Breakfast With Bwana
Simply vaccinating people in one’s own country is not enough. It is in the interest of every nation to ensure that all people around the world are being vaccinated
By Anil Madan
The National Center for Disaster Preparedness — yes, there is such an entity — at Columbia University has a Pandemic Resource and Response Initiative, yes really. Irwin Redlener, the director of that initiative explained that if we don’t eliminate the Covid-19 virus everywhere, “then nowhere is going to be safe.” Areas in which there are large unvaccinated people will see the virus festering and mutating. “Those mutations are dangerous for the country in which they occur, and also for the rest of the world. None of these viruses obey boundaries,” he said.
As infections surge around the world and Covid-19 virus variants are detected in one country but soon appear in places distant from their seeming origin, infectious disease experts and health officials recognize that simply vaccinating people in one’s own country is not enough. It is in the interest of every nation to ensure that all people around the world are being vaccinated.
Vaccine production in India. Photo – sciencemag.org
President Biden’s Secretary of State Antony Blinken has said: “Until everyone in the world is vaccinated, then no one is really safe.”
So, there we have it, the scientific view and the diplomatic view tempered by science converge to address the problem from different perspectives. Then there is the humanitarian need to distribute vaccines equitably.
Against these concordant views is a stark reality. There are about 7.7 billion people in the world. The available vaccine supply is simply not enough, in the short term, to vaccinate everybody. Therefore, putting aside all questions about morality and equity, the distribution of vaccines is not going to be, and simply cannot be, equal if, “equality” here is measured as an equivalence based on pro-rata allocation to each country. And if one were to proceed down that path of pro-rata allocation, how would that be addressed? On the basis of population, ability (or inability) to pay, who developed the vaccine(s), who paid for the development of the vaccine(s), or some other factor?
Although this will not sit well with those who believe the U.S. should have shared its vaccine hoard more equitably, the simple fact is that the Pfizer and Moderna vaccines have made up the vast, vast majority of vaccines administered in America. And given the need for extreme cold storage in both cases, with Pfizer’s product more so than with Moderna’s, export of the vaccines is impractical unless recipient countries have the necessary infrastructure to secure the cold chain. The recent announcement by the Biden administration that it will send supplies of the Oxford AstraZeneca vaccine to Canada and Mexico does not involve the super cold chain requirements of the Pfizer and Moderna vaccines but it highlights that even with the best of intentions, the U.S. government is constrained in its ability to share vaccines with the rest of the world.
Let us step back to get an overview of vaccine development and production. In a December 2020 publication, the British Medical Journal (BMJ) reported that as of November 15, 2020, several countries had made premarket purchase commitments totalling 7.48 billion doses, or 3.76 billion courses (based on two shots per recipient), of Covid-19 vaccines from 13 vaccine manufacturers. Just over half of these doses were preordered by high income countries, which represent 14% of the world’s population.
The good news is that the BMJ reported that 48 candidate vaccines were undergoing clinical testing and at least 164 candidates were at preclinical stages.
Several countries made commitments to purchase vaccines from different manufacturers prioritizing securing vaccine doses for their own populations. As has become clear, many countries, including the US, Canada, Australia, have committed to ordering more vaccines than they will need or can use. Of course, there is some uncertainty here as there is talk of a possible third shot as a booster for the Pfizer and Moderna vaccines, and the possibility of tweaking those vaccines to deal with variants of the virus.
This is, in a sense, good news. Countries with excess vaccines supplies will be compelled to give them away on humanitarian grounds and one can expect a fair degree of diplomatic compulsion.
But the numbers are daunting. Even with 3.76 billion courses accounted for, there is a worldwide shortage of vaccines for about 4 billion people, or 8 billion courses.
President Biden has agreed to contribute $4 billion to providing vaccines to countries that would otherwise not be in a position to afford the vaccines. More importantly, he has chosen to address the pressing worldwide need for vaccines by partnering with Japan, Australia, and India to increase manufacturing capacity to produce vaccines.
The Serum Institute of India is already a powerhouse in vaccine production. This new initiative commits to providing support to Biological E, another major Indian vaccine manufacturer with the aim of producing about 1 billion doses of covid-19 vaccines by the end of 2022.
But note that the end of 2022 is 21 months away.
The stark reality is that regardless of anything that the wealthier nations of the world do, the global population will remain woefully undervaccinated for at least the next two years.
This is not to say all is lost. U.S. vaccine manufacturers are ramping up production. Both Pfizer and Moderna are substantially increasing production. The Biden administration has facilitated a partnership between Johnson & Johnson and Merck for the latter to produce J&J’s vaccine. The good news prospect for the world is that the U.S. is unlikely to need these additional vaccines for domestic use unless the coronavirus vaccine becomes an annual event à la the flu vaccine or unless booster doses are needed.
The prospect that the U.S. will have spent $105 million in aiding Merck’s production of J&J’s vaccine for the benefit of the world at large is very real. Against the $4 billion already contributed by the U.S., $105 million is a small sum. The U.S. adult population—minus the naysayers who will refuse the shots—will likely be fully vaccinated within another two months. Whether children under 16 are vaccinated remains to be seen. That ramped up production of vaccines will inure to the benefit of the rest of the world.
There is additional pressure on the Biden administration to implement policies that will erode patent protection for pharma manufacturers. This is unlikely to happen. The U.S. is hardly in a position to diminish respect for intellectual property as it criticizes China for theft of industrial secrets.
But there is little reason to despair here. Pharma companies are notorious for overpricing their products in the U.S. and selling excess capacity to the rest of the world at throwaway prices. The low prices charged by the Serum Institute of India for the Oxford Astrazeneca vaccine produced under license in India will remain a competitive constraint forcing Pfizer, Moderna, and J&J to charge lower prices around the world.
Vaccines are being produced by Chinese and Russian manufacturers as well. With some luck it may be possible to get a total of 5 to 5-1/2 billion courses or 10-11 billion doses produced worldwide by the end of 2022, certainly 2023. That tells us we may have to live with another two to three years of uncertainty on top of the uncertain times we have seen. The impact of this on the worldwide economic recovery remains a real concern.
I end with a realistic note. All of the good news about vaccine development in record time and vaccine production to scale, has to be tempered by four practical considerations. First, no matter what is produced, there are many countries that simply cannot afford the vaccines. The world has to depend on the generosity of the wealthy nations. Fortunately, the need to provide vaccines is in their self interest, so there is hope for enlightened behaviour. Add to that the observation that pharma manufacturers will be forced by competition to reduce prices around the world, and the prospects are good.
Second, the Pfizer and Moderna vaccines will be difficult to transport due to cold chain considerations. But the good news is that both companies are working on modifications that will eliminate the need for ultra-cold storage.
Third, supply chain constraints loom large. Pfizer, for example, has been recycling scarce filters needed on its production lines. Vials, seals, labels, needles, syringes, are all necessary for a successful vaccination program.
Fourth, and finally, people have to be trained to administer the vaccines and monitor recipients for adverse reactions in the immediate short-term.
Meeting the world’s needs for vaccines goes beyond simple production numbers.
Readers may find this article from The Washington Post interesting
Drug companies defend vaccine monopolies in face of global outcry
Global vaccine supply shortages challenge drug company monopoly practices – The Washington Post
* Published in print edition on 23 March 2021
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