“I am because you are.” Ubuntu is a Zulu phrase and concept that inherently accounts for common humanity; we all have a fundamental responsibility to others.
I did not anticipate discussing the fundamentals of human nature when I sat down to speak with Doctor Kayum Ahmed, a human rights law lecturer at Columbia University and Division Director for the Open Society Foundation Public Health Program, about COVID-19 vaccine distribution, but it was at the heart of our conversation.
As the world rang in the New Year, many hoped that the suffering of 2020 would soon be brought to an end. 2021 brings with it, however, familiar and foreboding challenges. UN Secretary General Antonio Guterres was not so quick to jump for joy, warning this year brings “the biggest moral test before the global community” that the modern world has to offer.
The COVID-19 pandemic brought countries to their knees—decimating populations by targeting the elderly, vulnerable, and oppressed. Billions of dollars in funding and resources have been poured into vaccine development and wrought success—Moderna, Pfizer, Oxford, and AstraZeneca have all managed to introduce viable vaccine candidates into the global market. Widespread vaccination is critical to ending this pandemic, but it’s not that simple. Vaccine equity is a rising concern, and the start of distribution has already revealed stark discrepancies in how nations are prioritized in the global community.
The European Union broke headlines at the end of January for threatening to withhold the exportation of doses of the AstraZeneca and Pfizer vaccines until European nations achieved their “fair share” according to Jens Spahn, the German health minister. Only a handful of countries have been given access to the vaccine thus far; a mere ten nations have administered 75 percent of all available vaccines, while 130 nations are still awaiting their first dose. Determining who gets their “fair share” is indicative of the larger picture of international interactions— wealthy nations dominate the conversation on global health and do not prioritize low and middle income countries (LMICs).
Immediate relief for European nations comes at the cost of prolonged suffering for lower income nations. This disparity is no coincidence. Colonialism and its legacy have led to the concentration of wealth in the hands of a few, while subjugated nations are still recovering from exploitation that left them economically disadvantaged. The impacts of this extend to vaccine equity; the global north takes priority over the global south because of the same systems that created such a large power imbalance. “Vaccinating one country and not others makes no sense from a public health perspective. What it does is deepen the historic inequalities that we’ve seen between the global north and south,” said Doctor Kayum Ahmed in an interview with The Politic. Ahmed, in his roles as a law lecturer at Columbia University and Division Director for the Open Society Foundation Public Health Program, works to mitigate these disparities. Equity in the global distribution of COVID-19 vaccines is vital to ensuring the health and safety of not only vulnerable populations but global populations as a whole. Failure to adequately vaccinate a certain region could result in superspreader events of new variants and pose threats to high and low income countries alike. In spite of this, current distribution efforts do not reflect equity.
Collaborating with the primary organizations of Gavi, the Vaccine Alliance and Coalition for Epidemic Preparedness Innovations (CEPI), The World Health Organization, developed COVAX: a plan for equitable vaccine distribution. Similar to the United States’ general plan, age and population are the bases for priority and access, allocating the first phase of doses in every country towards front-line workers and vulnerable populations, with the goal of three percent vaccination. This phased approach promises up to 20 percent vaccination and includes a buffer for humanitarian efforts to vaccinate refugees and similarly displaced at-risk communities. However, COVAX has already fallen short of its goal to begin vaccination in low-income nations concurrent with wealthy ones.
“High income-countries, wealthy countries, the United States chief among them, have a responsibility to not just support the global vaccination effort but to be driving the global vaccination effort. Both because it’s in their own self-interest, but really because it’s the right thing to do,” said Professor Jason Schwartz of the Yale School of Public Health, an expert in vaccine policy and ethics, in an interview with The Politic. The United States, which had backed out of most global health initiatives under the Trump Administration, took action to rejoin the World Health Organization and pledge support for the COVAX plan upon President Biden’s takeover. However, without definitive action, these are nominal shows of support.
Historically, “vaccine nationalism” has been a legitimate concern; Schwartz draws attention to Australia’s export holds on H1N1/influenza vaccines until the fulfillment of its own domestic needs. The EU’s recent action exemplifies this problem—high income countries are consistently given priority over lower and middle income nations. In the United States, the Pfizer and Moderna vaccine development efforts were publicly funded, drawing in billions of dollars of investment from the federal government with no real guarantee that pricing and distribution would be equitable in the long run for the states, let alone the international community.
Even when lower-income countries come together to purchase doses, wealthy nations have denied them access. Ahmed spoke with frustrated members of the African Union who came together and requested to purchase excess vaccines from Europe but were denied that ability until Western domestic needs were fulfilled. Wealthy nations directly force LMICs to be beholden to their benevolence. This power dynamic is a direct extension of colonialism and a manifestation of “biopolitics” and “biopower,” terms coined by philosopher Michel Foucault. Foucault posited that state power can extend into forms of biopolitical control over different populations, directly seen in how the dispersion of medicines and vaccines decide which populations die. Ahmed similarly argues that the COVID-19 vaccine is inherently an “instrument of political power to determine who will live and who must die.” The idea that nations in power are actively preventing LMICs from attaining self-reliance speaks to how a colonial mentality permeates the global health space.
In any case, an emphasis must also be put on expanding manufacturing capacity in general. Doctor Saad B. Omer, Director of the Yale Institute for Global Health, analogized vaccine availability to that of a pie in an interview with The Politic: “We don’t have to assume that the size of the pie is fixed and we have to split the pie. We can also increase the size of the pie itself. We have to make sure that we expand the overall capacity and that would also take not just money but leadership from countries that have more resources.”
Investing in other technologies and adding new products to the market is one way of alleviating these disparities—larger supply typically means lower prices and wider access to consumers. How can we make more pie? Vaccine candidates in China and Russia might be the next step forward.
Ahmed worries that COVAX and the international financial institutions that fund access to vaccines are completely ignoring Chinese and Russian vaccines. These groups, run by members of wealthier nations, tend to privilege vaccine production in Europe and the United States. Pfizer, AstraZeneca, Moderna all have immense support. But by refusing to approve or invest in non-Western technologies, wealthy nations emphasize that colonial mentality—the idea that vaccines produced in spaces other than Europe and the United States are not good enough.
A handful of companies run the global market for vaccines, and the demand for COVID-19 vaccines is astronomical. Schwartz stressed that the pandemic will last well into 2022, and vaccination will be exceedingly profitable for the foreseeable future (with the possibility for booster shots and variants increasing its importance). These manufacturers have little to no incentive to provide low-cost, accessible vaccines outside of maintaining a positive public image.
Regulation is a point of contention. Notably, Oxford initially agreed to donate the rights to produce its vaccine to any drugmaker, allowing it to come into the market at little to no cost. However, they changed their positions and sold the intellectual property rights for its vaccine to AstraZeneca, a move that would allow the company to mark up drug prices. Though AstraZeneca pledged to prioritize distribution for lower income countries (like India, who is their primary manufacturing hub), there have been no explicit agreements binding AstraZeneca or Oxford from raising their prices to meet demand. Exclusive patents and pricing can render the vaccine inaccessible to lower-income nations who may not have the capacity to buy rights for production or the income to buy and import doses.
How can we hold “big pharma” accountable? Experts point to the HIV/AIDs movement, wherein activists saw treatments approved and distributed in the United States, but not to Africa. By taking companies to court and fighting against patents, organizers were able to force their hand into providing low cost therapeutics in LMICs on the African continent. Ahmed’s own organization is trying to circumvent the dominant pharma model all together. Instead, look at small scale manufacturers or alternative methods or invest in new technologies openly.
Controversially, countries like Israel and Chile have opted to implement “compulsory licensing”—a tactic that allows for the mass production of potential therapeutics or vaccines for COVID-19 without legal oversight. Many private companies have taken issue with this approach, arguing that manufacturers will have no incentive to develop technologies and therapeutics if they are not reaping the benefits of profit. These arguments, however, undermine the urgency and necessity of these therapeutics for lower-income nations. Balancing private benefit to public good is a persistent question, and one that Schwartz emphasizes is inherently tied to who has power over these companies—a dynamic driven by manufacturers’ ties to wealthier nations.
The lack of infrastructure in place to help aid vaccine distribution further compounds these issues. Even if lower income nations have access to doses, “there is almost no cohesive, systematic system for adult vaccinations in middle and low income countries,” Schwartz says. Though working with the WHO to adapt, groups like GAVI and CEPI are typically focused on a different demographic: children. Adapting these systems to work for the adult population takes time, not to mention the added obstacle of proper infrastructure and storage. For that reason, the AstraZeneca vaccine has largely been the product of choice when discussing global vaccination campaigns because of its ease of transportation and storage relative to Pfizer and Moderna; however, facilities and resources must be put into place for an equitable mobilization of vaccines in lower income nations.
Support from wealthy nations in Europe and North America is essential in supporting these plans. The UK and the United States, hubs for vaccine manufacturers and funding, have a responsibility to pressure these companies into equitable terms of distribution. Agreements thus far have prioritized vaccine distribution in domestic arenas, but provide little to LMICs outside of vague pledges of support and fair pricing. Wealthy nations not only have a role to play in the private sphere but also a responsibility to aid other nations in their own efforts to expand infrastructure and health systems so that the COVID-19 vaccine can reach the most vulnerable. We are at a turning point. “There has been a global vacuum in leadership because of the Trump administration on one hand and the movement towards the right in Europe. The Biden administration has a chance to fix that,” says Doctor Ahmed, hopeful by their recent efforts to rejoin and reinvest in public health.
Not oblivious to the many challenges equitable distribution faces, Schwartz is hopeful that current efforts will be successful in bringing about widespread immunization, “So much about global health is about thinking about those relationships between preserving the autonomy, the authority, the insights, the expertise of local communities, local governments, local health professionals while still providing the kind of support and infrastructure and resources that global coordination can provide. And if we are doing it right, it’s not a top down leaders in Geneva around the world parachuting into countries and saying here’s how you’re gonna run your vaccination program but, hopefully, if things are going well, there are the kinds of communications and exchanges that can help ensure that countries and national health officials are taking both responsibility and ownership and leadership for their efforts and just get the kind of support to follow that.”
There are groups working to combat the inequities at a less institutional level, including Ahmed’s Open Society Foundation. Combating global inequities in public health will take a concerted approach. Ahmed emphasized the importance of supporting institutions like the Africa Centers of Disease Control so long-term change in tactics and power can occur. Supporting worker civil society movements and voices not typically heard (Black-led, youth-led, etc) to call for a people’s vaccine. Additionally, groups can work to change structures of power by investing in research & development capacity in the global south. Finding and amplifying ideas to sustain long term changes in power (from universities, think tanks, research, etc) is important. The global vaccination effort should be taking cues from the countries that are in need. Governments can handle smaller scale decisions about distribution on a national level, but wealthier nations must do their part in ensuring that the vaccine is accessible to all—not just a well-endowed minority.
All these debates have one common thread: how do we balance self-interest and collective good? How we choose to address these global disparities to vaccine access is a reflection of who we are as a nation. Holding pharmaceutical companies accountable, increasing access to the vaccine by expanding capacity and lowering prices, and allowing LMICs autonomy over their own public health decisions would bring us one step closer to a more equitable world. Schwartz and Omer both understand the appeal and instinct of nations to cling to the vaccine, to take care of our own before we look to others, but recognize the importance of a successful global vaccination campaign.
The global community, particularly lower and middle income countries were never given the chance to look out for themselves in the first place. Dependency on goodwill from COVAX and donations from the U.S. or the E.U. reinforces hierarchies in global power and will result in countless deaths. Equity in global vaccine distribution is inherently beneficial to wealthier nations—preventing future outbreaks and opening up borders is to everyone’s benefit. At the end of the day, thinking for the collective will benefit the individual through increased safety and the satisfaction of doing the right thing. Nations with privilege have an inherent moral responsibility to support the billions of people who were not granted the ability to receive doses quickly and en masse. Supporting the global vaccination effort is simply the right thing to do.