When the swine flu pandemic struck in 2009, some of the world’s richest countries scrambled to get their hands on vaccines however they could. Poorer countries — among the worst affected — were pushed to the back of the queue, as western nations signed deals with drugmakers to guarantee access to vaccines.
Australia even stopped a domestic drugmaker from exporting doses to the US until it had immunised its entire population, while the Obama administration delayed a promise to donate vaccines to poorer countries in order to prioritise distribution in the US.
Swine flu resulted in about 18,000 confirmed deaths but one study estimates as many as 575,000 people worldwide could have died from it, including a “disproportionate” number in Africa and south-east Asia.
For many global health experts, swine flu acts as a warning for the far more serious coronavirus crisis, which has already killed more than 290,000 people and brought economies around the world to a standstill. They fear that the current pandemic could lead to a geopolitical fight over vaccines that would exceed the failings over swine flu.
A mixture of the intense and growing rivalry between the US and China, and the related rise of nationalism and decline in multilateralism — exemplified by the Trump administration threatening to withdraw US funding from the World Health Organization — is making students of pandemics anxious.
“There are things that make it more problematic than in the past. It will magnify the political and economic cleavages that have been hidden from sight,” says Stuart Blume, emeritus professor of science and technology at the University of Amsterdam. “We are in an extremely poor state to confront a global challenge.”
The hunt for a vaccine — which many experts believe is at least 12 to 18 months away — is central to global efforts to restart economies. But, like swine flu, it raises big questions about whether countries will act in their narrow self-interest or embrace a more collaborative, global approach. More than 100 potential vaccines are in the testing phase and an enormous effort costing tens of billions of dollars and using complex logistics will be needed to manufacture and distribute the successful drugs worldwide.
European countries and the WHO are trying to keep the multilateral option alive with a series of fundraising summits. But the US and China have been reluctant to commit, instead drafting in their militaries as well as pharmaceutical and biotech groups for what some see as a tussle for national bragging rights.
“The race to develop a vaccine is like the US and Soviet Union competing in the space race,” says Brad Loncar, founder of Loncar Investments, a US fund manager which runs a China-focused biotech fund, “it’s like a cold war”.
Race to be first
Beijing and Washington are pouring huge resources into trying to be the first to develop a vaccine, and to do so in record time. US President Donald Trump has launched Operation Warp Speed, a public-private partnership that aims to make hundreds of millions of doses available in the US by the end of the year, according to one government scientist involved in the project.
Scott Gottlieb, who was the first head of the Food and Drug Administration under Mr Trump, says swine flu showed how the “utopian view” that countries could give a vaccine away before satisfying their local needs was unrealistic. “It’s important that America has a vaccine available from an American manufacturer because what history has shown us is that in the setting of public health crises, countries nationalised their products,” he adds.
In China, the race is no less intense. Four of the eight candidate vaccines currently in clinical evaluation, according to the WHO, come from China. Another pair are from the US, while the others are a collaboration between Germany’s BioNTech, China’s Fosun Pharma and Pfizer of the US, and another between the University of Oxford and AstraZeneca.
“Chinese officials view this not only as a matter of national pride and important for their own health, but also as a way to demonstrate superiority,” says Mr Loncar. One of his funds has invested in Cansino Biologics, the first Chinese biotech company to start studying its experimental vaccine in “phase two” human trials under a partnership with a branch of the People’s Liberation Army.
Weidong Yin, chief executive of Sinovac, another Chinese company with a potential vaccine undergoing tests, has said it could complete phase two trials and go to production by July, according to local media. Mr Loncar adds: “Let’s suppose China succeeds four months before the US. The implication of that is it helps them get their economy fully more open than the US and other areas. Also, think of it in the context of the US [presidential] election in November. Imagine the headline, ‘Chinese People are Getting Vaccinated,’ and we don’t have it yet.”
Dr Gottlieb says that while China may be the first to get “shots in the arm” it does not seem to be “focused on getting the best vaccine”. Instead, he argues that multiple vaccines from different manufacturers worldwide will be needed. “If we have multiple manufacturers being successful, this is going to be less of a challenge. The hard situation is going to be if you only have one or two manufacturers that make it over the finish line.”
Many global health experts agree that it is short-sighted to place too much focus on being first. “The US and China should be worried because at least one of them will not get there first. It’s a truly global issue. The scale of manufacturing is global — you’re going to run out of glass vials, API [active pharmaceutical ingredients], there aren’t enough facilities in a single country [to do this],” says Kalipso Chalkidou, director of global health at the Center for Global Development, a think-tank. “You need to build the plane as you’re flying it.”
The early days of the Covid-19 pandemic have left many experts fearful for what will happen when distribution of a vaccine starts. There have already been skirmishes over personal protective equipment such as gowns and masks. German politicians accused the US of “modern piracy” when masks produced by 3M and destined for Berlin’s police force were diverted to America. Within the EU, there have been problems such as France seizing millions of masks belonging to a Swedish healthcare company, sparking furious protests.
The case of CureVac, a German biopharma company developing a potential vaccine against Covid-19, caused even greater alarm. German media reported that the US government had offered to buy CureVac after its chief executive Daniel Menichella met Mr Trump at the White House in March. This sparked fury in Berlin, with economy minister Peter Altmaier insisting: “Germany is not for sale.” The company’s management denied that there had been an approach from the Trump administration, but CureVac’s majority owner Dietmar Hopp refused to deny it and Mr Menichella has now left the company.
“It goes without saying that a German company should not be developing a vaccine for exclusive use in the US,” Mr Hopp said.
Mr Blume argues that one of the most worrying trends in recent decades has been “the securitisation of global health”, making it as much about national security and international diplomacy as health. He adds that China could use any vaccine as a way of “announcing their international prestige” by giving it to African and Latin American countries.
“We all know that we will rely on international co-operation to get the logistics of a vaccine to work,” says one senior European official. “China will be crucial, the US will be crucial. If we don’t have their support, then what?”
Self interest vs global interest
Others are trying to back a multilateral approach. The European Commission led a donor conference last month that raised €7.4bn for the development and distribution of vaccines and treatments against coronavirus, including the aim of equitable access for poorer countries.
But the US, Russia, India, Brazil and Argentina stayed away from the meeting, while China sent its EU ambassador rather than a head of state or government like other countries. “Maybe naively we had a hope that China and the US could put aside their differences on trade. But it’s not getting better,” says the European official.
Much of the €7.4bn would be funnelled through a number of international initiatives that have been set up in recent years to ease past problems with vaccines. The Global Alliance for Vaccines and Immunisation (Gavi) was founded 20 years ago by the Bill & Melinda Gates Foundation and others to help the rollout of vaccines globally, particularly in the poorest countries.
A separate multilateral summit in London in June is aiming to raise at least $7.4bn to develop various vaccines, including against coronavirus. Another initiative — the Coalition for Epidemic Preparedness Innovations (Cepi), set up in 2017 to help finance vaccines against infectious diseases — is aiming to raise $2bn to find at least three viable Covid-19 candidates.
But even in the UK, the government has rushed to secure supplies of viable vaccines ahead of time by relying on domestic pharmaceutical companies. “The upside of being the first country in the world to develop a successful vaccine is so huge that I am throwing everything at it,” Matt Hancock, the UK health secretary, said in April as he unveiled £42.5m in financial support for two homegrown efforts. British-based drugmaker AstraZeneca signed a deal with the University of Oxford to manufacture up to 100m doses by the end of 2020, prioritising supply in the UK.
Experts applaud the various initiatives, but many argue they are unlikely to be sufficient for coronavirus.
“There is no global authority that has the money and the influence to direct what the private sector — the pharmaceutical industry — will do. You can have as many sentiments of altruism but the question is how you translate that into reality,” says David Salisbury, associate fellow at the global health programme at think-tank Chatham House and a former chair of the WHO committee on global immunisation.
Paul Hudson, chief executive of French drugmaker Sanofi which is working on two potential vaccines including one with GlaxoSmithKline of the UK, has said the US might receive first access to the drugs because it bankrolled their early development.
The WHO itself has been severely weakened by Mr Trump’s threat to stop $400m in annual US funding for the UN body. Mr Blume calls it “one of the great losses in global health”, adding: “What we have lost is a forum that had sufficient moral authority that countries felt bound by what was decided there.”
One veteran of several global health crises says: “The leadership vacuum left by the US is incredibly palpable. Nobody expected this level of disengagement. It’s stunning and scary. It leaves a huge question of who steps in now.”
Fairer distribution system
Many global health advocates are worried because there is no formal system over how to hand out vaccines and in what order. That is crucial because there is unlikely to be enough doses to meet global demand for a long time, perhaps years.
“There is a fear that this will be more readily available to richer countries, and furthermore to rich people and communities in those countries. You’ve seen it play out already with PPE,” says Loyce Pace, executive director of the Global Health Council, a non-profit organisation. Cepi has tried to ease those concerns by stressing the need for equitable access for poorer countries when it finances potential vaccines, but many experts are sceptical that this will be enough to trump national self-interest.
“Will America invoke legislation and prevent vaccines manufactured in the states leaving the US? Will European producers prioritise European countries?” asks Mr Salisbury.
Gavi is leading the push for a fairer, global distribution. Its chief executive Seth Berkley argued in April that the first priority for a coronavirus vaccine should be given to health workers, then countries with out-of-control outbreaks, then the elderly and those with underlying risk factors, before finally the rest of the population.
Some hope that even the most nationalist politician will conclude that in an interconnected world it is counter-productive to focus only on their own citizens. Gayle Smith, a former Obama and Clinton administration official who is now chief executive of the One Campaign against poverty, says: “There’s a natural tendency for every national leader to think: ‘Oh my God, I have to get all the vaccines possible for my country.’ But to overcome that, they need to think that to succeed you can’t have the virus running rampant in other countries. A fragmented approach will take us longer to come out of this pandemic.”
Assuming one or more vaccines are found, experts say there are broadly two possible outcomes: the world rediscovers multilateralism and works together, or there is a more piecemeal approach where every country is forced to fend for itself. There are plenty of unknowns: many privately speculate that a change of president in the US could lead the country to alter its position. “This would look a lot different under a President Biden, I think,” says one European official, referring to Democratic hopeful Joe Biden.
Ms Smith, who was involved in the US response to both swine flu and the 2014 Ebola outbreak, says: “It’s a very bad time for multilateralism to be under siege. But it’s the most dramatic example of why multilateralism is absolutely essential. A global plan without some of the main powers is not a global plan.”
Additional reporting by Donato Paolo Mancini in London, Joe Miller in Frankfurt and Xueqiao Wang in Shanghai
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