Covid-19 vaccines have been developed in record time and are being distributed around the world. But issues like vaccine hesitancy, slow production and unequal access between as well as within countries are inhibiting the global vaccination progress needed to combat the pandemic. In this first episode of season 2, we’re joined by Dr. Suerie Moon (Graduate Institute) to explore how vaccine nationalism and patents pose obstacles to increasing vaccine production.
Covid-19 vaccines have been developed in record time and are being distributed around the world. But issues like vaccine hesitancy, slow production and unequal access between as well as within countries are inhibiting the global vaccination progress needed to combat the pandemic. In this first episode of season 2, we’re joined by Dr. Suerie Moon (Graduate Institute) to explore how vaccine nationalism and patents pose obstacles to increasing vaccine production.
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BIBLIOGRAPHY
• Who funded the research behind the Oxford-AstraZeneca COVID-19 vaccine?(2021).
• The Vaccine Race: Will Public Health Prevail Over Geopolitics. (2020).
GLOSSARY
What is the “Texas Project” Chicken Egg Vaccine?
(00:13:00)
This new vaccine, currently undergoing clinical trials in Brazil, Mexico, Thailand and Vietnam, called NDV-HXP-S, is widely expected to create more potent antibodies than the current generation of vaccines and to be far easier to produce. Production would be done, like influenza vaccines, through injecting the virus into chicken eggs to multiply it and extract a “dead” variant to combine in the vaccine concoction. It would make the production much cheaper and simpler, allowing low- and middle-income countries, who struggle to obtain current vaccines from wealthy countries to produce their own supply. The vaccine itself was developed by scientists at the University of Texas and licensed through the Public Health non-profit PATH. Source. Non-Profit PATH.
What is the Gamaleya Research Institute and the Sputnik Vaccine Timeline?
(00:15:00)
The Gamaleya National Center of Epidemiology and Microbiology is a Russian biomedical research institute in Moscow under the Ministry of Health of the Russian Federation, named after Ukrainian, Russian and Soviet scientist Nikolai Fyodorovich Gamaleya. The Gamaleya Institute announced a COVID-19 vaccine candidate for the first time in May 2020, with clinical trials starting the month after. Before Phase 3 trials of the vaccine started, which are the largest trials on thousands of people and final step before openly registering and allowing a vaccine on the market, President Putin officially announced the registration of the world’s first COVID-19 vaccine, Sputnik V. Official Phase 3 trials began in September 2020 and rollout in December 2020. The first official study of Sputnik V in a peer-reviewed medical journal was published only in February 2021 in “The Lancet”. The vaccine has been viewed critically by the international community due to the Russian Federations attempts to use it as a tool for diplomacy and to exert geopolitical influence. Learn more about Sputnik V. “The Lancet” study.
What is the TRIPS Agreement?
(00:20:30)
The TRIPS Agreement is the most comprehensive multilateral agreement on intellectual property overseen by the WTO. It came into effect on 1 January 1995. It covers and protects copyright, trademarks, industrial designs, patents and undisclosed information such as trade secrets. In March 2021 more than 80 developing countries have pushed for a waiver of the TRIPS Agreement to boost production of vaccines in their countries. The push was ultimately blocked in the WTO by wealthy nations, such as EU countries, Britain, Switzerland and the United States, supported by large domestic pharmaceutical industries, keeping vaccine access away from poorer countries. Find it here.
What is COVAX?
(00:21:30)
COVAX is a platform of the WHO’s COVID-19 (ACT) Accelerator Initiative, focused on pooling together the investments into vaccine research, development and production by wealthy countries and ensuring fair distribution globally. Its aim is to control vaccine allocation, provide access, negotiate pricing and prevent scarcity and inequality due to financial and intellectual competition. The driving actors are the Gavi Vaccine Alliance, the Coalition for Epidemic Preparedness and Innovations (CEPI) and the WHO. Learn more.
Shalini Randeria: Welcome to the second season of Democracy in Question?, the podcast that reflects on the crises of representative democracy in these troubled times. I'm Shalini Randeria, the director of the Albert Hirschman Center on Democracy at the Graduate Institute in Geneva, and director of the Institute for Human Sciences in Vienna.
I'm really excited to bring you a second season of challenging essential conversations about democracies around the world. We have a great season planned, and to kick things off today, I'm joined by my colleague at the Graduate Institute in Geneva, Dr. Suerie Moon, who co-directs the Global Health Center at the Graduate Institute. She's also an adjunct lecturer at Harvard School of Public Health. Her work focuses on the intersection of global governance and public health. So, thank you very much, Suerie, for joining me today despite your many other preoccupations, including the World Health Assembly.
[00:01:00]
Suerie Moon: Thank you so much for having me, Shalini. It's a great pleasure to be here. And I think, exploring the intersections of health and democracy is a very underexplored topic. So, I'm looking forward to diving in together with you.
SR: So, our conversation today, in a way, couldn't be more topical as we grapple with restrictions and also the changes in our daily lives due to the ongoing pandemic. Let me first begin with the good news. It is no small feat that researchers have managed to create within the space of a year, several vaccines against COVID-19. Several of these vaccines have also got quick approval and are being administered in millions of doses every day around the world. And yet, many questions remain. Vaccine skepticism or vaccine hesitancies remains high in many countries. The production of vaccines is far too slow, and is beset by unexpected hiccups now and then. And of course, vaccine distribution to populations around the globe has been uneven, to say the least.
[00:02:15]
So, what I would like to explore with you today are all of these issues around the global politics of the pandemic, and especially the question, how access to safe vaccines could be democratized, made more affordable, and equitable. Suerie, let me start with the question of vaccine nationalism and vaccine diplomacy. The press has highlighted for us recently the role of Russia, China, and also India. All of these countries have vaccinated partly their own populations, but have also been exporting vaccines, sometimes donating them as gifts and often also selling them. There have been a lot of misrepresentations in the press and a rather oversimplified picture of the kind of vaccine diplomacy that is involved here and vaccine nationalism when countries refuse to export or share their vaccines.
[00:03:15]
Can democracies export vaccines much less easily than authoritarian countries, because democratic governments must care much more about vaccinating their own populations, and therefore, can be accused much more easily of vaccine nationalism.
SM: I do think that we have to maybe spend a couple minutes kind of describing what is the current situation. I think it's no secret that high-income countries do have the lion's share of the world's vaccine supply, that they have used every means at their disposal to secure that supply. And that includes money, it includes political ties, it includes investments at risk in research and development. And so, we do indeed have a highly imbalanced situation.
[00:04:00]
Into this picture come then the role played by other countries, in particular, some middle-income countries that have vaccine development and production capacity, as you've just mentioned, Russia, India, and China. What's interesting to note is that all three of those countries have been sharing vaccines either through donations or sales much more widely than Europe or the [00:04:30] United States, for example. And I would say, one under the spectrum is, in fact, the United States, which has one of the largest volumes of vaccines available to it, secured by it, and has not exported any with the small exception of a recent offer of a loan to the neighboring countries of Canada and Mexico. Europe, in contrast, also has a very, very high volume of vaccines that it has secured. But it has actually allowed for export. And there have been some restrictions, some tightening of those exports, but I think this is an important distinction.
[00:05:00]
Now, when you look at India and China and Russia, it is indeed a very, very different picture. And, of course, India is the world's largest democracy, and has recently announced that it will also be restricting exports, which on the one hand is fully understandable because India is certainly undergoing right now a very dramatic and very worrying increase in cases. But the whole world is really relying on Indian manufacturers for access to vaccine supply. So, this has terrible, terrible public health implications and equity implications for the rest of the world. And I do think that we see that it is politically more feasible, I don't know if it's easier, but I would say, more feasible for non-democracies indeed to export vaccines even when their own citizens still remain unvaccinated.
And indeed, you do see here an interesting tension between democratic accountability of political leaders and the ability to actually think beyond one's borders and ensure vaccines internationally.
[00:06:00]
SR: So, the Russian case, Suerie, is also an interesting one because it seems as if there is very, very high vaccine skepticism or hesitancy in Russia itself. Traditionally, historically, France has been a country in which there is a very low acceptance rate in Europe, especially. But what you just told me before we started recording is that Switzerland seems to have a curiously low acceptance rate, especially among the above 55 population. And so, obviously, the amount available for export or sharing or gifting is also a little bit of a factor of domestic need or consumption. Are there very different reasons for the hesitancy in Switzerland and in Russia, for example?
SM: Yeah, it's a great question. And from previous research on vaccine hesitancy, we know that there are indeed a number of different factors at play. We know that the specific characteristics of the vaccine matter. The severity of the disease matters. You know, broader factors, such as trust in governments, trust in science matters. And we know that vaccine hesitancy is higher in certain age groups, for example. It's higher among women, generally, than among men. So, there's a number... You know, it's a very complicated phenomenon.
[00:07:15]
We don't, for example, see that in democracies you have higher trust in government and therefore, higher willingness to get vaccinated. We don't see such simple relationships. And you mentioned the example of France. Switzerland, the vaccine hesitancy issue, I would say, is less pervasive than it is just across the border in France. But it is a very serious challenge, nonetheless. And indeed, here right in our own backyard in Geneva, they've recently expanded the number of people who are eligible to be immunized because not enough people are coming forward in the 55-and-older age group.
To me, one of the key takeaways however from previous research is that government policies and the interventions by healthcare providers, for example, interventions by individuals with your friends and your neighbors and your family members, all of that can make a difference. Vaccine hesitancy is not something that is set in stone, that is unchangeable. It actually seems to move quite fluidly. We see these numbers going up and down as various organizations have been trying to poll the population in different countries on their willingness to be vaccinated. And so, this actually provides a source of optimism, because it means there's something we can do about it. We don't have to just sit back and accept that half the population will not be willing to come forward. We can actually put in place proactive measures to try to persuade people.
[00:08:40]
SR: Let's look at the production challenges. The paradox for me, at the moment, is the paradox of production capacity lying idle in many countries of the Global South, including India at the same time as we have acute shortages of vaccines all over the world. And one of the barriers to the production capacity being fully utilized is intellectual property rights, patents. Is the pandemic not the best possible situation under which we should rethink our whole model of patents on pharmaceutical products and to say that patents could be waived under this particular emergency condition for a short period of time? And this is something which India and South Africa have both asked for, patent waivers in the WTO. Is it justifiable to have such a patent regime on vaccines at all? What if we were to treat them as public goods and had a very different approach to how we think about vaccines?
[00:09:45]
SM: I do think and hope that the pandemic will in fact prompt this rethink of the current pharmaceutical research and development model. So far, we've only seen, I would say, baby steps towards that happening. And this has been one of the big debates over the last 6 to 12 months: Is it feasible? Can we really scale up production? Can it be done in a way that is safe and affordable? That, I think there's much more consensus in the public health community that “yes, it is possible”. And this does put much more emphasis then on the question of what is standing in the way.
[00:10:30]
Monopolies on knowledge, including those protected by intellectual property rights, are one of the important barriers that does stand in the way. And I think this is why we've seen a lot of attention on debates at the World Trade Organization on whether a waiver, a temporary waiver on COVID-19-related IP should be, in fact, accepted and adopted. To me, this debate is important for COVID-19, but it's also important far beyond COVID-19. And that's because one of the other key questions on the table is, how much flexibility can we expect in global rules, including global IP rules, in the middle of a crisis? And these rules are supposed to flex. They are supposed to allow for national governments to take extraordinary measures and extraordinary times. But the question of how far they can flex and who gets to make those decisions, I think...I mean, that remains hotly contested. We're not going to see the end of that debate anytime soon.
We've seen something almost unique in this pandemic where when we look at the money that's gone into research and development of vaccines, we've been collecting data on this. We estimate that it's about $6 billion. And of that $6 billion in investment, it's 98% public money with just a tiny, tiny bit philanthropic and private sector money. Now, pharmaceutical companies have not shared what they are investing in R&D. This isn't a complete picture, but I think nobody [00:12:00] disagrees that the public sector has really assumed a lion's share of the risk, has put tremendous amount of capital in the early stages into R&D. And therefore, the risk that companies that companies have taken on is far reduced.
The fact that even in such a situation, even when the risk has largely been removed from the equation, governments have still been unable to control the production processes. They've been unable or, in some cases, [00:12:30] unwilling to require that the technology be shared. I think it's very sobering. Because here's a situation where governments should be able to require that the technologies that they've paid to develop are, in fact, shared more widely. The fact that they've not been able to do that, I think, does require us to step back and think for a moment what's gone wrong with the system. And what do we need to change with the way public money is invested in the future and any kind of pharmaceutical R&D so that more people indeed can benefit from the fruits of science that follow?
[00:13:00]
SR: So, what could an alternative innovative R&D model look like? So, the Texas project, for example, would be one. And if you could elaborate a little bit on that.
SM: Yes. In terms of different ways of approaching R&D, I think the most important principle...so, certainly not the mainstream approach to R&D currently. The most important principle is that you build global access into the research and development process from the earliest steps. And that means building affordability into that process. It means thinking ahead about where will the product be manufactured. And can it be manufactured, for example, at a low price? Involving also, I think, a number of different countries in the R&D process.
And this is why, I think, this recently announced R&D project that the University of Texas has been quite centrally involved in is very, very interesting because they have, by intentional design, designed a COVID-19 vaccine candidate that can be produced inside chicken eggs. And chicken eggs are the traditional way in which vaccines have been manufactured for decades. That technology is widely available in a number of different countries around the world and manufacturers are familiar with it.
What you can see is that it's a project that from the very beginning is trying to ensure that people will benefit from those advances in science and technology. It is a very different approach to relying very heavily on a large industrial partner, which will have a strong incentive not to share the technology. And that's unfortunately what we've seen with a number of other projects. What I would lo ve to see in the future is that that kind of thinking becomes the norm. It's not the exception. It's not what happens in the second wave. But immediately, as soon as we have a crisis, those who have skills and knowledge of how to develop vaccines are immediately thinking, "How do we do this in such a way that we are not manufacturing scarcity?"
[00:15:00]
Just going back for a moment to the Russian vaccine, the Sputnik vaccine. One of the interesting features of that vaccine is that it was developed not by a large company, but by a research institute, the Gamaleya Research Institute. It was funded by a sovereign wealth fund, the Russian Direct Investment Fund. And so, because it's not a big company, it doesn't have factories everywhere. And it doesn't have global markets that it's trying to defend. And so, that initiative has announced 50 technology transfer and production partnerships, 50. And we haven't found a lot of details on what exactly those entail, but it's quite interesting to see that...again, this is a different business model. This is not a large pharmaceutical company, multinational saying, "We will manufacture and distribute to the world." It is a small research institute saying, "We will share the knowhow."
And if you hear the governments that are pushing for the IP waiver up the WTO, one of the messages that comes up over and over and over again is, "We want to produce for ourselves. We do not want to rely on exports from another country that at any moment can decide to block those exports. We do not want to rely on the pricing of a monopoly seller." And so, one of the interesting features of what I would call Russian vaccine diplomacy has been that it is, in fact, responding more directly to the stated desires of many developing countries who would like to produce for themselves in a way that donations and sales and sharing of stockpiles is not.
[00:16:30]
SR: So, if I follow this...your remarks on Russia with a question which has always intrigued me, and this is Cuba. A small country actually impoverished even further by decades of American sanctions, and yet it has produced not one, but as far as I know, two different vaccines. And not only developed them in terms of research, but also manufactured them, and is willing to share. And if I recall rightly, at the start of the pandemic, Cuba not only was sending medical supplies, but also personnel, nurses and doctors, to Italy. So, what lessons can we draw from the Cuban experience?
[00:17:15]
SM: That's a great question. Indeed, Cuba is well-known as being a center of biomedical innovation. And certainly, this is not the first set of vaccines or medical tools that have been developed by Cuban research institutes. I think it's also notable that for many, many years, Cuba has engaged in very proactive, you know, what one might call, health diplomacy that the Cuban medical brigades have been deployed in many countries around the world. Not just in Italy a year ago, but for example, in West Africa during the Ebola crisis and many, many other crises.
I'm not familiar enough with the technical details on the Cuban vaccine candidates to comment one way or the other on how they might compare with other vaccine candidates. But I do think that the Cuban example highlights how high stakes are some of the geopolitical games being played. I mean, these are geopolitical contests that different countries are competing for influence, for goodwill, to strengthen political and diplomatic relationships. And I think that's every country. I think that's not just Cuba or just the U.S. or just Russia. I think it's every country. Every country is, in some ways, playing this game.
And so, for me, I don't have a value judgement to pass on, you know, which countries are playing good diplomatic games or bad diplomatic games. We see this a lot in the media. Depending on which media you read, another country's vaccine diplomacy is called vaccine nationalism. You know, it's in the eyes of the beholder. But I think what we see is that there are incentives for every government actually to treat vaccines as the strategic assets that they are.
[00:19:00]
SR: The relationship between states themselves, so, intergovernmental cooperation, would be another area to explore with you. People have been talking about a pandemic treaty or even thinking about what kind of post-COVID reforms could we envisage here.
SM: It's very clear that the momentum for reform is growing and that the massive breakdown in intergovernmental cooperation that we have seen throughout this pandemic has to be somehow addressed. Because you simply cannot be effective in controlling a pandemic without at least some kind of government-to-government cooperation. So, indeed there has been a lot of momentum around the idea of a pandemic treaty. I think the idea remains very broad and vague at the moment, but one political priority that has emerged quite clearly already is that we have to address this question of access to what we call medical countermeasures, vaccines, drugs, and diagnostics. That has to be one of the things that we do, in fact, develop stronger and clearer international rules for.
We do currently have a set of international rules relevant for R&D, and that is the intellectual property rules, the TRIPS Agreement. But that set of rules is heavily imbalanced. That set of rules really puts a lot of emphasis on the development of a new technology, and not on arrangements to ensure that people worldwide have access to it.
And so, there is an interesting possibility here that we could have a new set of rules that is negotiated, that would have equal legal weight, and that would in fact institutionalize and curate incentives for the kinds of new business models that I was just describing, ways of paying for R&D with public money, ways of ensuring that the outcomes and outputs of that R&D are made available without monopoly protections, without IP rights so that in fact everybody can benefit from the knowledge that is created.
I do think that will require countries, whether low, middle or high-income, to come together with a different logic from what we've seen. I think a lot of the logic vaccine access, for example, over the last few months, has been a logic of development aid. It's been a logic of charity or of philanthropy. And we've seen that that logic has its limits. We see that in the limited volume of vaccines that COVAX has been able to get.
[00:21:30]
SR: Suerie, that's exactly what I wanted to turn to next. So, sorry to interrupt you, but could you explain COVAX as a facility? Could you just explain what is the new mechanism which we've come up with this time to ensure at least some distribution and availability at a price which may be affordable to countries in the Global South?
SM: Okay. Sure. COVAX is the multilateral initiative that is seeking to ensure globally equitable access to COVID-19 vaccines. It's co-led by the World Health Organization, the Gavi Alliance, and CEPI, the Coalition for Epidemic Preparedness Innovations. And it has set a goal for 2021, providing enough vaccines for 20% of participating countries, which I think everybody agrees is not enough, but at least I would argue, is a start. And it's an important start because prior to the outbreak of COVID-19, we had almost nothing at the international level. We had almost no international rules or institutions that would, in fact, ensure some kind of equity in vaccine access in a pandemic.
Now, all of that said, COVAX requires governments to not eat more than their fair share. The size of the pie, the total amount of vaccines is finite. And so, with risk countries eating up more and more of the pie, there is less and less for COVAX. And this is because COVAX continues to operate in what I call a global health 1.0 mentality, which is a mentality of charity or philanthropy or development aid. They were seen not by our stakeholders, but I would say, by a number of stakeholders as a way of subsidizing for the poorest countries a small volume of vaccines that could be made available on the side. It was not seen as the main global mechanism by which countries would agree to only take their fair share.
[00:23:30]
The question becomes, how do we change the rules for the future? How do we try to make sure we are not in this situation again? And I think the negotiation of binding rules to share access to countermeasures has to be one of those sets of rules.
Now, if any new framework for access to vaccines remains grounded in the logic of charity, it will fail. All countries have to feel that they can contribute either financially or by participating in research. And all countries should benefit. And this is a very different principle. This is a principle of governments cooperating with each other for their mutual benefit, to meet their own self-interest and, of course, also to protect the world against pandemics. And it's the kind of logic, and it's the kind of politics that I think we're going to need to see in any pandemic treaty negotiation if we're going to have rules that are robust.
We're not talking about a situation where everybody agrees that health is a beautiful goal and therefore we can all hold hands and cooperate. And I think this pandemic has made it very clear and the vaccine situation is probably the clearest illustration of that. At the end of the day, those reforms have to meet the interests of all countries. They have to take into account geopolitical competition. They have to be realists in that way.
[00:25:00]
And so, if we remain in a charitable development aid mindset, we're going to completely ignore the geopolitical reality. And we're not going to be able to achieve rules that actually work for the big power blocks of the world.
SR: Suerie, there has been a lot of public debate on vaccine passports in many countries providing those who are either already vaccinated or who have just undergone a test to provide all of these different categories of people with the so-called vaccine passport. The question for me is, does such a passport strike a good balance between public health and civil liberties?
[00:25:30]
SM: I think it's clear that the implementation of such passports will create or exacerbate inequalities. For me, the big question is not whether it will create inequalities. I think it will. But what kinds of inequalities are acceptable and which ones are not? And if you ask me personally, is it okay to have unequal access to a concert so that musicians can again make a living, so that actors and theaters and arts venues and restaurant owners can also begin to get back to work, these are discretionary activities. And they're activities for which you can, I think, make a strong case that there is broader benefits for other parts of society.
But when we begin thinking about, you know, should we predicate access to schooling, the ability to work, the ability to take public transportation, essential public services and activities, I think it becomes much more problematic. And the kinds of inequalities that we would see, I think, should not be acceptable to societies. And I think, every society has to make these judgements on its own. How do we strike that balance? Hopefully, these debates are conducted in a democratic and open and a participatory way.
But what do we consider are acceptable tradeoffs to restart life again? I do think that there's a strong argument to be made that we need to get economies moving in order to try to reduce poverty, to try to support those have fallen into unemployment. If vaccine passports can help to do that, well-designed, carefully conceived passports that have protections in place, I think we have to embrace the possibility.
[00:27:15]
SR: So, thank you very, very much for this fascinating set of observations, background information, and arguments that relate to the whole politics of the pandemic and especially the politics around the production and the distribution of vaccines. Among the issues you've highlighted are questions of the monopoly of knowledge, intellectual property rights as barriers to the diffusion and the use of that knowledge for public common good, which go well beyond questions of just COVID or the current health emergency that we are facing, but also include thinking about flexibility of global rules about whether we can have a new, innovative research and development model and a business model that would allow us to share knowledge for the common. And for pointing out that if we use charity logic, the logic of developmental aid, to think about how vaccine distribution can be democratized or more equalized, we are making a fundamental mistake and that we really need to rethink and to retool ourselves to think differently in the future about health-related public goods, including the question of vaccines.
SM: I think you have synthesized more eloquently and beautifully than I ever could have my own reflections on this. So, really, thank you.
[00:29:00]
SR: This concludes the first episode of the second season of Democracy in Question? Thank you so much for joining us again. Next time, we'll be delving into a fundamental question for Western democracies. Namely, is liberalism dead, or can it learn from its mistakes and emerge stronger?