Why the Covid-19 vaccine is so poorly shared around the world

A conversation with WHO exec Tania Cernuschi

Vaccine nationalism was always going to win, if you ask me. However self-defeating it is to let the pandemic spread and the virus mutate across the world, it's simply too much to ask, of politicians and of ourselves, to give up our own immediate protection for the sake of health workers or vulnerable people we've never met on the other side of the world. It was never going to happen. It's ugly, but it's the truth.

That's how I see it but I spoke with one woman who is trying to make it happen anyway. Tania Cernuschi is team lead for global access in the Immunization, Vaccines and Biologicals department at the World Health Organization. Simply put, she works on improving vaccine access and equity around the world. Covid-19 has kept her busy.

Listen to the full podcast episode or read condensed excerpts below.

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Isabelle Roughol: Could you paint a picture of the state of the vaccination campaign worldwide?

Tania Cernuschi: The situation is in constant evolution, but there are about 20 countries or so that have not yet been able to introduce the vaccine. About 50% of the global administered doses are going to high-income countries. You can really see that they're tiered by income: as you go down the chain from high-income to low-income countries, you really see a declining number of doses that have been administered.

(This interactive chart from The Washington Post shows vaccine per 100k residents in each country, broken down by GDP levels. Worth playing with.)

High-income countries certainly represent a smaller share of the population, but I think we need to look also at the high-risk groups and the cases and deaths that these countries represent. They have been most hit by the pandemic and in that sense, we see that the distribution tends to be focused to countries that have had higher needs. But certainly that's not fully the case and it requires some course correction.

What has prevented poorer nations from having equitable access to the vaccine? 

There's been an attempt to set up through COVAX a centralized global procurement mechanism for countries to access vaccines that are of course in scarce supply. The idea was that the great majority of procurement could happen through these means and that through a fair allocation mechanism, we would be able to mediate distribution of doses across the globe.

In reality, what has happened is that the great majority of doses that are under contract at this stage, about 80% of the doses, are actually being purchased outside of COVAX, through bilateral deals and other multilateral deals. And therefore, despite the attempt to have an overarching framework for distribution, currently that distribution is not coordinated.

North America and the European region have been hit hard. They are under enormous political pressure to reduce both the human and socioeconomic costs of the pandemic. It's understandable that countries are trying to protect their populations first and faster through what are more flexible contracts given the case loads. 

Nevertheless, I think that the lack of coordination that we're seeing across all these existing procurement channels is short-sighted. A lack of access can trigger a global decline in gross domestic product with trillions of dollars that could be lost, and a significant burden of these losses would also accrue to high-income countries. We also predict that ineffective distribution could allow the pandemic to continue to thrive as new variants emerge. This is something that clearly needs a course correction.

Should wealthy countries be vaccinating their young people right now when you have countries that haven't seen a single vaccine yet?

This is a sovereign decision that each member state will take. The issue is to ensure that the minimum goal of reducing mortality and severe disease, that pretty much all countries in the world are pursuing, can be achieved. It does require a more coordinated approach now to the distribution of doses. 

Obviously the challenge is how to get there. I personally believe very much in two measures to get there. One is to have a clear vision and set clear goals and objectives for vaccination strategy across the globe so that we can inform bolder and coordinated investments by both public and private entities. 

We have seen for COVID-19 really unprecedented investments by the public sector. I believe 70% of the costs of clinical developments were covered by the public sector. Incredible collaboration with private entities and really an effort to move from sequential risk-averse processes towards parallel processes with risk-taking behavior in terms of making large investments early in the game, where there was a lot of uncertainty on vaccine candidates. There's really been a clear will and investments that brought us to incredible achievements on the development of vaccines at record times. This is normally a 10-year endeavour and in 11 months this time we had several successful candidates!

But I think that the goals that countries are now starting to set for themselves, such as the intention of some high-income countries to start vaccinating younger populations, require further investments. And that investment is probably worth the game given the very high economic costs that we have and the stimulus packages that countries have to put in. 

The point is, setting bolder goals to drive investment is something that could get us to a more equal distribution just by increasing the available supply for all. And at the same time, we need greater collaboration. We need high-level diplomacy between countries. And to your point, I think a goal could be established to reduce severe disease and deaths in all countries before there is a broader vaccine rollout in richer settings.

Should vaccines be a public good then? Would it help move things faster?

Not just for COVID but generally, vaccines are supply-constrained in part due to the technologies that are currently used in vaccine manufacturing. We're talking about very complex biological products, often with underestimated complexity in the process of scale-up. We're talking about products that are manufactured in product-specific facilities, where changeover is cumbersome. This very much limits flexibility. You can have technology transfer, changes in production scale, manufacturing technologies and processes, but all of this is costly and takes time, including due to quality assurance and regulatory review that is very, very strict in the case of vaccines, and rightly so.

Another consideration is that companies are protected by intellectual property rights and know-how for managing these complex processes. Because they face uncertain demand relative to relatively low prices and they also face the risk of vaccine hesitancy and long-term competition from superior products of potentially lower costs, they fundamentally have quite little incentive to invest in new manufacturing technologies, in processes or in increasing manufacturing capacities.

So you can say that the incentives are not aligned with the maximization of social welfare, and this does need some correction in my opinion, through more incentives and through more public intervention. We've seen it in the past for vaccines like meningitis for instance. There is certainly value to increasing public investments that can be justified based on the impact and the costs of inaction. 

We also need to see probably a more active role in oversight of active markets. The current plans for production of Covid-19 vaccines are very uncertain. The allocation amounts and delivery dates are unclear. governments and stakeholders are actually struggling to make informed and proper strategic decisions for the public, lacking this reliable data.

Moving forward, we do need governments to require more transparency in manufacturing cost, in capacity, in contracts and operations. This visibility would then allow governments to strike what needs to be a careful balance between rewarding private investment, but also ensuring there is licensing, if not a technology transfer, to enable increased production. There is certainly some more work to be done.

At the rate that we're going today, when would we reach a point of so-called herd immunity in the world?

This is the billion dollar question. There are too many unknowns to provide a definite answer. There is an incredible effort from experts in modeling groups to try and guide both countries and the global agenda to understand the path forward. At this stage I think really the focus is to ensure that we can have both a health impact and a socio economic impact, focusing on the primary goal of reducing mortality and severe disease.

What are the risks if that finish line is pushed too far into the future?

There are several unknowns. We know we have effective vaccines and safe vaccines. We are not yet clear on the duration of protection. That's one unknown, with the possibility there of a need for booster doses. We have seen variants and we are still trying to get our heads around the ability of these variants to bypass a defect of the vaccine. There is a risk that there may be a need for revaccination of the population if there is no cross protection by some vaccines against the variants, assuming the virus continues to mutate, which we don't know.

We're dealing with a new virus. There's some unknowns that we can't predict. And there is certainly a risk, as you're correctly pointing out, that different and uncoordinated decisions by different countries could have a negative impact on others, both in terms of access, but also in terms of trade and travel.

You mentioned safe and effective vaccines. Are you still using the AstraZeneca and Johnson & Johnson vaccines in your initiative?

Yes, of course. Actually, the AstraZeneca vaccine is the vaccine that has been procured for the moment and has been distributed. Both the European Medicine Agency and the WHO have been reviewing carefully the evidence and evaluated that the benefits clearly outweighed the risks for these vaccines. There is clear guidance to continue the use of these vaccines. They are very powerful tools that we have in the fight against this pandemic. 

What’s a takeaway you think we should learn from this crisis?

We have an opportunity to establish a new paradigm for vaccine development and access. That paradigm shift is really looking for governments to play a very central role, to first of all establish early evidence, inform strategic goals and leadership to serve the collective global interest. Second, to shoulder risks and invest aggressively for the needs of today but also to prepare for future emergencies. Third, to strengthen our market preparedness. We're learning that we need to leverage new vaccine technologies and to establish (probably at the regional level) manufacturing hubs that can also serve as insurance to be used at times of pandemics. We need governments to really drive market transparency and oversight. And finally, governments need to work together to really define principles and operational details for collaboration at times of scarcity, as this will enable countries to protect their own citizens but also ensure that no country is left behind.

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