Photo Source: New York National Guard/Sebastian Rothwyn
Vaccine Nationalism and Multilateralism
by Yash Bajaj
July 14th, 2021
The COVID-19 pandemic has claimed more than four million lives to this day, making the global supply and distribution of vaccines critical to the health and safety of all civilians. The project discusses past and current trends in vaccine allocation as well as multilateral initiatives that address issues surrounding the equitable distribution of doses. Furthermore, the project also emphasizes the importance and benefits of vaccine multilateralism over vaccine nationalism in order to meet global vaccination needs.
Amid the coronavirus pandemic, which has claimed more than three million lives, the supply and distribution of scientifically proven vaccines gains new urgency every day. The development of safe and effective vaccines is a testament to modern scientific capabilities, but despite the growing number of options, manufacturing capacity does not meet global needs. Current global vaccination rates of approximately 6.7 million doses per day translate to achieving herd immunity (70 to 85% of the total population receiving all doses required for a vaccine) in 4.6 years. The delivery and procurement of vaccines by some of the poorest countries remains relatively non-existent; experts suggest 80% of the population in nations without resources and money will not receive a vaccine this year. While wealthier countries are moving to reopen in preparation for tourism and other activities, the rest of the world is facing new peaks in the pandemic. India, for example, is currently in the midst of a humanitarian emergency: the country is recording incredibly high levels of new daily cases and deaths, the health system is collapsing, hospitalized patients do not have access to ventilators and oxygen, and bodies are burning on pyres in the streets.
Bodies burning on pyres in East Delhi
Source: New York Times
The cross-border dimensions of health have long been recognized as a challenge and have become even more prominent during the latest crisis. Tedros Adhanom, the Director General of the World Health Organization, has called for better cooperation between nations in order to achieve worldwide immunity. He advocates against vaccine nationalism, which occurs when powerful nations sign agreements with pharmaceutical manufacturers to hoard supplies and protect their own populations first instead of equitably disseminating vaccines to all countries as a global public good. Vaccine nationalism has become an important topic in discussing the inequalities in global public health and the treatment of vaccines as a market commodity rather than a global public good.
History suggests that in response to pandemics, national governments tend to follow their own interests instead of pursuing a more globally coordinated approach. In 2009, when H1N1 (swine flu) became a global issue, the United Nations urged wealthy countries to ensure that vaccine doses be made available to needier countries. Unfortunately, until recently, the United States faced shortages and made providing the vaccine to its own citizens its foremost priority, leaving other states more vulnerable to the spread of disease. In the past, most outbreaks have tapered off before a vaccine became a dire necessity. As a result, no equitable sharing system was introduced in global governance for future health crises. Without an organized and permanent global mechanism to deal with pandemics, many countries have turned towards internal approaches to support their citizens, embracing the concept of vaccine nationalism.
So far, the scramble for vaccines has been dominated by powerful governments, who have hedged their bets by investing billions of dollars to ensure that the majority of the initial supply of doses will be provided to its citizens. Advance purchasing agreements between pharmaceutical companies and high-income countries are undermining initiatives to equitably distribute vaccines, potentially leaving low and middle-income countries without enough supply.
Disparities in global vaccination rates between low-income and high-income countries
Source: Our World in Data
As of April 2021, 87% of doses had been administered in high-income countries, while only 0.2% of doses have been distributed in low-income countries. Furthermore, up to 60 of the low-income nations might not receive any additional supply of the vaccine until June. Conversely, the supply of shots in Western countries such as the United States and Canada has begun to significantly outpace demand – several states, such as Louisiana, Kansas, and Mississippi have turned down vaccine shipments from the federal government. Canada has purchased enough doses to vaccinate its population five times over. High-income countries have had little incentive to share from their stock considering that their populations have not reached herd immunity. Nationalist approaches have significantly altered the global production and distribution of vaccines.
Although many countries have focused on supporting their own populations first through vaccine nationalism, several multilateral initiatives and proposals have emerged, which seek to ensure that the distribution of vaccines reflects global needs. Launched in April 2020, the ACT (Access to COVID-19 Tools) Accelerator is an ambitious project that is meant to speed up the development, production, and equitable access to COVID-19 diagnostics, therapeutics, and vaccines, in an effort to subside gross inequities in access for low-income countries. Under the ACT Accelerator, COVAX (co-led by the World Health Organization, the Global Alliance for Vaccines and Immunizations, and the Coalition for Epidemic Preparedness Innovations) — a vaccine allocation mechanism — aims to develop and equitably distribute 2 billion doses by the end of 2021. The alliance of more than 180 countries with widely varying levels of development is pooling its resources and sharing the costs of vaccine research and distribution. According to Director General Adhanom, international cooperation among scientists was critical for vaccine development, and is just as important for ending the pandemic. The establishment of COVAX makes vaccines accessible for vulnerable populations and helps fill a void for countries who do not have the infrastructure for delivery and production. As of June 8, 2021, COVAX has distributed over 81 million doses to 129 countries, with many receiving the doses for free.
Although COVAX has raised more than $6 billion, the initiative requires another $2 billion in order to meet its distribution target for 2021. The United States has taken some steps to support COVAX; the country intends to share up to 80 million doses of the AstraZeneca vaccine, as well as provide the supplies and infrastructure for global vaccine production. At the G7 summit, Joe Biden pledged to donate 500 million doses of the Pfizer vaccine for low and middle-income countries. Furthermore, the United Kingdom has pledged to donate most of its surplus vaccine supply to poorer countries and France has called for wealthier countries to provide at least 5% of their surplus to struggling nations. So far, President Emmanuel Macron has committed to sending 500,000 doses to other nations for free. Although wealthy countries have pledged their support for multilateral efforts, access to vaccines remains highly inequitable. According to research by the Duke Global Health Innovation Center, four billion doses of the COVID-19 vaccines have already been purchased through deals involving high-income countries, with another five billion doses being negotiated by the same parties. On the contrary, only 250 million doses were purchased by COVAX.
Confirmed number of doses purchases by country income level classification (in billions) as of June 4, 2021
Source: Duke Global Health Innovation Center
The fact that high-income countries have purchased 36 times the number of vaccines as COVAX has is indicative of the prevalence of vaccine nationalism, which has undermined the effectiveness of vaccine multilateralism. Side deals for large vaccine shipments have left considerably less supply for global allocation. The research culminates with a bleak statement: most people in low-income countries will be waiting until 2024 for vaccinations if current trends continue. Multilateral mechanisms are critical in order to achieve herd immunity and health security, but have been relatively ineffective in the wake of nationalist agendas and priorities.
The Consequences of Nationalism and Importance of Multilateralism
Vaccine nationalism has left poorer nations with tough choices. Although there has been movement in this position over the past month, the United States had previously decided that it would not share the raw materials for vaccines with India, the current epicenter of the pandemic. The decision to not send resources and supplies has resulted in somewhat of a ripple effect: The Serum Institute of India (the largest manufacturer of vaccines in the world) is now unable to provide sufficient doses to COVAX and ignore the crisis within their own borders. The low- and middle-income countries relying on COVAX and the Serum Institute will also face major shortages in supply. This domino effect stems from the unwillingness of developed countries to share their excess supply. As Director General Adhanom has pointed out, allowing the majority of the world’s population to go unvaccinated not only increases the number of deaths from COVID-19, but will also spawn new virus mutations that could possibly be more contagious. New variants could result in vaccine resistance and infect people who have already survived the virus or received multiple doses. There has already been evidence that some vaccines were less effective against variants identified in Brazil and South Africa, and the Indian variant is a large reason why there was a surge in cases across India. The more people that new variants infect, the more likely it is that further mutations will occur, increasing the likelihood that the virus can evade the immune response set out by vaccinations; a more contagious or deadly mutation could even become a new dominant strain. The health care systems in poorer countries would continue to be overwhelmed for years to come. Uncoordinated supply chains and health infrastructures could magnify the risks of escape variants, alter the effectiveness of vaccines, and leave all nations — not only low and middle-income ones — in the same dire situation the world was in last year.
Controlling outbreaks of major infectious diseases requires urgent and greater international collaboration. Global cooperation on vaccine allocation and distribution is the most efficient way to disrupt the spread of the virus and counter the rise in deaths. Besides countering the death toll, there are economic incentives to support COVAX and provide access to vaccines in all countries. According to estimates by the Eurasia Group, the economic benefits of an equitable vaccine solution by the top ten donor countries would be approximately $153 billion in 2020-21 and would rise to $466 billion over the next five years. Compared to the profit earned in the long-term by donor countries, COVAX requires significantly less funding. Additionally, as COVID-19 has hurt various sectors of the economy, such as tourism and dining, it has negatively impacted the output of the global economy. The pandemic will cost the global economy $11 trillion in output before the end of 2021, growing to $28 trillion by 2025. If lockdown measures continue due to low vaccination rates in low and middle-income countries, the global economy will suffer for a prolonged period of time. The global economy will not fully recover until it recovers everywhere, and this goal hinges on the fair and equitable distribution of vaccines.
Other than the impact on the economy, vaccine multilateralism is especially important to support global supply chains. The local supply chains of years past have been replaced by global ones that leverage economies of scale and lower-cost production. Each vaccine player has different partners and supply chains, and addressing issues of supply constraints and global distribution will require using all available expertise and resources. For example, in Europe, Pfizer (US manufacturer) receives the ingredients for the formulation process from their European partners, in particular, BioNTech. Once the vaccine is filled in vials, they are packaged and sent to a “freezer farm” (an ultra-cold facility). Additionally, Pfizer has hired contract manufacturers in Germany to purify the substance and prepare it for shipping. In essence, worldwide distribution requires the collaboration of multiple companies and partners. If one country decides to engage in vaccine nationalism, countries unable to produce vaccines can create logistical challenges by threatening not to export the necessary supplies.
COVID vaccine "freezer farms" are essential to ensure that doses remain cold through the distribution process
Source: UPS/The New York Times
Additionally, many low and middle-income countries do not have access to “freezer farms,” cryogenic containers for shipping and storage which often use liquid nitrogen for cooling, and a reliable power supply to ensure that the vaccines stay cold. Without the help of nations that have the proper infrastructure and facilities, supplying vaccines across the globe will be slowed. There have been some initiatives that address the gaps in the vaccine supply chain. CEPI has created a regionally diverse network so that the vaccine dispersal is not blocked by export restrictions – their supply chain extends to 30 countries in five continents. However, without a multilateral and universal undertaking, governments in low and middle-income countries will not be able to protect their citizens from the coronavirus for years to come.
Even though a proposal for equitable vaccine distribution should prevail, there is still plenty of room for a hybrid approach that embraces nationalism and multilateralism. Nationalist approaches for meeting vaccine requirements can still be achieved without disregarding the vulnerability of other global populations.
President Joe Biden announced his plan for the United States to share vaccine doses with the rest of the world.
Source: AP Photo/Evan Vucci
Western nations can pledge to make excess doses available to developing countries in COVAX instead of hoarding the entire supply. The collaboration of the international community is necessary to achieve some level of normalcy economically and socially, as well as to reopen borders. Determined efforts at home and abroad are necessary to empower public health and protect the lives of civilians in each nation.
The pandemic presents an extensive opportunity for cooperation and improvement in global governance amidst a wave of nationalist and populist politics around the world. In the modern “G-X” world, networks and partnerships are essential to solve global issues, such as the delivery of vaccines. If all actors can adopt principles of fairness and justice regarding vaccine distribution and focus on multilateral solutions, the prospects for a prompt global recovery to the pandemic will grow. Differences in economic and social power should not determine who has access to the COVID-19 vaccines. The vaccines should be considered a global public good and be equitably distributed amongst the masses, without priorities set in place by location or power. If the global community succeeds in overcoming national protectionism impulses and focuses on protecting people’s rights to equitable access, the current pandemic response could pave the road for a future of cooperation in global health.
Acknowledgements: I would like to thank Elad Raymond, Jared Tucker, and Andrew Ma for their assistance during the editing and publishing and the Onero Team for giving young writers like myself a platform to discuss local and global issues we are passionate about.
About the Author: Yash Bajaj is a third-year student at the George Washington University studying International Affairs and Economics with a concentration in Security Policy. He is from New Jersey, and interested in the politics of Western Europe and South Asia. He is also fluent in Hindi.and partially fluent in French.
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