We enter 2021 with stark reminders of how a pandemic can wreck a global economy and destabilize nations. After almost twenty years of steady poverty reduction through the Global Goals, the coronavirus disease 2019 (COVID-19) sent more than 100 million people back to extreme poverty, and simultaneously collapsed oil markets, the airlines, and other industries. It also altered the results of the US Presidential election, incited a failed mob attempt in Berlin to storm the Bundestag (German Parliament) during anti-mask and antivaccine protests, and deepened economic disparities in Latin America.
Such wrenching changes in global geopolitics are not unique to COVID-19. Historically, smallpox and measles epidemics decimated Native American populations and facilitated European conquests in the Western Hemisphere. In modern times, the Zika virus infection drained up to $18 billion from the Latin American and Caribbean regional economy from 2015 to 2017, and an Ebola epidemic in the Democratic Republic of the Congo threatened to destabilize Central Africa in 2019.
Vaccines and poverty. Clearly, the impact of vaccines exceeds their capacity to prevent global infectious diseases and promote public health. A new framework for the “antipoverty vaccines” reflects the economic declines highlighted above, together with findings linking illness to declines in the physical and emotional development of children, agricultural productivity, or pregnancy outcomes. Such revelations from World Bank and World Health Organization (WHO) studies during the 1990s, culminated in adding infectious disease targets such as HIV/AIDS, tuberculosis, malaria, and the neglected tropical diseases to the 2000 UN Millennium Development Goals. They stimulated efforts led by non-profit product development partnerships (PDPs) to work with industry for developing new-generation antipoverty vaccines for global health. Vaccine PDPs were established to develop new vaccines in the LMICs of Africa and the Middle East, Latin America, and Asia, where poverty-related illnesses such as malaria and neglected tropical diseases are widespread. Among those illnesses targeted by PDPs are malaria and schistosomiasis in Africa, leishmaniasis in the Middle East and North Africa, and Chagas disease in Latin America, among others. Some of these same vaccine PDPs are now turning their attention to COVID-19.
Vaccines and foreign policy. Almost twenty years ago, a second modern framework for vaccines built around the concept of “vaccine diplomacy”, recognizing how vaccines are not only economic drivers, but also powerful and historically relevant instruments of foreign policy. Following his discovery of the first vaccine for smallpox in 1796 and in the years of the Napoleonic Wars that followed, the British physician Edward Jenner used the prospect of either his vaccine or its method to promote diplomatic relations with France. During the late 1950s, the US and Soviet Union collaborated on polio vaccine development and in the 1960s on smallpox eradication. The two nations briefly suspended their Cold War differences and economic and political allegiances in order to save lives, ultimately combining their strengths to develop and deliver breakthrough vaccine biotechnologies. Later, I worked to revisit this approach while serving as US Science Envoy for the Obama White House and State Department. My efforts focused on joint vaccine collaborations between research institutions in the US and Muslim-majority nations in the Middle East and North Africa. The Middle East and North Africa is one of several regions of the world “left behind” in terms of vaccine development capacity. Other regions lacking in this aspect include most of the Latin American and Caribbean region and all of Sub-Saharan Africa.
COVID-19 vaccines. As COVID-19 emerged in 2020, so did two extremes of vaccine diplomacy. A positive development was a new COVAX Facility once it became clear COVID-19 had pandemic potential. COVAX convenes Gavi, the Vaccine Alliance, WHO, and a Coalition for Epidemic Preparedness Innovations (CEPI) to support the development, manufacture, or distribution of new COVID-19 vaccines. It emphasizes equity access for low- and middle-income countries (LMICs), especially for cutting edge mRNA, adenovirus-vectored, and recombinant protein vaccines. Otherwise, the LMICs might only receive traditional vaccines based on whole inactivated virus (WIV) or other approaches, or even vaccines of uncertain quality. To promote equity in innovation access, COVAX raises funds from donor nations, with the largest donation so far from the UK Government. Another COVAX objective seeks to preserve the global governance of COVID-19 vaccines. This requires funneling vaccines through a WHO prequalification process to certify its quality, safety, and efficacy, or passing review by one of the “stringent” regulatory agencies in the US, Europe, or Japan. For example, India currently hosts some of the largest vaccine producers, which now work with WHO for prequalification and COVAX for financing and distribution.
Opposing vaccine diplomacy is the refusal by the US Government to participate in COVAX, its withdrawal from WHO, and even a December 2020 “America First” executive order claiming “priority access” for COVID-19 vaccines. In addition, vaccine producers in Russia and China test or approve vaccines of uncertain quality, so far avoiding stringent regulatory authorities, yet negotiating bilateral agreements with Latin American, Asian, and African nations to sell vaccines or propose joint production. The term “vaccinationalism” describes this reversal in international cooperation. Still another opposing force includes a globalizing antivaccine movement, in some cases linked increasingly to political extremism. The Russian Government also aggressively pursues an international program of antivaccine disinformation.
Resolving differences, restoring vaccine diplomacy. The COVID-19 vaccine ecosystem is fragile, complex and shifting. After a rough beginning, things appear to be headed in a more positive direction. COVAX financing has improved and the mRNA vaccine manufacturers continue to work with COVAX despite complex vaccine manufacture, cost, and onerous freezer-chain requirements. However, much of the supply for LMIC vaccines in the near future may still rely on the major adenovirus vaccines from the multinational pharma companies or those from Russia and China, together with low-cost WIV and some recombinant protein vaccines produced in LMICs. The organizations making such traditional vaccines belong to a Developing Country Vaccine Manufacturers Network (DCVMN). The good news is that Russia and China continue to engage the WHO for possible prequalification, with the former recently launching a new joint development partnership with a UK and European-based multinational pharma company. A new US President has committed to rejoining the WHO, and possibly COVAX, with an expectation that the America First executive order will be terminated.
Concluding comments. With each major epidemic or pandemic, the global policymakers respond by installing new infrastructure and mechanisms to ensure a robust response emphasizing health security. However, the COVID-19 vaccine ecosystem still faces significant gaps, and lacks a well-financed system of research, development, or training and capacity building for new vaccines and their distribution. Given that COVID-19 represents this century’s third major coronavirus infection of pandemic potential, we must assume others will follow. There is an urgency to support the development of universal coronavirus vaccines or other pandemic threat vaccines, and improve access to cutting-edge vaccine technologies. There are also needs to strengthen national regulatory authorities not currently meeting stringency standards. To date, financing this enterprise still depends heavily on the US and European Governments in addition to the Gates Foundation, without full participation from the group of 20 (G20) nations. Finally, we must identify international mechanisms to counter dangerous anti-science extremism.
Peter Hotez MD PhD is Professor of Pediatrics and Molecular Virology & Microbiology, and Dean of the National School of Tropical Medicine at Baylor College of Medicine, where he is also Co-Director of the Texas Children’s Center for Vaccine Development. His forthcoming book is Preventing the Next Pandemic: Vaccine Diplomacy in a Time of Anti-Science (Johns Hopkins University Press)
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