Vaccine Nationalism and COVID-19
By Alexandra Maters, Sam Baron, Cyril Kazan, Cal Koger-Pease, Esther Lee
What is vaccine nationalism?
The early purchase of a massive number of vaccine doses through Advance Purchase Agreements (APAs) by high-income countries (HICs) raised concerns that countries would display vaccine nationalism - a phenomenon where each country is only interested in securing vaccines for its own people. As of February 2022, more than half of high income countries’ populations have been given at least one dose of vaccine, while the percentage rests at only 11% in low to middle-income countries (LMICs). COVAX is a multi-stakeholder organization involving governments, corporations, foundations and nonprofits that aims to minimize the discrepancy by providing the platform for global investment in and purchasing of COVID-19 vaccines at a fair price, and ensuring access in LMICs. However, inequities within global distribution of vaccines persist with HICs such as Canada, a COVAX investor, having pre-ordered over 6 doses per person, while COVAX holds less than 1 per person. Even if COVAX meets its goal of vaccinating 20% of the 92 LMICs of its target, it is not enough to stop the spread of the virus and halt the pandemic.
Causes of vaccine nationalism
A major driver for the unequal distribution of vaccines is the prevalence of bilateral advance pricing agreements (APAs) between HICs and pharmaceutical companies. These contracts typically involve a country’s government and a single company (usually domestic) and are written before the vaccine has been approved. As a result of APAs, early supply ends up going almost exclusively to HICs, and there is a significant manufacturing lag where there is limited supply for LMICs. APAs are an inherently risky endeavor for a single country to enter into as there is always the possibility that the vaccine candidate will not succeed. Therefore, HICs like the United States have attempted to leverage their role in funding vaccine research to gain larger shares of vaccines manufactured in other countries. Practices like this contribute to vaccine nationalism and make it much more difficult for LMICs to secure these agreements as these risks would be much more significant for these countries.
Consequences of Vaccine Nationalism
Vaccine nationalism is an issue that has had serious moral and political repercussions globally. The ongoing argument in favor of vaccine nationalism is that governments should prioritize the physical and economic health of their own citizens; however, there are compelling reasons why governments should choose to share their vaccine supplies with the rest of the world.
To better understand the benefits of an equitable and global approach to vaccine distribution, one must first consider how viral replication works: every time a virus replicates, there is a chance that a mistake will occur while replicating the genetic information. Such a mistake is called a mutation, and can lead to new features in the virus that can make it more virulent or even resistant to vaccines. Through some simple math and modeling, it is clear that the more the virus is allowed to replicate in hosts, the higher the risk of such mutations arising. As replication will occur much more rapidly in unvaccinated populations, by hoarding vaccines and thereby limiting their access to LMICs, many HICs are prolonging the pandemic by creating conditions that are favorable for new variants. This is the process by which new, more transmissible, and more severe COVID-19 variants, such as Delta and Omicron, have arisen. Furthermore, we have seen that new variants of the virus are better at bypassing vaccine-generated immunity and cause breakthrough infections at higher rates than the original strains, meaning that current vaccines are less efficacious against these new variants. Although mRNA vaccines can theoretically be tweaked in response to evolving variants, the corporations in charge of vaccine production have not done so. Instead, they have elected to fund research to validate their position that their current vaccines work if given as ‘boosters’. This has further weakened the push for vaccine equity, as HIC governments secure more APA deals with pharmaceutical companies for booster doses while many LMICs still go unvaccinated.
The option to hoard vaccines is a privilege held by wealthy, vaccine-distributing nations, which consequently leaves LMICs behind. The development and global spread of vaccine-resistant viral variants caused by ongoing transmission in LMICs, the resulting global economic cost, and the preventable deaths of people in vulnerable populations are all consequences to consider when analyzing the global burden of national health decisions. What will bring an end to this pandemic is the global reduction of transmission, and vaccine nationalism acts contrary to this goal. Without an appropriate model for global and equitable vaccine distribution, the COVID-19 pandemic will continue to affect the world due to variant evolution. This means that there will be more deaths and further economic instability due to the disruption of global supply chains. Ultimately, if the virus persists anywhere, it will continue to pose a threat everywhere.
HIV case study
While many of the confounding effects of the COVID-19 pandemic had yet to manifest historically until now, the discrepancies in access to medicine across the globe are far from novel. Through the history of global attempts in dealing with infectious diseases, we can learn that the continued practice of vaccine nationalism may be an obstacle in reducing the spread of the virus.
Access to affordable medicines for long-term conditions such as HIV, Hepatitis C, and diabetes have been historically difficult to access in LMICs due to the high volume needed and the high cost to import them from HICs. Contrary to common portrayals, LMICs have high vaccine uptake and efficient methods of distribution when there is access to supply, as seen with 93% vaccination rates for HPV in Rwanda in 2006 (Figure1).
A large contributor to these expensive prices is related to patent policies. Wealthy markets, such as the US, can establish monopolies on patents for up to 20 years, preventing the production of low-cost generic drugs. These policies have the intention of protecting intellectual property and motivating novel drug production by covering research costs; however, 13 companies in the US alone make up 45% of the world’s pharmaceutical profits, and the margins are only increasing.
Figure 1: Comparison of number of HIV/AIDS cases and availability of medication for patients between Sub-Saharan Africa and the United States
The impact of conflating profit and medicine in global health is no more evident than in the HIV/AIDS drug crisis at the end of the 20th century. HIV was classified as a viral disease in 1980, and reached epidemic proportions throughout Sub-Saharan Africa around 1985. Despite the effectiveness of long-term treatments, the cases in Sub-Saharan Africa remained disproportionately high and the number of treatments low when compared to the US in 2006.
The 1990s HIV epidemic in Sub-saharan Africa proliferated as a result of stagnant and expensive drug access. This issue is widespread in LMICs, and is largely due to the World Trade Organization’s patent protections. These allowed Western pharmaceutical companies to block access to low-cost HIV/AIDS treatments in spite of the fact that 90% of their sales profits are from HICs, with just a meager 1% coming from Africa. This allowed HIV/AIDS to become the leading cause of death in Sub-Saharan Africa, and caused the loss of 15 million African lives in 2000.
The TRIPS agreement, signed in 1994, attempted to put in place basic standards for patent sharing to increase access to affordable drugs while also protecting intellectual property in the HIV drug crisis. Since then, drug access in LMIC has increased and HIV-positive cases have slowed; However, the global HIV impact still disproportionately affects LMICs, and TRIPS agreements remain flawed and ambiguous.
The consequences of these ambiguities continue to infiltrate global access to affordable medicines in the COVID-19 pandemic. A TRIPS waiver to lift intellectual property protections for COVID-19 vaccines until the end of the pandemic has been suggested to accelerate access in LMICs, but as of June 2021 few HICs have backed it. The Canadian government has yet to support this venture. The balance between patent protection and global management of public health continues to be under scrutiny.
Conclusions
The fight to vaccinate the world against COVID-19 is ongoing, and far from complete, however it has not been without some success. Unable to rely on global efforts for equitable access to vaccines, LMICs have utilized internal strategies for community-based non-pharmaceutical COVID-19 interventions. Additionally, the G7 nations have pledged one billion vaccine doses to LMICs. Unfortunately, this donation will be unable to cover the majority of the global population, but it is a step in the right direction. Ultimately, when individual nations cannot be trusted to distribute COVID-19 vaccines beyond their own borders, the onus falls on global cooperatives to carry the load. Initiatives by the UN and WHO, such as COVAX, are important for equitable distribution of vaccines worldwide. However, these initiatives require global cooperation, including for wealthy and influential nations such as the United States and China to literally and figuratively “buy-in”. Sharing of intellectual property, as intended with the TRIPS waiver, would provide each country, especially LMICs, with the autonomy to economically and efficiently direct their vaccination programs. Overcoming vaccine nationalism will require global efforts with emphasis on equity, autonomy, and the prioritization of global health before national health.
About the Authors:
Alexandra Maters is graduating from McGill with a Bachelor’s in Microbiology and Immunology, and a minor in Education. She has long been interested in global health and public health efforts to improve access to quality healthcare, diagnostics, and treatment for women in underserved communities. Alexandra has most recently been working on developing rapid COVID-19 RT-PCR point of care diagnostics for global use, and hopes to continue applying a global health perspective as she pursues an MD/MPH.
Sam Baron is a U3 student in the Faculty of Arts studying Sociology, Microbiology & Immunology, and Social Studies of Medicine. Sam is deeply interested in global health and health policy and has been paying attention to the issue of vaccine nationalism as it relates to those interests for a long time.
Cyril is a third-year physiology student at McGill. His interests include biotechnology, global health, and politics. He was part of the Canadian Association for Global Health, Community Initiatives and Fundraising Committee in the 2020-2021 academic year.
Cal is a fourth-year student in Microbiology and Immunology and Hispanic Studies. They aim to pursue a career in microbiology research. Outside of class Cal is involved with many organizations in the Montreal community and loves to explore the outdoors.
Esther Lee is a Master of Science candidate at McGill University (Division of Experimental Medicine) with research interests in disease prevention and delivering safe and effective health care to vulnerable populations. For her thesis research, she employed epidemiological methods to assess effects of a specifically-designed educational tool on patient disease knowledge as well as preventive medication use and adherence to help improve reproductive outcomes in an immunocompromised population.