV, H5N1 bird flu and H1N1swine flu have underlined how difficult it is to ensure equitable access between developed and developing countries to early treatments and vaccines. Even wealthy countries have struggled to obtain enough vaccine during an epidemic. During the 2009 swine flu outbreak, the Australian government prohibited the export to the United States of a single-dose vaccine that one of its companies produced until enough of the vaccine had been manufactured to meet its own domestic needs.
“The national interests of most developed states vis-à-vis dangerous influenza strains favor retaining the existing imbalanced, reactive, and ad hoc approach to vaccine access,” concludes a 2010 paper by international law and biosecurity expert David Fidler in the PLOS Medicine journal. “Developed countries will prize their power and flexibility of action more in a severe pandemic than in a mild one, thus making hope for a crisis-sparked breakthrough misguided.”
A staged vaccination program
The lack of international norms surrounding how to equitably distribute an eventual vaccine or treatment for COVID-19 has left many global health experts pessimistic about what that will mean for the world’s poorer countries, particularly in Africa.
“I’m worried that there is this scramble for all countries to have access to any sort of innovation, particularly a life-saving vaccine, and yet the biggest and strongest nations will get there first,” said Loyce Pace, executive director of the Global Health Council, a member organization of health care companies, professional medical associations, academics and humanitarian organizations that advocates for equitable health care access around the world. “The weaker economies or governments will lag behind not just in their access but in their outcomes; they will suffer the longest.”
In an ideal world, global health experts interviewed by CQ Roll Call said they would like to see an international agreement that would cooperatively finance the development and manufacturing of multiple different COVID-19 medical treatments and vaccines. It is important, they say, that at least some vaccines be produced that are suitable for developing countries where vaccine characteristics such as ease of administration and little need for refrigeration are prized.
Importantly, these experts say, there should be a global consensus about the most efficient path for eradicating the virus while also gradually reopening the globalized economy. Rather than seeing wealthy countries such as the United States insist on inoculating all of their citizens before permitting the export of a vaccine, global health advocates want to see a tiered strategy for vaccinating different population groups based on which groups are most needed in the fight against the coronavirus and which are most vulnerable to dying from it.
Based on interviews with multiple experts and the U.S. Centers for Disease Control and Prevention’s own domestic guidelines for pandemic influenza vaccination programs, a priority list for global COVID-19 vaccination might look something like this:
- Medical workers all around the world with prioritization for front-line and hospital-based specialists caring for the sickest persons and other health care personnel with the highest risk of exposure.
- Other categories of essential personnel including law enforcement, fire services and grocery workers.
- People living in the center of a major geographical outbreak.
- The elderly, with the oldest age groups immunized first, and those with underlying health conditions.
“My sense of the priorities would be health workers globally should be protected,” Seth Berkley, CEO of GAVI, a multilateral immunization campaign that receives U.S. government funding, said during a Council on Foreign Relations conference call. “Then one needs to go to places that have epidemics that are out of control and try to bring them under control. … [The next] highest priority would be the elderly and those with underlying risk factors. And then, eventually, the rest of the population.”
Such a distribution scenario would mean that the young and healthy, including those in developed countries, would be among the last to receive the vaccine.
But that kind of an outcome — where wealthy countries voluntarily agree to leave large portions of their populations for a longer period of time unvaccinated, homebound and unable to fully participate in the local economy, all for the greater good of worldwide humanity — is unlikely, predicts Amesh Adalja, a medical doctor and senior scholar at Johns Hopkins University’s Center for Health Security.
“No matter how much you say that and how much you hold them up as an ideal, you will find governments wanting to vaccinate their own populations first before an export license is granted,” predicts Adalja, who specializes in pandemic preparedness and biosecurity.
Global competition and suspicion
President Donald Trump touched off a furor in Germany when it was reported last month that he tried to entice a German firm, CureVac, into moving its research and development of a promising vaccine candidate to the United States, presumably to ensure that any eventual vaccine production would be controlled by the U.S. government.
Though U.S. officials have denied Trump offered large sums of money to the firm to lure it to the United States, investors with CureVac have confirmed that some type of approach did take place.
“The fact that we have a president who is suggesting that any vaccine development right now will only be to the benefit of Americans is a major, major problem,” said Amy Pope, a former deputy homeland security adviser in the Obama White House, during a conference call with reporters organized by the liberal foreign policy group National Security Action.
Indeed, the Trump administration is in good company when it comes to adopting a "to the victor go the spoils" mindset in the race to find a vaccine.
“The upside of being the first country in the world to develop a successful vaccine is so huge that I am throwing everything at it,” British Health Secretary Matt Hancock acknowledged at a press briefing last week announcing new monetary support for two leading vaccine candidates under development at the University of Oxford and at Imperial College London.
The timeline for a vaccine being ready for public use is projected to be a year at the earliest, though health care workers could receive it earlier on an emergency basis. While U.S. biotechnology companies are considered very competitive in the race to develop a cure, several other countries, particularly China, are also well-positioned to develop a vaccine.
There are some 115 vaccine candidates in development. Already, six have begun clinical evaluation, according to a running tally kept by the World Health Organization.
U.S. companies are developing two of the potential vaccines that have entered clinical evaluations. China is developing three others and the United Kingdom is developing the sixth. It is entirely possible that none of the vaccine candidates currently in clinical development will ultimately prove safe and efficacious enough for commercial use but that some other vaccine further behind in the development pipeline will.
“While I do believe a few very successful vaccines will come out of the U.S., there will mostly likely be one or two highly efficacious vaccines that may come out of Europe. So if we want them for the U.S. population, then we have to work with them,” said Prashant Yadav, a senior fellow at the progressive Center for Global Development, who specializes in global health care supply chains.
The World Health Organization’s freshly announced goal of raising $8 billion to support the development, manufacture and global distribution of coronavirus vaccines and therapeutics has drawn support from influential players including the European Commission, France, Germany and the United Kingdom, whose heads of state all participated in the virtual Friday kick-off event. Notably absent, however, were China and the United States.
“We hope we can reconcile the initiative with China and the U.S.,” French President Emmanuel Macron said. “There should not be any divisions between countries. We need to join forces.”
Reasons to collaborate
Gayle Smith, the former head of the U.S. Agency for International Development during the Obama administration, told CQ Roll Call she sees plenty of good reasons for governments, even nationalist ones like the Trump administration, to pursue a collaborative approach in the search for a vaccine, rather than a competitive one.
“The science [is clear that to] actually succeed in bringing a global pandemic to an end, there has got to be the availability of mass and swift inoculation all over the world,” said Smith, who now leads the global anti-poverty advocacy ONE Campaign. “The longer that takes, the longer we will suffer the consequences on the health and economic fronts.”
Wealthy countries such as the United States, which has globalized supply chains all over the world for things like pharmaceuticals, electronics and cars, are fooling themselves if they imagine that life will be able to return to normal at home while factories in the developing world are still shut down because it’s not safe for their employees to go into work. Massive trade disruptions including bottlenecks and shortages of in-demand goods at stores in the United States will be prolonged and even worsen unless a vaccine is equitably and sensibly shared, Smith argued.
And finally, the longer the developing world goes without access to an affordable vaccine, particularly in parts of the Middle East, South Asia, Africa and Latin America, the greater the likelihood is that political instability will spread and with it the risks of coups, civil war and a resurgence of extremist groups.
“Those issues that are challenging national security questions now will be more difficult by a factor of thousands if this virus continues to move around unchecked,” said Smith, who served on the National Security Council under both the Obama and Clinton administrations.
Smith says it’s plausible that if Trump were to use his position to work with longtime U.S. allies in Europe as well as Canada, South Korea, Japan and Australia, on a collaborative approach, then China might feel compelled to join in to preserve its image as a responsible player. In such a scenario, other important countries such as India, Brazil and Russia would also feel pressured to join the fold.
“I can’t find any good reasons not to do it this way,” Smith said. “It is fair, so it is the right thing to do, but it is unquestionably the smart thing to do.”
Absence of U.S. leadership
At the moment, rather than using the platform of being the most powerful country in the world to try to build an international vaccine framework, Trump and his secretary of State, Mike Pompeo, have used their public remarks to deflect blame for the U.S. government’s stumbling response to the crisis onto China and the World Health Organization, which the administration has temporarily frozen funding to.
“What is striking about this crisis is that based on our past history and the history of the world, one would think there would be more world leaders coming together on this as a matter of urgency,” Smith said. “Some are, but we don’t have the sort of global weight that we need to get it over the finish line.”
A State Department spokesman, when asked to comment on multilateral efforts to cooperate on a vaccine, kept to the criticism of the WHO. "America’s world-leading scientists are working hard on a COVID-19 vaccine," the spokesman said. "We welcome serious efforts to assist in that endeavor, and look forward to learning more about the World Health Organization’s proposal. We remain deeply concerned about the WHO’s effectiveness, given that its gross failures helped fuel the current pandemic."
Some U.S. lawmakers are trying to persuade the Trump administration to adopt a more collaborative and less confrontational approach, including by adding USAID to its White House Coronavirus Task Force.
“If the United States executes a comprehensive and collaborative international response effort now, we may avoid a worst-case scenario; continued delay could result in hundreds of thousands of lives lost, and a global economic downturn that will jeopardize our own recovery,” all Democratic members of the Senate Foreign Relations Committee said in a letter sent last week to Vice President Mike Pence. "We urge you to lead in ensuring that the United States is not perceived as casting blame, disrupting global supply chains, and sowing discord and xenophobia among countries and institutions who must be seen and treated as partners in combating the COVID-19 pandemic.”
There are some reasons to hope that eventual vaccines and therapies will be better shared than they were during previous pandemics. For one thing, influential multilateral institutions exist now that didn’t back then such as The Coalition for Epidemic Preparedness Innovations, also known as CEPI.
Started in 2017, the coalition was launched with funding from the Bill and Melinda Gates Foundation, Norway and India with the goal of financing and coordinating the development of vaccines against emerging infectious diseases that the private sector might not otherwise pursue. CEPI is privately and publicly funded. Its public funders include Australia, Belgium, Canada, Denmark, Ethiopia, the European Commission, Finland, Germany, Japan, the Netherlands, Saudi Arabia, Switzerland and the United Kingdom.
CEPI says it includes the requirement in its research contracts that vaccines developed with its funding be equitably shared.
“Equitable access to epidemic vaccines by people in Affected Territories is woven into each of those agreements and means that the vaccines developed through CEPI funding will be first available to populations when and where they are needed to end an outbreak or curtail an epidemic, regardless of the recipients’ ability to pay,” reads a 2019 CEPI fact sheet.
CEPI has been an active player in the search for a COVID-19 cure. The coalition has provided funding for some of the most promising vaccine candidates including ones in early clinical trials in the United States and the United Kingdom. CEPI’s vaccine funding mechanism is expected to be one of the main beneficiaries of the WHO’s coronavirus fundraising drive.
“I do think the involvement of CEPI and the Gates foundation does make it more likely that we won’t have the same problem that we had during H1N1 with the Australian vaccine,” said Adalja.
Multilateral negotiations needed
Experts differ as to what would be the most sensible mechanism for negotiating an international coronavirus vaccine agreement. Some would like to see the World Health Organization serve as the coordinating forum.
“The World Health Organization is the best starting point for coming up with recommendations. It has the technical expertise or linkages with academia and think-tanks to develop the recommendations based on science and data,” Margaret Gadabu, head of chancery at the Malawi Embassy in Washington, said in an email.
Any WHO recommendations should be forwarded to the U.N. General Assembly and not the Security Council for endorsement, she said, adding it was important on this issue that the Security Council’s five permanent members — the United States, the United Kingdom, France, China and Russia — abstain from using their vetoes and respect the voting decisions of the majority of the U.N. member states.
“WHO as an entity has greater influence in low and lower-middle income countries but the G-20 countries don’t necessarily rely on the WHO in determining how to run their internal health systems,” Yadav said. “The WHO cannot tell the U.S. or the EU ‘this is how you will allocate vaccine or this is how much vaccine you will buy.’”
However, the WHO can coordinate with G-20 countries on best practices and vaccine supplies for the developing world, he said.
Smith recommends the world’s most industrialized economies, known as the G-7, which are the United States, the United Kingdom, Germany, Canada, Japan, France and Italy, each designate a special representative that will be charged with hammering out the details of an international accord covering the funding, development, manufacturing and distribution of an eventual vaccine.
“The key thing is to get in the same room the heads of state and decision-makers, the international multilateral mechanisms like GAVI and WHO and the major pharmaceutical companies,” she said, adding that the need to hold meetings virtually shouldn’t impede progress on a potential international vaccine agreement if there is enough political urgency to get one done. “I think it would take political capital from leaders to get major industry into the room early. I think if a president of the United States called for a high-level meeting with heads of industry, I suspect they would show up, even if it was virtual.”
Added Pope of the Obama NSC: “Really, unless the United States itself is leading with that message, then I think we are going to have difficulty in terms of encouraging the kind of cooperation on information-sharing and funding for the type of wide-scale vaccine development research that needs to happen right now.”