By Heather Wipfli & Daniel Luo
“Persistent failures must be addressed and overcome in the future if international organisations are to be recognised as meaningful actors promoting global public goods within the international system.”
Over the past 12 months the world has witnessed a microscopic virus bring entire nations to their knees time and time again, infecting nearly 118 million people and resulting in over 2.6 million deaths1. The pandemic was not unanticipated. For decades, as globalisation and environmental degradation has intensified, global health and development scholars and practitioners alike have stressed our growing microbial interdependence and the need to develop strategies to manage a likely global disease outbreak2-4.Mother Nature also sent plenty of warning signals, including a direct shot across the bow in 2003 with the SARS CoV-2 outbreak. SARS motivated some international institutional action to improve global public goods for health. Examples include the World Health Organization (WHO) Member States’ revision of the International Health Regulations in 20055, the adoption of the WHO Global Vaccine Sharing Plan in 20126, and the launch of a handful of public – private partnerships promising to enhance global health security and international pandemic response capacity, such as the Global Health Security Agenda7 and Coalition for Epidemic Preparedness Innovations (CEPI)8.
Time and time again, however, the COVID crisis has illustrated how incapable our international institutions (IOs) remain at protecting and promoting global public goods for health. Despite decades of investment in the United Nations and other IOs, COVID-19 revealed that our IOs are, by and large, invisible when it comes to effectively addressing large global crises. Nowhere has international institutional impotence been more evident than in relation to global COVID-19 vaccine governance – from research and testing, to manufacturing, to procurement and allocation, IOs have failed to advance the global public good over vaccine nationalism and corporate greed.
It has become increasingly clear that our ability to return to previous cross-border interactions, including economic and social collaborations towards the United Nations’ Sustainable Development Goals, relies on equitable access to vaccines for all people, irrespective of age, gender, ethnicity, country, and other social and economic factors9. It has been estimated that the global economy stands to lose as much as US$9.2 trillion if governments fail to ensure access to COVID-19 vaccines in low and middle-income countries (LMICs)10. Time to achieve global herd immunity is already running low as more contagious and potentially more virulent variants arise, including those in Brazil and South Africa which have already spread to dozens of other countries around the planet. Within this context, global collaboration focused on fair global access to data and research on COVID-19 vaccines, as well as global solidarity in the manufacturing and distribution of the vaccine to ensure its accessibility and affordability, is an unquestionable global public good and thus a core responsibility of IOs to advance.
At the outset of the outbreak in China, IOs had an immediate responsibility to support collaborative research and facilitate widespread public access to research and data relevant to the novel COVID-19 virus. While WHO and its organisational partners coordinated joint statements and research forums related to vaccines11,12, they failed to motivate large pharmaceutical companies and other key stakeholders to join in open-source, multilateral vaccine research collaborations. Alternatively, multiple high-income nation states invested in private pharmaceutical research efforts, most linked to priority access to any eventual vaccines developed. For example, the United States’ Operation Warp Speed included a $2.5 billion deal with Moderna and a $1.95 billion contract with Pfizer/BioNTech to develop the vaccine13. Other countries, including China, Russia, India, and the United Kingdom, rushed to develop vaccines with their own in-house developers as well14. Consequently, instead of a collaborative scientific effort, the world witnessed a nationalist and corporate race to be the first to formulate an effective vaccine. The national vaccine race undermined public trust in vaccine safety and linked public confidence in the vaccines to the (often very low) level of public trust in the specific government institutions directly linked to them15.
The failure of international institutions to broker collaborative research and data sharing agreements at the outset of the pandemic carried over to efforts to ensure sufficient vaccine production. The lack of open-source COVID-19 vaccine research resulted in most data and discoveries being owned and protected as corporate intellectual property (IP).
The World Trade Organization (WTO), with its authority to allow for patent flexibilities, has a critical role to play in overcoming IP-related obstacles to vaccine access (as it did in the early 2000s for antiretroviral drug access for HIV). In October 2020, India and South Africa, two countries with generic manufacturing capabilities to quickly ramp up global vaccine supply, proposed a waiver of intellectual property rights to WTO member states16. However, wealthy countries who funded the private research, including the European Union, the United States, and the United Kingdom opposed the waiver request (as recently as March 2021 they were still blocking any efforts to share IP through WTO).
Instead, they have brokered their own domestic manufacturing partnerships to increase their own national supply (e.g., US enacted its Domestic Production Supply Act and supported agreement between Johnson and Johnson and Merck to increase vaccine supply). These national efforts are not just limiting the number of facilities allowed to produce but are also resulting in shortages of other raw materials including vials, glass, plastic and stoppers, needed for manufacturing elsewhere17. Without international patent flexibilities, production agreements, and rules against embargos on essential supplies, manufacturing remains limited to facilities owned and operated by companies that own the IP and are located in the highest income countries.
Finally, in the context of manufacturing limitations and vaccine shortages, there is more need than ever for IOs to take significant steps to ensure equitable allocation of available vaccines. But here again, in the current state of vaccine scarcity, national wealth and power is largely determining price and allocation while IOs make comparatively feeble attempts to offset the unfolding moral catastrophe. According to WHO Director-General Dr. Tedros Adhanom Ghebreyesus, over three fourths of the world’s vaccine doses are currently owned by 10 countries which account for 60% of the world’s GDP18. Canada, for example, has already confirmed deals to secure over five doses per person that cover their entire population, while many countries don’t have even half a dose per person19.
Ironically, higher income countries are also paying less for vaccines after procuring the doses through secretive bi-lateral agreements which have not been extended to lower income countries. South Africa, for example, had to pay over twice as much per dose of the Oxford-AstraZeneca vaccine ($5.25) as compared to the EU ($2.16 per dose)20. Even in cases where LMICs have secured vaccine contracts, there is no guarantee that the vaccines will be delivered as promised given material shortages and producing countries threatening to embargo vaccines earmarked for export to other countries (e.g., Italy blocking Aestaxenca vaccine exports headed to Australia)21.
IOs have launched efforts to ensure some vaccine access in LMICs. In October 2020, the World Bank approved $12 billion in grants and concessional loans for LMICs to finance the purchase and distribution of COVID-19 vaccines, tests, and treatments for their citizens. Although, they must still get in line and negotiate for their doses against the wealth and power of high-income countries. To assist with this process, WHO manages the Vaccine Product, Price, and Procurement Project (V3P) and the Market Information 4 Access to Vaccines (MI4A) – a database on vaccine prices, purchases, volumes, and contract lengths to assist countries in their negotiations with vaccine manufacturers.
However, no IOs have the ability to put in place any prescriptive measures to regulate the vaccine market. Instead, the largest collaborative IO effort to ensure vaccine access, COVAX, builds on the GAVI approach of bulk purchasing and subsidised distribution to LMICs. As late as February 2021, COVAX was still short over $2 billion to meet its target goals for 2021 and faces a “very high” risk of failure, which could leave some low-income countries without access to the vaccine until 202422.
Even if COVAX’s goal of two billion vaccinations within a year is met, that would still fall far short of WHO’s suggested requirement of vaccinating 70% of the global population to achieve global immunity23. On March 5, 2021, Director-General Ghebreyesus recognised that despite efforts, COVAX has failed to shift any of the realities within the global allocation and distribution of vaccines in the short-term24. Consequently, UNAIDS Executive Director Winnie Byanyima predicts that nine out of 10 people living in the poorest countries are set to miss out on a vaccine this year25.
IOs were created to facilitate cooperation and coordination among member nations and protect the poorest from the abusive use of power in the international system, particularly in times of crisis. Unfortunately, in the case of our current COVID-19 vaccine crisis, IOs have failed time and time again to fulfill their basic mandate. The inability of our international institutions to establish meaningful mechanisms for credible and open-sourced vaccine development points to their persistent inability to offset traditional levers of public and private power in the international system. This weakness was further illustrated by the ability of high-income countries to subsequently block IO processes and procedures developed to ensure LMICs can access information and materials needed to meet their basic healthcare needs, including vaccines.
Finally, after failing to broker meaningful collaboration or transparency within the global vaccine market, the most extensive effort by IOs to distribute COVID-19 vaccines to the poorest counties lacks proper funding, faces major supply risks, and is hampered by overly complex contractual agreements22. These persistent failures must be addressed and overcome in the future if IOs are to be recognised as meaningful actors promoting global public goods within the international system.
- “COVID-19 Dashboard by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU).” Johns Hopkins Coronavirus Resource Center, Johns Hopkins University & Medicine, 2021, coronavirus.jhu.edu/map.html. Accessed 10 Mar. 2021.
- Berlin, Leonard. “Tuberculosis: resurgent disease, renewed liability.” AJR. American journal of roentgenology vol. 190,6 (2008): 1438-44. doi:10.2214/AJR.07.3719
- Fontanet A. Les enseignements du SRAS [Lessons from SARS]. Presse Med. 2007 Feb;36(2 Pt 2):299-302. French. doi: 10.1016/j.lpm.2006.12.005. Epub 2007 Jan 2. PMID: 17258678; PMCID: PMC7134802.
- Winter, George. “Global virus alert. How SARS highlighted the risk of viral pandemics.” Nursing standard (Royal College of Nursing (Great Britain) : 1987) vol. 19,44 (2005): 24-6. doi:10.7748/ns.19.44.24.s24
- International Health Regulations, Second Edition. World Health Organization, 2005, https://www.who.int/ihr/9789241596664/en/. Accessed 10 Mar. 2021.
- Global Vaccine Action Plan. World Health Organization, May 2012, https://www.who.int/teams/immunization-vaccines-and-biologicals/strategies/global-vaccine-action-plan. Accessed 10 Mar. 2021.
- Global Health Security Agenda, 15 Dec. 2020, ghsagenda.org/. Accessed 10 Mar. 2021.
- “New Vaccines For A Safer World.” CEPI, The Coalition for Epidemic Preparedness Innovations, 27 Jan. 2021, cepi.net/.
- Yunus, Muhammad, et al. “COVID-19 Vaccines A Global Common Good.” The Lancet Healthy Longevity, vol. 1, no. 1, 1 Oct. 2020, doi:10.1016/s2666-7568(20)30003-9.
- “Study Shows Vaccine Nationalism Could Cost Rich Countries US$4.5 Trillion.” ICC, International Chamber of Commerce, 25 Jan. 2021, iccwbo.org/media-wall/news-speeches/study-shows-vaccine-nationalism-could-cost-rich-countries-us4-5-trillion/. Accessed 10 Mar. 2021.
- “Public Statement for Collaboration on COVID-19 Vaccine Development.” World Health Organization, World Health Organization, 13 Apr. 2020, www.who.int/news/item/13-04-2020-public-statement-for-collaboration-on-covid-19-vaccine-development.
- “Global Research and Innovation Forum to Mobilize International Action in Response to the Novel Coronavirus (2019-NCoV) Emergency.” World Health Organization, World Health Organization, 12 Feb. 2020, www.who.int/news-room/events/detail/2020/02/11/default-calendar/global-research-and-innovation-forum-to-mobilize-international-action-in-response-to-the-novel-coronavirus-(2019-ncov)-emergency.
- Sagonowsky, Eric. “After Nearly $1B in Research Funding, Moderna Takes $1.5B Coronavirus Vaccine Order from U.S.” FiercePharma, Questex, 12 Aug. 2020, www.fiercepharma.com/pharma/after-nearly-1b-research-funding-moderna-takes-1-5b-coronavirus-vaccine-order-from-u-s. Accessed 10 Mar. 2021
- Claire Felter. “A Guide to Global COVID-19 Vaccine Efforts.” Council on Foreign Relations, Council on Foreign Relations, 1 Mar. 2021, www.cfr.org/backgrounder/guide-global-covid-19-vaccine-efforts. Accessed 10 Mar. 2021.
- Jamison, Amelia M et al. “”You don’t trust a government vaccine”: Narratives of institutional trust and influenza vaccination among African American and white adults.” Social science & medicine (1982) vol. 221 (2019): 87-94. doi:10.1016/j.socscimed.2018.12.020
- Thier, Hadas. “The Global South Faces a ‘Vaccine Apartheid’.” In These Times, The Institute For Public Affairs, 19 Feb. 2021, inthesetimes.com/article/global-south-vaccines-south-africa-apartheid-covid-19-hiv. Accessed 10 Mar. 2021.
- Kay, Chris. “Largest Vaccine Maker Warns of Delays as U.S. Prioritizes Pfizer.” Bloomberg.com, Bloomberg, 4 Mar. 2021, www.bloomberg.com/news/articles/2021-03-04/largest-vaccine-maker-warns-of-delays-as-u-s-prioritizes-pfizer?sref=XGjS8839. Accessed 10 Mar. 2021.
- “WHO Director-General’s Opening Remarks at the Media Briefing on COVID-19 – 5 February 2021.” World Health Organization, World Health Organization, 5 Feb. 2021, www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19-5-february-2021. Accessed 10 Mar. 2021.
- Kirk, Ashley, et al. “Canada and UK among Countries with Most Vaccine Doses Ordered per Person.” The Guardian, Guardian News and Media, 29 Jan. 2021, www.theguardian.com/world/2021/jan/29/canada-and-uk-among-countries-with-most-vaccine-doses-ordered-per-person. Accessed 10 Mar. 2021.
- Sullivan, Helen. “South Africa Paying More than Double EU Price for Oxford Vaccine.” The Guardian, Guardian News and Media, 21 Jan. 2021, www.theguardian.com/world/2021/jan/22/south-africa-paying-more-than-double-eu-price-for-oxford-astrazeneca-vaccine. Accessed 10 Mar. 2021.
- Mueller, Benjamin, and Matina Stevis-Gridneff. “Desperate Italy Blocks Exports of Vaccines Bound for Australia.” The New York Times, The New York Times, 4 Mar. 2021, www.nytimes.com/2021/03/04/world/europe/Covid-AstraZeneca-vaccines-Europe.html. Accessed 10 Mar. 2021.
- Guarascio, Francesco. “WHO Vaccine Scheme Risks Failure, Leaving Poor Countries No COVID Shots until 2024.” Reuters, Thomson Reuters, 16 Dec. 2020, www.reuters.com/article/health-coronavirus-who-vaccines/exclusive-who-vaccine-scheme-risks-failure-leaving-poor-countries-no-covid-shots-until-2024-idUSL8N2IV50J. Accessed 10 Mar. 2021.
- “Covax: How Will Covid Vaccines Be Shared around the World?” BBC News, BBC, 24 Feb. 2021, www.bbc.com/news/world-55795297. Accessed 10 Mar. 2021.
- “WHO Director-General’s Opening Remarks at the Media Briefing on COVID-19 – 5 March 2021.” World Health Organization, World Health Organization, 5 Mar. 2021, www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19-5-march-2021. Accessed 10 Mar. 2021.
- Byanyima, Winnie. “A Global Vaccine Apartheid Is Unfolding. People’s Lives Must Come before Profit.” UNAIDS, UNAIDS, 3 Feb. 2021, www.unaids.org/en/20210203_oped_guardian. Accessed 10 Mar. 2021.
Heather Wipfli is an Associate Professor of Public Health and International Relations at the University of Southern California. Her research focuses on international cooperation and governance approaches to improve health.
Daniel Luo is an undergraduate global health major at the University of Southern California.
Disclaimer: The views expressed in this article reflect the opinions of the author and not necessarily the views of The Big Q.