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PLOS BLOGS Speaking of Medicine and Health

Vaccine equity is not for sale

By guest contributor Els Torreele

After excruciating months of Covid-19 vaccine scarcity and highly inequitable access leading to avoidable death and unimaginable suffering of millions, we now hear there’s a “vaccine glut” and that we are “drowning in vaccine.” While the apparent surplus once more shows the inadequacy of relying on market supply and demand dynamics to efficiently respond to epidemics, those who think that this means the vaccine inequity problem is solved, or that waiving intellectual property monopolies and technology sharing no longer matters, cannot be further from the truth.

Last year’s acute vaccine supply and inequity problem cannot be solved by oversupply of these first-generation vaccines a year later. These are yesterday’s vaccines developed against the Wuhan strain, and their health impact was maximal –protecting immune naïve people, against severe disease and death– last year when all wealthy countries got them, while lower-income countries went without.

The expected health impact (individually and on public health) of massively rolling out these vaccines now in low- and middle-income countries, amidst transmission of mainly Omicron sub-variants, and among an already largely immunized population (through natural infection plus some vaccination of the most vulnerable), is far less clear.

We must of course continue fighting for access to these vaccines for those who still can benefit from them, especially people most at risk for exposure (e.g. healthcare workers), and at risk of severe disease and death (e.g. elderly people and those with comorbidities) for which the vaccines still offer critical protection. But we cannot overlook that this first-generation vaccines are only mediocre in protecting against transmission, especially Omicron, with rapidly waning effect (4-6 months).

It is therefore equally important to get ready for a next generation vaccines that should be more effective against current and future variants (possibly also other coronaviruses). And ensure that, this time, we do not allow low- and middle-income countries to be shoved to the back of the queue in the marketplace – equitable access cannot be bought in a monopoly market.

Companies including Moderna and Pfizer are preparing shots based on Omicron for a possible new round of vaccination in the fall, and these are likely already being hoarded through advance purchase commitments by the usual suspects (EU, US, other wealthy countries). Unless we can unlock the technologies and ensure massively decentralized production that is immediately distributed equitably, we risk having a repeat of the extreme inequities we saw in 2021. And the oversupply of older, less effective vaccines will likely be sent to developing countries…

This is why we urgently need to open up the monopolies over these critical technologies and transfer knowledge and technology of not only specific vaccines, but of the underlying technology platforms such that many more manufactures can adapt to the changing needs, including with updated vaccines. In order to have a shot at vaccine equity, we must wrest control from the handful of pharma companies now monopolizing supply. Which is also why the shareholder resolutions put forward by Oxfam to Moderna, Pfizer and J&J are timely and highly relevant. But governments of wealthy countries have a key responsibility in shaping and enforcing rules that make critical health technologies common goods.

Ensuring the development and timely availability of health technologies like vaccines for pandemic preparedness and response is a collective public health responsibility, which is why unprecedented amounts of taxpayer money have been poured into the development and manufacturing of Covid-19 vaccines. It is however inexplicable why this was done without any strings attached to guarantee maximal public health benefit from these investments. Instead, the control over the technology behind, and supply of, these and future vaccines, was left in the hands of pharmaceutical companies that respond to shareholder expectations, not health imperatives. The consequences have been dramatic – a “catastrophic moral failure” as WHO Director General Dr Tedros called out the vaccine inequity. We must learn from our experience with anti-retroviral drugs for HIV. It took many years for ARVs to reach lower income countries, with disastrous consequences in terms of transmission and deaths.

A critical activity to address global health crises, epidemic response R&D does not sit well with the classic “winner-takes-it-all” and “one-size-fits-all” pharmaceutical business model, in which companies compete with their proprietary technologies to get to the market first, and then scale up monopoly production for global supply – controlling whom to sell their products to, when, and at what price. In this model, which is increasingly being challenged for having become a barrier to genuine innovation, “winning” companies moreover have vested interests in selling more of the same, rather than investing in improved products that are best adapted to respond to an evolving pandemic, for instance vaccines with much longer protection, or that effectively cut transmission.

In addition to immediately sharing knowledge and technologies to address the Covid-19 pandemic and empower lower income countries to produce and adapt vaccines according to their needs, we must redesign our pharmaceutical ecosystem for public health purpose and govern medical innovation for the common good.  This includes directing it to truly address people’s health needs and deliver affordable access, instead of prioritizing market opportunities and maximizing shareholder return.  In particular for epidemic response R&D, we need an R&D system that puts timely equitable access at the centre and can flexibly adapt to the evolving health needs of an epidemic, which may include the emergence of new variants, a changing immune status of the population, and evolving public health response strategies. Vaccine equity is not a matter of volumes; it is ensuring equitable access to appropriate vaccines at the right time for optimal health impact.

Els Torreele, PhD, is a global health and social justice researcher and advocate, focusing on transforming medical innovation to prioritize health needs and equitable access to knowledge and technologies. For over 20 years, she has combined medical R&D with policy-advocacy at Brussels University, Médecins Sans Frontières, Drugs for Neglected Diseases initiative, Open Society Foundations and is now free-lance and Visiting Fellow at the Institute for Innovation and Public Purpose, University College London. She tweets at @ElsTorreele

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