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As soon as the first COVID-19 vaccines are approved, an astonishing global need will face limited supplies. Many health experts say it is clear who should receive the first vaccines: healthcare workers worldwide, then people at highest risk for serious illness, then those in areas where the disease is spreading rapidly, and finally the rest of us. Such a strategy "saves most lives and slows down transmission faster," says Christopher Elias, who heads the Global Development Division of the Bill and Melinda Gates Foundation. "It would be ridiculous for low-risk people in wealthy countries to receive the vaccine when health workers in South Africa fail to do so," adds Ellen 't Hoen, a Dutch lawyer and public health activist.
However, money and national interest can win. The United States and Europe are pre-ordering hundreds of millions of doses of successful vaccines, which could leave little for the poorest parts of the world. "I am very concerned," says John Nkengasong, director of the Centers for Disease Control and Prevention in Africa.
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To avoid this scenario, the World Health Organization and other international organizations have established a system to accelerate and equitably distribute vaccines, the COVID-19 Vaccines Global Access (COVAX) Facility, which seeks to attract rich countries to register. By reducing their risks, they are betting on the wrong vaccine candidates. But the idea has been developed on the fly, and it is not clear how many rich countries will join.
Recent history is not encouraging. A cocktail of powerful antiviral drugs revolutionized HIV treatment in the West in 1996, saving many lives, but it took 7 years for the drugs to become widely available in Africa, the worst affected continent. "That was catastrophic and that experience is high on my mind," says Nkengasong. During the 2009 H1N1 influenza pandemic, the United States and many European countries donated 10% of their vaccine stocks to the poorest countries, but only after it became clear that they had enough for their own populations. "Too many had to wait too long for too little," says Richard Hatchett, CEO of the Coalition for Epidemic Preparedness Innovations, a partner at COVAX.
This time, too, the biggest concern of rich countries is protecting their own citizens. The United States government has signed more than $ 6 billion agreements with various vaccine companies as part of Operation Warp Speed, which aims to provide vaccines to the population of the United States by January 2021. The Alliance of Inclusive Vaccines in Europe, made up of France, Germany, Italy and the Netherlands, has signed an agreement to buy 400 million doses of the AstraZeneca vaccine to be used in the EU member states. The United Kingdom has also signed agreements with AstraZeneca and other companies. China is developing its own vaccines; It is unclear how soon she will be willing to share or if the shooting will come with attached political conditions.
The idea behind COVAX is to invest in approximately 12 different vaccines and ensure early access when available. "The goal is to have 2 billion doses by the end of 2021," says Seth Berkley, director of GAVI, Vaccine Alliance, COVAX's third partner: $ 950 million for high-income and upper-middle-income countries, $ 950 million for low-income countries. income. and lower middle-income countries, and $ 100 million for "humanitarian situations and outbreaks that are out of control." A first $ 750 million deal with AstraZeneca for 300 million doses was announced on June 4.
Berkley accepts that many rich countries will make their own agreements with manufacturers. But subscribing to COVAX is also an insurance policy, he says. If the vaccines they have invested in do not materialize, they would still have access to others through COVAX, although only enough for 20% of their populations. The money they invest will be used to guarantee lower prices for the poorest countries. Separately, COVAX's Advanced Market Commitment is collecting donations from higher-income countries. GAVI says COVAX will need $ 2 billion in donations to pay for the vaccine doses in 90 countries. "We are trying to do everything possible to have a global approach because we believe that it is the right thing from the point of view of science and from the point of view of equity," says Berkley.
COVAX plans to spread its own risk by investing in a variety of vaccine strategies. Single-dose vaccines might be easier to administer in refugee camps, for example, while a double-dose regimen might work well in a European doctor's office. Some vaccines are based on new technologies, creating more uncertainty about regulatory approval and manufacturing capacity. COVAX also hopes to obtain its vaccines from companies in different places, so that no country can prevent them from being exported.
COVAX is a smart way to try to hold the interests of different countries together, says David Fidler, deputy member of global health at the Council on Foreign Relations. "Even from the point of view of self-interest that governments often have, you can see why this would look attractive," he says. "They don't ignore political reality." But he is concerned that countries may hesitate to sign up, and that those who do so may withdraw from the deal once the fight over doses begins.
So far, more than 70 countries planning to fund their own vaccine have expressed interest in subscribing to COVAX. (They must formally commit by the end of August and provide an advance of 15% of the total amount). Whether they will materialize is another matter. Some countries in the European Union, which often emphasize the importance of global solidarity, have indicated that they intend to donate money, but cannot order vaccines through COVAX. "When it comes to acquiring doses for themselves, we are still actively discussing with them," says Hatchett. "There are models we could work on together."
Nkengasong says Africa also needs to explore other avenues. "We welcome the arrangement of the COVAX Facility, but we cannot wait for the discussions in Geneva," he says. "We have to take charge of our own destiny." At a meeting of the African Union in late June, South African President Cyril Ramaphosa called on leaders to secure vaccine supplies for the continent and ensure that the vaccines are manufactured there. Nkengasong says African governments are reaching out to banks to finance deals with pharmaceutical companies similar to those signed by the United States. "We need to unite as a continent of 1.3 billion people so as not to be left behind."
Kate Elder, a vaccine expert at the Doctors Without Borders Access Campaign, sees COVAX as perhaps the best option for an equitable distribution of vaccines, but says it should be more transparent. "How did you choose AstraZeneca? What conditions are there in the agreement with AstraZeneca if the company does not meet the volume commitments? she asks. "None of the conditions surrounding it are known." Both COVAX and governments should also make sure that funded vaccine producers make their data available to any company that wants to use it, '' Hoen adds. "I am very concerned that they are doing this unconditionally, that the knowledge that is developed with these public funds is not publicly available for others to use," she says.
What is most needed for COVAX to function is political commitment at the highest levels of government, says Alexandra Phelan, a lawyer at Georgetown University who specializes in global health. Without "a great deal of international effort," for example, at the United Nations or the G-20, the first doses of vaccines are unlikely to reach those who need them most, Phelan says. "It will be slow, it will be inadequate and there will be unnecessary deaths."
