“A vaccine? We cannot afford to think that far ahead,” explains Subash Thalekar, President of the Mumbai Dabbawala Association. Over the course of a single regular afternoon, this famed lunchbox delivery service would navigate the bustling streets of Mumbai to deliver 250,000 ‘tiffins’ from households to workplaces. But Thalekar doesn’t remember his last regular afternoon. The strict ‘work-at-home’ measures and cessation of metro services by the Indian government to curb the spread of COVID-19 has left all 5,000 ‘dabbawalas’ (Hindi for lunchbox men) without disposable incomes for over six months. Some have taken up temporary daily-wage jobs with meager pay and virtually no social distancing; others remain unemployed.
They are not alone in their plight. According to Reuters, over 65 percent of Mumbai’s 12 million residents live in “cramped, airless slums, making for easy transmission” of the coronavirus. With a hint of trepidation in his voice, Thalekar expressed doubt that his dabbawalas would be able to bear the expenses of a potential vaccine when it becomes available. In reality, they may not even get the chance to.
With millions of lives and trillions of dollars on the line, medical companies and research institutes around the world are racing against time—and each other—to design an effective COVID-19 vaccine. The World Health Organization reports that there are approximately 170 candidate vaccines currently between preclinical and Phase 3 trial stages. Though promising, the imminent approval of a vaccine does not portend the pandemic’s end.
COVID-19 has accelerated the past decade’s international shift from multilateral cooperation to individualist action. For many countries, the vaccine race is the greatest opportunity in recent history to demonstrate scientific superiority: more pressing than the space race and with more tangible outcomes than the nuclear arms race. Medical ethics experts fear this may incentivize government-run research institutes, like Russia’s Gamaleya Research Institute and China’s SinoPharm Group, to hasten production by cutting corners during clinical trial phases. Governments are also facing increasing pressure to prioritize vaccine access for their own citizens over other nations.
A report published by Oxfam International shows that a group of wealthy nations comprising 13 percent of the world’s population have already secured over half of the globe’s vaccine capacity through preorders. Canada has secured 154 million doses of vaccine preorders to inoculate its 35 million residents, while the United Kingdom has purchased 340 million doses for their population of 67 million. A two-dose vaccine would require 15 billion doses to be produced to cover the entire global population. According to Serum Institute of India’s CEO Adar Poonawala, at the current capacity, producing such a volume would take five years. Preorders will significantly prolong this wait for poorer countries.
COVAX, an organization founded by the WHO with hopes of ensuring equitable COVID-19 vaccine access globally, is attempting to change that. According to its official website, the multilateral organization’s specific aim is to accelerate effective vaccine development “for all countries” and to collect vaccine supplies “so that 2 billion doses can be fairly distributed by the end of 2021.” The coalition’s membership extends across 184 countries and represents 93 percent of the world’s population—Russia and the United States are conspicuous absences. However, even the countries who pledged to facilitate equitable access have signed large unilateral pre-orders that may cause delays in COVAX distribution.
This rise in ‘vaccine nationalism’—when governments secure vaccines through pre-orders and otherwise prioritize their citizens and self-interest over global vaccine access—is concerning. If the trend of countries preordering excessive vaccine doses continues, developing and lesser developed countries’ hopes of vaccinating a substantial proportion of their populations will be postponed by at least a couple of years. Furthermore, it may set a dangerous medical precedent regarding the ethics of vaccination. Leaders of rich and powerful nations may find a country-first perspective viscerally appealing, but it remains to be seen whether the benefits of isolationism during a pandemic will outweigh its latent disadvantages.
Medical Malfeasance
In an email correspondence with The Politic, Charles Hill, the Brady-Johnson Distinguished Fellow in Grand Strategy at Yale, argued that “scientific prestige” is the political motive for nations to engage in vaccine nationalism. He compared the potential reward from this vaccine to the reputation “the US gained by the Salk anti-polio vaccine years ago”—where the poliomyelitis vaccine was discovered by American scientist Jonas Salk in 1955, revolutionizing vaccine development methods and helping effectively neutralize the disease worldwide.
With the stakes being even higher this time around, many governments have been pushing for emergency domestic vaccine research. Among others, China, Russia, Australia, South Korea, Japan and India have all developed homegrown vaccine candidates that are currently in human trial phases. What may be concerning is that the first two vaccines that moved to human trials were commissioned by the Russian and Chinese governments, while private research institutes have been much more cautious.
To Dr. Jorge Alfaro-Murillo, Associate Research Scientist at the Yale School of Public Health, this speed raises serious red flags. In his interview with The Politic, he claimed that the breakneck speed achieved by the Chinese and Russian domestic vaccines could only come at the expense of conventional practices, such as placebo testing and assessing secondary endpoints integral to ensuring widespread safety—adding that he would not take the vaccines at their current levels of testing. Nevertheless, Alfaro-Murillo admitted that “the unprecedented nature of our current situation” still mandated an emergency pace that could safely be achieved by simultaneously testing the vaccine’s safety and efficacy in “combined Phase 2 and 3 trials.” He also defended the safety of other expedition processes such as the UK’s challenge trials that deliberately infected healthy individuals to later vaccinate them, claiming that keeping volunteers “well-informed” and “in controlled environments” would result in “minimal personal risk.”
Ultimately, he maintained that research institutes could avoid medical complications largely by adhering to standard procedure. As a cautionary tale, Alfaro-Murillo recounted the case of the dengue vaccine Dengvaxia in the Philippines that was given to over one million people— 600 of whom died. If handled responsibly and benevolently, the vaccine fervor could fast track a vaccine for the entire world. But speed should not result in negligence—intentional or otherwise—and the prospect of international plaudits must not blur ethical lines for competing countries.
Vaccine Capitalism
The other obvious flaw with vaccine nationalism is the danger it presents to lower income countries. Medical companies like Moderna have exploited the international demand for pre-ordered vaccines by selling their doses for profit to the highest bidder. Although the Astra-Zeneca/Oxford Vaccine has pledged two-thirds of its doses to developing countries, they would only be able to produce enough for roughly 20 to 40 percent of that population (depending on the number of doses required). Clearly, their actions alone will not be enough.
Antonio Guterres, Secretary-General of the United Nations, called for the vaccine to be treated as a public good, making it freely available to everyone or provided by the government at a highly subsidized rate. To facilitate this, countries and international non-governmental organizations must finance most of the $70.6 billion price tag associated with vaccine research and distribution —an already herculean task, rendered inconceivable without complete cooperation.
In an interview with The Politic, Giovanni Maggi, Howard H. Leach Professor of Economics & International Affairs at Yale, explained the drawbacks of an unregulated market for vaccines. He first tackled the issue of equity, stating that “it’s not acceptable for poor countries to be devastated by the pandemic while richer countries find shelter in the vaccine.” A necessary characteristic of public goods is that they must be non-rivalrous and non-excludable. While it may be impossible to make the vaccine non-rivalrous, opening them up to an unregulated global market definitely makes it more excludable than necessary. He also mentioned that “the world needs to coordinate in order to avoid waste of resources in vaccine development and production.” If each country attempts to create their own vaccine, the lesser productive vaccines will eventually be wasted. These factors will force financially weaker governments to make tough choices about who gets vaccinated and at what cost.
Thalekar admitted that he believed the dabbawalas he managed would be of a “lower priority” to the government. If certain states are strong-armed into inoculating only a tiny sliver of their populations, low-income individuals living both in densely populated cities and rural areas are likely to be hardest hit. It will also lead to the prolonging of the virus, potentially resulting in greater losses to the international economy than the 1.2 trillion dollars already projected by the International Monetary Fund for 2020-2021.
Sharing is Self Caring
Although vaccine nationalism is evidently detrimental to poorer countries, the global economy and overall public health, it seems to make sense for individual countries on the surface. Why would a country not put its citizens first? Professor Hill argued that a country’s responsibility to its citizens is paramount and that their “[responsibility] to the international community will follow.” Considering that safeguarding the right to life has been virtually the oldest right conferred by a state, unilateral action looks like a reasonable approach. As a result, Hill backed the US’s decision not to join COVAX, claiming that “these multilateral commitments come with conditions that we don’t or should not agree to.” However, in the instance of a public health crisis in the 21st century, shunning multilateralism may not even make strategic or economic sense for the state as an individual actor.
Whenever a COVID-19 vaccine is discovered, it will not be a panacea to states’ problems. Dr. Alfaro-Murillo pointed out that vaccines, even with years of trials and data collection, are never completely effective. The United States’ Food and Drug Administration announced that it would approve a vaccine for use if it “prevent[ed] disease or decrease its severity in at least 50 percent of people who are vaccinated.” Medical giants Pfizer and Moderna have released data showing their vaccines to be 90 and 94.5 percent effective in respective clinical trials. A vaccine of such efficacy distributed across a small population of each country would drastically reduce global infection rates. Providing the vaccine almost exclusively to a few nations would not be nearly as effective, most ostensibly due to travel to and from affected areas of the world. There could also be a global supply chain problem if the vaccine was developed and distributed solely using domestic products, since some raw materials are endemic to other countries. For instance, the Novavax vaccine candidate—based in Maryland—requires a saponin from the soapbark tree only found in Chile. Without aid from the international community, distributing the vaccine and maintaining a cold temperature in transit would be a logistical nightmare. Resentment from other countries could also lead to a reluctance to share the medical and protective equipment essential to controlling disease spread in the months leading up to mass vaccinations.
States could also be tempted to pursue vaccine nationalism to regain control of their spiraling economies. But economic isolationism requires a level of self-sufficiency that is impossible to achieve with the status quo’s global supply chains. Globalization has allowed products to be produced more cheaply by leveraging individual country’s comparative advantages. However, it also made the global market highly susceptible to large supply shocks, such as the one we are facing right now. Anticipating this, Professor Maggi commented that “this will create all sorts of negative externalities from [richer countries] to [poorer countries], for example through economic disruptions. To address these externalities it is important to make vaccines available to poor countries and support vaccination programs in those countries.”
Vaccine nationalism doesn’t make strategic sense. Destabilization caused by the coronavirus pandemic could upend state hegemonies and redefine international power dynamics; influential nations could find themselves losing political capital if they leave strategic diplomacy by the wayside. At the beginning of the vaccine race, China, Russia and the United States seemed to be creating competition and adopting unilateral stances: Russia’s vaccine Sputnik V was a not-so-subtle allusion to the satellite that ushered in the Space Age, and the United States’ Operation Warp Speed demonstrated a reluctance to cooperate with other nations.
During a time of crisis, the world is looking for a cooperative leader to rally around. The United States, who has played this role for the past century, is faltering. For the first few months of the pandemic, China looked to expand into the power vacuum left by the Trump administration’s aggressive protectionism, and has also recently agreed to join COVAX. These differences have also been reflected in the world opinion; a poll by Pew Research indicates that more people disapprove of the United States’ handling of the COVID-19 outbreak than China’s (although both approval ratings are very low). Maggi attributes much of this multilateral failure to the Trump administration, and hopes that the United States’ vaccine policy will look different in a Biden administration. These examples show how absolute self-prioritization may cause backlash from other nations, resulting in the loss of soft power among more powerful nations. Professor Hill agreed that countries like China and Russia could gain on the United States in terms of soft power, but remained skeptical about the notion of it causing wild changes in the geopolitical power structure.
Vaccine nationalism may glisten seductively, but it is definitely not golden. Either out of economic pragmatism, strategic self-interest, or basic ethics, states must discard this toxic approach. If not, the victims will not just be the dabbawalas and the billions like them, it will also be the nations that practice vaccine nationalism. This year has been too devastating for states to foil their own path to recovery.