Vaccine inequity: Countries fail at ‘global solidarity’

Sub-Saharan Africa has no shortage of public health challenges: as a region, it carries the highest burden of disease in the world and boasts some of the lowest allocations of public funding to deal with that burden.

So, when pandemics such as COVID-19 strike, they hit hard – some would argue with disproportionate force – at both social and economic levels. To make matters worse: when vaccines are needed, Africa finds itself at the back of a long international queue.

Tolerance of this deleterious situation is not infinite and it was significant that several speakers on Day 1 of the African Research Universities Alliance (ARUA) 2021 Biennial International Conference, ‘Global Health Challenges – Facing them in Africa’, raised the topic of inequity in health, and COVID-19 vaccine inequity in particular, with many calling for African researchers and scientists to ensure greater involvement in the development and manufacture of vaccines as one way to correct what can only be seen as a grievous global imbalance.

The three-day conference, held from 17-19 November, was co-hosted by the universities of Pretoria and the Witwatersrand.

Failures in solidarity

Keynote speaker Professor Salim Abdool Karim, a world renowned epidemiologist and infectious disease specialist who was the first chair of the South African Ministerial Advisory Committee on COVID-19 set up in early 2020 to advise the government on its pandemic response, set the tone when he drew attention to the failure of the world’s countries to appreciate the importance of “mutual interdependence” and “global solidarity” in dealing with the COVID-19 pandemic.

Referring to the COVAX initiative, an international initiative launched in April 2020 to facilitate equitable access to vaccines around the world, Abdool Karim said the initiative had failed to meet its delivery targets because too many rich countries were not willing to be part of an equitable solution.

“They wanted vaccines first and wanted the lion’s share,” he said. “By May of this year, over 50% of the world’s stocks of vaccines were being held by 15% of the world’s population.”

While millions of unused doses in the United States were expiring and being destroyed, Africa sat in 2021 with a 470 million vaccine shortfall – in part due to the fact that the pharmaceutical companies producing the vaccine prioritised the protection of their traditional markets, he said.

For example, the supply of Pfizer booster shots to Israel was prioritised above an existing order from South Africa for 20 million doses. (According to World Health Organization and World Bank figures, more than 43% of the Israeli population has received a (third) booster shot, while more than 98% of people in low-income African countries are yet to receive a single dose.)

For a medical scientist like Abdool Karim who spent more than three decades at the coalface of HIV/Aids research, during which time he witnessed first-hand the power of global solidarity – expressed in organisations such as Pepfar, the Global Fund and Unitaid – to change the trajectory of a pandemic for the better, the prevalence of COVID-19 vaccine nationalism and the failure of richer countries to recognise their mutual interdependence presents as particularly frustrating.

This is particularly so, given the success of vaccines – both COVID-19 vaccines and vaccines generally – in saving lives.

Anger and determination

In her own presentation, which discussed the lessons learned from vaccination programmes in Africa, Professor Helen Rees, executive director of the Wits Reproductive Health and HIV Institute of the University of the Witwatersrand, highlighted the importance of GAVI, the global vaccine alliance – another example of what is possible through global unity and cooperation and co-lead of the COVAX initiative – in helping the world’s poorest countries to roll out mass vaccination programmes for children against a range of preventable diseases.

Rees reminded her audience that vaccination is the most cost-effective health intervention currently available in the world, saving two to three million deaths annually.

Professor Barnabas Nawangwe, the vice-chancellor of Uganda’s Makerere University and ARUA board chair, echoed some of the frustration around the vaccine inequity highlighted by Abdool Karim when he told the conference he hoped the keynote address had made them angry: “… angry that we have not been able to do something, angry that we were basically abandoned to fate … and that anger should translate into something, into determination that we must change the situation on the continent”.

That determination finds expression in initiatives such as ARUA which is, itself, an embodiment of African academic solidarity, a fact that Abdool Karim recognised when he congratulated the alliance for “rising to the challenge of understanding that no one can deal with a pandemic – or any of the scientific challenges – by facing them alone”.

Formed in 2015, ARUA is a network of 16 leading African universities that seeks to build the quality of research in Africa by pooling the resources of its institutional members, thereby generating a critical mass to more effectively support the limited but growing number of African researchers.

Although solidarity forms a strong strategic component of the alliance, ARUA’s raison d’être is based on a recognition of the fundamental need for Africa to be a serious producer of research that contributes to global knowledge and can produce solutions for some of the region’s most pressing developmental challenges – what University of Pretoria Vice-Chancellor and conference co-host Professor Tawana Kupe described in his official welcome as “knowledge-driven solutions” that can be translated into policy domains.

As highlighted by Nawangwe, Africa is home to 15% of the world’s population but accounts for 2% of the world’s knowledge creation.

“And many believe that’s why we lag behind in development. Many people also believe Africa is the next growth region in the world. Many of our leaders including [former] President [Thabo] Mbeki said that this should be the millennium for Africa, but are we going to get there without research? Research and higher education are crucial if Africa is going to change the current situation.”

Building understanding

In reality, many African scientists and researchers found in COVID-19 the opportunity to make a global contribution to understanding the disease.

Professor John Gyapong of the University of Health and Allied Sciences, Ghana, said genomic sequencing of the SARS-Cov2 virus in Africa had been “done pretty well”, with Nigeria releasing the first sequence from Africa within three days of the first case being announced there.

Other countries followed, with genomes being deposited in the GISAID database, a global science initiative and primary source that provides open-access to genomic data of influenza viruses and SARS-CoV-2.

The data was critical in helping to understand the dynamics of the pandemic in Africa, showing the spread of the disease between countries in the region as well as the emergence and spread of key variants in Africa.

Gyapong said it was critical that African countries continue to make investment in sequencing capacity. This would assist, not only in identifying variants of interest and concern, but it would also help in the development of new responses and vaccines, he said.

Commenting on the evidence that vaccine nationalism was jeopardising equitable distribution of vaccines, Gyapong said it was time to view vaccine acquisition as a public good.

“We cannot continue on this [unequal] pathway if we really think vaccines are going to be the solution to the problem,” he said.

While it was encouraging that developing countries were increasingly demanding equal access, it was also important to examine the role of African science in vaccine development.

“How much investment have we made in development? Even if we have no capacity to develop vaccines, how have we participated in clinical trials?”

Gyapong said that, in his opinion, Africa needed to take a more proactive approach.

“We need to take centre stage and take a role as we have the capacity. Young scientists can do it with appropriate advocacy from politicians to get the necessary resources to support development programmes and participation in clinical trials,” he said.

University of Cape Town (UCT) economist Professor John Ataguba, who sketched some of the economic impacts of COVID-19 in Africa, pointed out that part of the problem around achieving vaccine equity was that only 1% of all vaccines used in Africa (including those used for COVID-19) are produced on the continent.

Africa currently has only about 10 established or planned vaccine manufacturing sites, while Nigeria and South Africa also have facilities for vaccine research and development – a situation which obviously did not fully exploit the continent’s capacity.

Emphasising the health and social impact of COVID-19 at multiple levels, Professor Linda-Gail Bekker, who is director of the Desmond Tutu HIV Centre at UCT, agreed that the “politics of pandemics” was being played out in the global COVID-19 vaccine distribution patterns, with G20 member countries having received 15 times more vaccine doses per capita than Sub-Saharan Africa.

“We truly are the slowest in the world when it comes to the roll-out of vaccines,” she said.

Reminding conference participants of the power of community activism and advocacy in mitigating the HIV/AIDS crisis in the early 2000s in South Africa, Bekker said global equity movements such as The People’s Vaccine were now stepping up to campaign for, among other things, a waiver of intellectual property rules to allow for a scale-up in the manufacturing of vaccines around the world.

Bekker said there was a great deal to gain from global solidarity, ranging from better health to lower global death tolls, quicker economic recovery, fewer supply chain interruptions, and, importantly, it would present a challenge to the perpetuation of global health inequalities.

Sharing some of the research done on the economic impacts of COVID-19 by the Africa Centre of Excellence for Inequality Research, an ARUA centre of excellence hosted by the University of Cape Town, Professor Robert Osei of the University of Ghana said it was important not to underestimate the effects of the pandemic on the global economy, negatively impacting growth and human development, increasing debt and exacerbating inequality and poverty.

Osei said the pandemic had crystallised the need for deliberate economic policy. Reminding participants of the ongoing health challenge posed by the pandemic, he said rebuilding would be “difficult” and would depend on how quickly the world was able to contain COVID-19.