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COVAX: How a plan to vaccinate the world has failed

11 Nov 2021

Kate Elder, Senior Vaccines Policy Adviser at Médecins Sans Frontières joined Julian Morrow on ABC Radio National Sunday Extra to discuss the weaknesses and shortfalls in the system designed to ensure equitable global distribution of the COVID-19 vaccine. 

Julian Morrow: More than 70% of Australians aged 16 and over are now fully vaccinated against COVID-19. But the push to protect people around the world and especially in poorer countries still has a long way to go. Eighteen months ago, the UN backed a plan for global collaboration to deliver vaccine equity known as COVAX. The COVAX facility is administered by the vaccine alliance Gavi, working with the World Health Organization (WHO) and others. COVAX has delivered some 330 million vaccines to 144 countries, and it aims to distribute 1.1 billion vaccines in the last three months of 2021. But some countries have received less than half of their allocations, and even COVAX says that while its mechanism is now working at scale, volumes made available to it today are unacceptable. 

A recent report by the Bureau of Investigative Journalism has found that the targets set by COVAX were wildly unrealistic. Kate Elder is the Senior Vaccine Policy Adviser to Médecins Sans Frontières. In the Bureau of Investigative Journalism’s report, Kate describes COVAX as naively ambitious. Kate Elder, welcome to Sunday Extra.

Kate Elder: Thank you very much for having me.

Julian Morrow: Kate, what exactly is COVAX? 

Kate Elder: So COVAX is the global procurement mechanism that set out to deliver on the promises of many governments, back when the pandemic started in April of 2020. Many governments got together, leading governments like the French Government, the European Commission, WHO as a multilateral organisation, and pledged that future COVID-19 vaccines would be shared equitably across the world, they would be considered global public goods. And the COVAX facility, was quickly established to try and deliver on that promise. So, it is a global procurement mechanism that any country around the world can join, that is supposed to buy vaccines and deliver them equitably for the most sensible route of emerging from this pandemic. 

Julian Morrow: And why do you say the design of COVAX was naively ambitious?

Kate Elder: MSF has a long history of working to try and secure medicines, vaccines and diagnostics for our operations. We see all too well the experience of many low-income countries, the poorest countries of the world, which of course are the countries where we work, where we’re always last in the queue to get access to these medical tools. 

The current biomedical research and development system is very much driven by multinational pharmaceutical companies, despite tremendous public investment in developing medical tools, as was the case with COVID-19 vaccines, which garnered tens of billions of dollars from governments, ultimately these products are governed and decisions around access made by pharmaceutical companies. Pharmaceutical companies get to decide what volumes they produce, who they sell to first and what prices they set. So, fast forward to the concept of COVAX, while it was an impressive an ambitious concept, it seemed very naive if it was going to operate in the current system, which is see how much money you can raise and then what you could negotiate with the pharmaceutical industry to purchase for that.

Understanding that COVAX was going to be coming up against, if you will, the likes of the Australian Government, the United States Government here where I sit, the European Union and that represents 27 countries that we knew were already rushing to the front of the queue to buy vaccines, even at the time the COVAX facility was announced. It seemed relatively obvious that the COVAX facility would have a very uphill climb if they were going to secure doses for the developing world. 

"COVAX really faced a lot of challenges, some of the challenges of course were not under its control but should have been anticipated."

Julian Morrow: As we heard, it has delivered some 330 million doses, but has fallen far short of what it aimed to distribute. What are the main factors, that in your view, explain how far short COVAX has fallen? 

Kate Elder: So initially COVAX set out with a target of purchasing and delivering 2 billion vaccines by the end of 2021. They have fallen very short of that. It's expected, and this might still be an overestimate, that they might be able to deliver about 1.4 billion by the end of this year, but as you just said, the figure towards mid-October is still grossly short of that target. 

COVAX really faced a lot of challenges, some of the challenges of course were not under its control but should have been anticipated. There should have been a risk assessment to factor in vaccine nationalism, which has been obviously one of the predominant challenges that has faced anything related to equity, whether it's COVAX or whether it’s the African Union trying to get vaccines for the continent. So, vaccine nationalism, the race towards stockpiling and hoarding excessive amounts of vaccines, more than every country’s fair share, has certainly been one major barrier for COVAX. 

Another is the pharmaceutical companies are part in parcel of that, right, we see right now a lot of blame shifting. We have pharmaceutical corporations blaming wealthy countries for why there aren’t vaccines in developing countries. Moderna will say, Pfizer will say, Johnson & Johnson will say, “Well, go to the countries that have bought up of all the supplies.” But then, of course, pharmaceutical corporations were the ones that decided to engage in all of these bilateral agreements. The issue with public investment in vaccines not being ultimately used for the public good as I mentioned before, these are just a couple of examples of why COVAX has been falling so grossly behind. 

Julian Morrow: On Sunday Extra, we're speaking with Kate Elder, Senior Vaccine Policy Adviser to Médecins Sans Frontières. Kate, to what extent are the problems with rollouts through COVAX the result of over-reliance on one Indian vaccine manufacturer, and then what's been described as a de facto ban on vaccine exports that the Indian Government introduced when it was hit so hard by Delta in March this year?

Kate Elder: I think that’s a really important point you raise, because this also goes to the heart of equitable sharing of research and development and the fruits of research and development. It was very, very foolish for Gavi and The Bill and Melinda Gates Foundation, frankly, because they were a big backer of the COVAX facility, to put so many eggs in the basket of one country. India is home to many vaccine manufacturers, what we call developing country vaccine manufacturers, that are typically some of the largest suppliers for Gavi in the work that Gavi does outside of COVID-19. The Gates Foundation actually played quite an instrumental role in convincing Oxford, which had developed the AstraZeneca vaccine, but originally the technology developed by Oxford. At the behest of the Gates Foundation, Oxford exclusively licensed to AstraZeneca, AstraZeneca exclusively licensed within India to the Serum Institute of India, and a tremendous amount of money was put in by the Gates Foundation, about $300 million off the top of my head, it might have been more, into scaling up production capacity with the express intention of supplying COVAX. 

Now, I think your listeners will know the scale of the Indian population and will understand the infrastructure and the topography of health in India. It’s not such a large leap to guess that India would’ve suffered a massive outbreak, and of course, as we’ve seen with many other governments, that the Indian Government would look to protect its population first. So, perhaps this is too long an explanation, but I think the point I’m trying to make is, that when we have technology, we should be sharing it with capable manufacturers across the world, particularly in regions that have been time and time again left behind at the back of the queue in other health crises. I’m talking about the countries in Africa, Sub-Saharan Africa and many countries of the Middle East. Right now, we see many high-income countries feel like they’re emerging from this pandemic, but on the continent of Africa, we’re seeing now desperate, desperate measures from manufacturers there, with support from the African Union, to try and get technology there to produce and be self-sufficient for COVID-19 vaccines. So, the broader lesson learned is we should be building vaccine and other health commodity manufacturing capacity in places that are capable to do it. But of course, pharmaceutical corporations will doggedly protect what they consider their technology. 

" really can’t rely upon charity as a global public health strategy."

Julian Morrow: The net result of all this, Kate Elder, is that high-income countries, as a result of that vaccine nationalism, now have excesses of vaccine that they have in many cases pledged to redistribute but haven’t actually redistributed yet. Is it likely now that access to vaccines around the world is going to happen outside COVAX? The Bureau of Investigative Journalism describes a move from solidarity to charity.

Kate Elder: Yes. And when you’re in such a desperate situation, you’re going to take vaccines any way you can get them, right, so donations are needed urgently. But yes, it is now a hallmark of the COVAX facility that a significant portion of the doses running through it are donations, and this is worrisome for innumerable reasons. One of them is you really can’t rely upon charity as a global public health strategy. I mean, I think it’s obvious to your listeners why charity is not a solution. Charity, of course, is at the discretion of the donor, there’s no accountability for it, you know, as we’ve seen, frankly, with these dose donations pledged by governments, a very limited portion of them have actually materialised. But unfortunately, right now, because of COVAX’s position, that is really one of the things that they’re relying upon. 

Now, I mean, what is the lesson to be learned from this, aside from the obvious? I think it’s that we need systemic change, right, for sure. It’s quite, I would say, salt in the wound, to have these countries, as you said Julian, that have horded so many doses from the beginning, especially the governments that said that they were going to do things differently and we wouldn’t repeat past situations, for example, the HIV/AIDS pandemic of 25 years ago. But really, the salt in the wound is they horded the doses, now they have an excess of doses, now they’re making pledges to donate them, and the donations aren’t even coming in time. Donations can come with very minimal remaining shelf life. If vaccines come, and they’re close to their expiration, that’s not fair to put on the shoulders of developing countries that are trying to work to prepare to be able to distribute vaccines. But if they receive stocks that are close to expiration, how are they able to, as expeditiously as possible, get them across the country to people who need them most? 

MSF has been calling for dose redistribution as the band-aid, as the short-term measure to get shots in arms. But it is not at all the full solution. We also have to look at transfer of technology, better accountability for public investment, alleviating intellectual property barriers, and better balancing this horrible imbalance between pharmaceutical corporation, and frankly, a handful of very wealthy governments that hold all the power to make decisions for the health of the entire world. 

Julian Morrow: As you mentioned, distributed manufacturing, especially in developing nations, is preferable, but dosage redistribution is the band-aid in the meantime. The Australian Health Minister Greg Hunt confirmed this week that Australia will not renew its contract with CSL to produce the Oxford AstraZeneca vaccine beyond the 51 million doses that they promised to deliver. In terms of the dosage redistribution band-aid, Kate Elder, what do you make of the Australian Government’s decision? 

Kate Elder: I think it’s a very poor decision, I don’t think it’s in the interest of the world. I mean, doses are needed, we need to make them in places that have regulatory approval, that are capable of making them, and we need to be stepping up supply and supply that’s going to the right places. Pharmaceutical corporations, they’ll say, “Oh, there’s going to be enough supply, there’s going to be enough supply.” Well, one, they’ve been saying that since the beginning of the pandemic and have fallen quite short of the forecast that they were given, but then two, it’s not just a matter of whole numbers, or what is the supply, it’s a matter of getting it to the right places, the places that have been neglected. 

The Australian Government has the capability to be producing AstraZeneca doses and sharing them with the world. They should be maintaining that. The Australian Government, I think, has done a poor job so far sharing doses. If I’m not mistaken, I think it’s under four million doses and it’s predominantly been to countries in the region, I would imagine, with geopolitical intentions. This is not what we need from governments that should be leading the way, governments like Australia, governments in the European Union, the US Government. This is not behaviour that’s indicative of thinking globally, acting globally and being a good partner globally. 

Julian Morrow: Kate Elder, thanks very much for speaking with us on Radio National. 

Kate Elder: Thanks so much Julian, take care and be well. 

Julian Morrow: Kate Elder is the Senior Vaccine Policy Advisor to Médecins Sans Frontières and the Bureau of Investigative Journalism’s report into the COVAX scheme is called ‘How COVAX failed on its promise to vaccinate the world.