Getting It Right For the Next One
Statement from Get1Give1 Worldwide – a citizen-led initiative to confront the unequal distribution of COVID-19 vaccines across the world.
In May 2021 – concerned by the early and growing inequity in COVID-19 vaccine distribution – we set up Get1Give1 Worldwide. We hoped to tap the relief and gratitude that people across the world reported on being vaccinated. Joining other civil society initiatives, we asked ordinary citizens to “pass on the protection” by donating directly to COVAX’s effort to make vaccines available in every country, and by encouraging their governments to contribute more.
When we started Get1Give1 Worldwide, 30% of people in high-income countries had already received at least one vaccine jab; 0.5% of people in low-income countries had. Our donors were generous – providing donations that enabled COVAX to purchase nearly 20,000 vaccines.
Yet more than a year after vaccines have been available, vaccine equity is still a distant goal. As of March 2022, eighty-one percent of people in high-income countries have received at least one dose compared to just 14% of people in low-income countries. Of the 11 billion doses administered around the world to date, three quarters were given to the residents of high- and upper-middle income countries.
We feel it is time to step back and examine how this has happened, why it continues, and what needs to change to ensure national governments and global institutions better meet the challenges of the next pandemic or a new, more deadly COVID-19 variant.
The Race for COVID-19 Vaccines
On 11th March 2020, The World Health Organization (WHO) declared COVID-19 a global health pandemic. The first year of the pandemic was marked by global shortages – of masks, tests, personal protective equipment for health workers, emergency room beds and staff, ventilators, and even basic goods – that demonstrated the fragility of global supply chains. National governments struggled to find and purchase supplies for their citizens; too often access to health resources within and across nations depended on connections and resources. By the end of 2020, at least 83.8 million people had contracted the virus and 1.9 million people had died from it.
The virus did not respect national boundaries, ideologies, or income levels. It breezed through geopolitical alliances, efforts to pin blame, nationalism, and economic system distinctions. Even countries surrounded by thousands of miles of ocean whose governments imposed early lockdowns have been unable to keep new versions of the coronavirus from reaching their people. Everyone felt vulnerable, especially the elderly and immunocompromised.
The bright spot in these dark days was the professionalism and collaboration of the scientific community in sharing research on treatments and vaccines as the virus spread and mutated. And anticipating that as-yet-undiscovered vaccines might be inaccessible people in lower-income countries, WHO, CEPI, UNICEF and GAVI established a nonprofit entity – COVAX. Serving as a central purchasing hub for vaccines when approved, COVAX would negotiate bulk purchases from pharmaceutical companies; lower-income countries would be assured of access to vaccines, with their costs subsidized by wealthier governments. By August 2020, 172 countries had signed on to participate. The U.S., China, and Russia did not.
But in the beginning of 2021, the US joined the COVAX initiative and resumed funding the WHO, and successful clinical trials had occurred in the US, UK, and EU. In March 2021, WHO approved five vaccines for emergency use. The vaccines offered protection against serious illness and death by COVID-19; emergency rooms and morgues began to clear. International institutions and national governments began launching vaccination campaigns.
The astonishingly successful race to discovery became a lurching, slow plod to vaccinate, characterized by hoarding, conspiracy theories, misinformation, and profiteering. Despite scientists warning that “no one is safe until we are all safe,” cross-border resource sharing has been inadequate, half-hearted, and sluggish.
More than 15 months after effective vaccines were discovered, official statistics record 468 million people have been infected with COVID-19 and 6.1 million people have died. Statisticians say the actual number of “excess deaths” may be three times as high.
Humanity has the collective resources to rapidly and equitably deal with global disease outbreaks. We have the scientific knowledge and tools to protect ourselves. This pandemic has demonstrated the difficulty we having sharing with and trusting those who aren’t like us. And in times of extreme stress and uncertainty, trust and generosity are hard to build. Thus, it becomes even more important to iron out new rules of engagement and codify expectations and new standards of behaviour to prepare for the next pandemic or coronavirus mutant.
What went wrong and what has to happen to ensure a fairer response to the next pandemic or a more deadly variant of COVID-19?
What has to change?
To ensure a fairer, more effective response to the next pandemic or mutant, we make eight requests of the global community under four broad headings:
COVAX Must Be Automatically Funded and Inclusively Governed
Ten wealthy countries pre-purchased 80% of the supply of vaccines in development in 2020, thwarting COVAX’s aspiration to be the central vaccine purchasing and distribution hub, and making it difficult for other countries to purchase vaccines. Some countries “reserved” multiple times the amount needed from different manufacturers, to hedge their bets on which would be successful.
Non-transparent bilateral pre-purchasing agreements between wealthy countries and vaccine developers, made before scientists had even developed any effective vaccines, ensured a highly unequal early roll-out in 2021. COVAX’s difficulty in securing vaccines for lower-income countries was exacerbated when its major supplier, the Serum Institute in India, was prevented from exporting its vaccines when India experienced a COVID-19 surge. Wealthy countries were slow to fulfill their pledges of monetary support for COVAX in 2020.
Press reports about wealthy countries purchasing billions more doses than their people needed raised a public outcry, so they pledged to donate 785 million “excess doses” to COVAX. But despite these promises, COVAX was able to gather only about a billion doses to distribute to 86 lower-income countries in 2021. Getting vaccination rates up to 70% across the rest of the world in 2022 will require about 2.4 to 5 billion more doses, depending on whether 2 or 3 doses are required.
Effective vaccination campaigns require planning and predictable, consistent delivery of medication. A successful two dose + booster vaccination requires a predictable supply of vaccines being available over time period of weeks. Delays of a second shot can undermine effectiveness, especially in remote places where clinics and medical staff are sparse.
The world needs an automatic reliable stream of funding and vaccines to kick-in at the beginning of a declared pandemic emergency to ensure early global access to new vaccines for people in lower-income countries. This central pool of money and vaccines would be distributed according to urgent need. The governance of the vaccine supply for lower-income countries must have strong representation from lower-income countries, to ensure they bring information, knowledge, and voices from the ground to the discussions.
We ask that:
ONE: Wealthy governments, that negotiate directly with vaccine manufacturers to purchase vaccines, donate one vaccine to COVAX for every vaccine they buy for their own citizens.COVAX does not have an automatic, ongoing funding mechanism for purchasing vaccines, and even when funds were available, COVAX was consistently at the end of the purchasing queue – leaving residents of lower-income countries waiting months for vaccines. During this time, more contagious variants emerged and the lag allowed conspiracy theories and disinformation campaigns to spread.
TWO: COVAX expands its governance to include strong representation from the countries and regions dependent on the pooled fund for vaccines, including regional health organizations, country health professionals, and civil society organizations from lower-income countries. These organizations could inject a sense of urgency into the effort to distribute vaccines, demand accurate information on delivery and expiration dates, as well as providing crucial information about the ability of various national health systems to deliver vaccines within a particular time frame.
Contracts with Pharmaceutical Companies Must Be Transparent and Prices and Licenses Affordable
The most effective early vaccines – Pfizer, Moderna, AstraZenica, J&J – were heavily subsidized by the U.S., U.K., and EU governments, but these governments failed to negotiate pricing, licensing and contract transparency agreements to ensure their investments would benefit the world, not only their own citizens. Today, 33 different vaccines with varying degrees of efficacy have been approved by at least one regulatory body.
Only three vaccine developers (Oxford-AstraZenica, Novavax, and Corbevax) started with a commitment to make a vaccine that could be produced at an affordable price and stored and transported inexpensively (i.e., did not require super-cold refrigeration). Only Corbevax has committed to an open license, without patent protections. If Corbevax had received massive amounts of public funding early on and was available in early 2021, it might have changed the availability of affordable vaccines to lower-income countries, encouraged more manufacturing there, and saved hundreds of thousands of lives.
We ask that:
THREE: Wealthy governments develop a common set of rules about the behaviour of private corporations during global public health emergencies – especially companies that accept public financing. Contract transparency, open licensing, the sharing of vaccine recipes, prohibitions on differential pricing and price gouging must be written into contracts. Secret contracts make it impossible for national and global health officials to respond to outbreaks and to effectively work to reduce and prevent the spread of COVID-19 across the world. The pharmaceutical companies have held the information about delivery schedules instead of the health officials on the ground responsible to getting vaccines into arms.
FOUR: In countries where clinical trials are carried out, national governments negotiate for immediate access to affordable finished products. Lower-income countries can demand contract transparency, open licensing, the sharing of vaccine recipes, and prohibitions on differential pricing and price gouging.
Research and Manufacturing Hubs Should Be Established in Under-served Regions
Civil society groups have long demanded that more drug manufacturing facilities be developed in the global south. There are 221 COVID-19 vaccine production locations around the globe, but few are in Africa and the Middle East. This slows the world’s ability to ramp up production in the face of new health emergencies overall, and particularly disadvantages low-income countries.
During the COVID-19 pandemic, a few western companies created new “fill and package” facilities in the global south, but creating real manufacturing capacity requires major long-term investments, technology transfer hubs, and licensing without patent protections.
When Corbevax – a patent-free, low cost, easy-to-produce, store and transport vaccine using a well-tested and safe method – is approved for use, the power dynamics of vaccine distribution may change. If giving away the vaccine recipe and production techniques demonstrably increases the supply of vaccine available, it will create powerful new evidence in the debate about patents.
We ask that:
FIVE: International institutions, wealthy countries, and multinational drug companies mobilize funding and scientific expertise to develop pharmaceutical research and manufacturing in regions currently without this capacity. This way all regions of the world can find solutions to health issues that are a priority for them. As a first step, investment is needed in the WHO’s COVID-19 mRNA technology transfer hubs to help scientists in lower-income countries develop new pharmaceutical production capacities for future pandemics that are likely to arise, as deforestation and animal-to-human contact increases. Eqypt, Kenya, Nigeria, Senegal, South Africa, and Tunisia have been selected for initial investments.
SIX: These new tech hubs in Africa model a cooperative rather than competitive approach to vaccines development and distribution, sharing innovations, creating complementary specializations, and using open-source licensing to demonstrate to others how to “put people before profits” when providing vaccines and other life-saving medicines.
Investments Are Urgently Needed in Public Health Delivery Systems in Lower-income Countries
Prevention and control of COVID-19 has stretched economies everywhere. Public health is perpetually underfunded in most low-income countries. In 2019, for example, according to WHO, some high-income countries spent over $2000 per capita on health compared to $50 per capita in many low-income countries. Without additional support, it will not be possible for low-income countries to employ the human resources and set-up the logistics and infrastructure needed to deliver vaccinations to entire populations.
We ask that:
SEVEN: The World Bank Group (WB and IMF), the UN and bilateral funders earmark significant new funds (loans and grants) to invest in improving basic health care delivery systems in lower-income countries – with the goal of ensuring COVID-19 vaccines reach those who need them and to strengthening of public health systems to be prepared for future pandemics. Funds set aside for this purpose should remain available for at least five years; it may be difficult for lower-income governments to do the planning necessary to achieve these funds in the midst of COVID-19 and economic decline.
EIGHT: National leaders take advantage of the availability of these funds to make long-term investments in health infrastructure – staff, clinics, and equipment so that they can better respond new challenges. Effective social media communication campaigns must also be part of an effective health delivery system. Public health officials need to be able to deliver early, accurate, consistent information during health emergencies to prevent false information and conspiracy theories from developing.
Reimagining the Future
We need to proactively and collectively plan the roles and responsibilities of international organizations, national and local governments if we are to prevent and better respond to future pandemics. This is especially important since de-forestation and climate change are already increasing animal-to-people contacts that can cause new infectious diseases.
In December 2021, the 194 member states of the WHO agreed to begin negotiations on a global pandemic treaty, aiming for a draft agreement to be finalized by May 2024 for the 77th World Health Assembly. Unfortunately, only 70 states, including the EU and UK, are advocating for a legally binding pandemic treaty – the U.S., Brazil, and India are among those member states reluctant to commit to a treaty.
But our experience living through the past two years tells us that informal guidelines and unenforceable pledges are not enough. Our governments can and must do better.
When we started Get1Give1 Worldwide, we were searching for a citizen-to-citizen response to COVID-19 that allowed us to demonstrate our solidarity with the rest of the world in a direct and tangible way. We are still moved by this imperative, but as COVID-fatigue settles in and war breaks out in Europe, we believe the citizen solidarity most needed in the months and years ahead will be for all of us to demand our governments agree to abide by a common set of rules that will protect humanity from the urgent, existential challenges we face.