Understanding why we have got to the place where access to life-saving vaccines is out of reach to billions of people bears some scrutiny. But perhaps it would be relevant to start with some comments on the role that vaccines have played in bolstering public health systems.

The echo of denialism around their importance is prevalent across society, infecting even some in the government and, judging by the recent comments by Professor Barry Schoub in the Daily Maverick, some members of the Ministerial Advisory Committee (MAC) too. Prof Schoub says vaccines “are not a silver bullet”. Nobody is arguing that they are. But herd protection rather than herd immunity for the global population is not only possible, but particularly urgent given the emergence of new variant strains that are significantly more transmissible.

Whether the South African strain creates more severe disease is still to be determined by our scientists. What we do know is that before the advent of the new variant it was estimated by studies cited by Oxfam that equal access globally to Covid vaccines can save 50% of all anticipated deaths.

We are facing a global threat in the league of the climate crisis, if you like, an early warning system of ecological breakdown. And like with the climate crisis, only solutions that are global can provide the protection needed to save lives. This requires a high degree of international burden sharing, solidarity and cooperation.

This, I believe, is the emerging consensus by leading public health officials around the world. Herd protection without a wide vaccination rollout in South Africa would only be possible if we closed all our borders for the next few years. This is not an option for many reasons, not least the utter lack of humanity involved in shutting out people from bordering nations who are also victims to unequal access to drugs and treatment.

In this sense, I would argue we need a regional plan that puts vaccine acquisition and rollout front and centre and brings all those to the table who have the experience and expertise to make this happen, within the shortest possible time frame.

 The argument for vaccines

Vaccines of one form or another emerged early on in the development of natural sciences. Only in one instance has a vaccine completely eradicated a disease, smallpox, which claimed hundreds of millions of lives. That said, they have largely controlled many other diseases worldwide: rubella (German measles), polio, hepatitis A and B, influenza. The list is long and the reach of vaccine technology has been global.

Vaccine research and development began to take off in the late 1800s and early 1900s, with major outbreaks of disease wrought by squalid housing conditions in the advent of industrialisation. It then leapfrogged further in the post World War 1 period, in the wake of the devastation of the 1918 Spanish Flu. In the post World War 2 period, the charge was led primarily by the United States, followed closely by northern Europe. Nation states with the capacity had manufactured vaccines for diseases that presented a global health threat and did so in cooperation with one another.

But by the 1980s things began to change. Neo-liberalism saw the outsourcing of such vaccine research, development and production to big pharmaceutical companies, whose massive profit levels resulted in perhaps the strongest political lobbying power worldwide, a lobby designed primarily to protect and enhance their huge profits through the patents they registered. The 1995 World Trade Organisation (WTO) Treaty on Trade-Related Aspects of Intellectual Property (known as the TRIPs agreement), is one outcome of this lobby. As a member of the WTO, South Africa is bound by this agreement. However, a proposal made by South Africa that, in the context of the Covid crisis, countries be allowed a waiver from certain aspects of TRIPS can be found here.

Consequently, one and half million people die annually because of lack of access to vaccines, while tens of millions of children still do not have access to immunisation. Market failure in vaccines is borne out by the fact that, as recently as 2017, low- to middle-income countries (LMICs) accounted for 79% of the global market vaccine sales volume, and yet only 20% of the actual total value. Effectively, despite the level of need, poor people simply do not present a profitable enough market to drive the investment and production required. The reasons may seem obvious given the high price demanded for many vaccines, but it is not.

Social historian Prof Mike Davis has shown that big pharma largely only enters into vaccines and therapeutic treatment research and development (R&D) for diseases that are either more prevalent in richer countries, and/or require repeat treatment. These medicines are often very expensive and limited to those with private healthcare, or to those public sector hospitals where nation states can afford the stock.

Davis concludes that big pharma, in this context, has acted to put the brakes on the revolutionary bio-medical technological advances within society’s reach. Into the breach have stepped the universities, the National Health Institutes and US Centres for Disease Control (CDC). These have pioneered medical R&D, perhaps most prominently within the US.

Yet while biomedical R&D at universities has been partially funded by medical corporations, this is not the case for research capacity within the state.

State funding for medical research around infectious disease has been eroded drastically over the past decades, and in terms of pandemic preparedness programmes in the US, have been sliced to the bone by Donald Trump. It’s time to jettison the rhetoric on incentivising innovation when it comes to medicine. Big pharma has largely been relegated to the supply and distribution of vaccines and treatments required globally. According to Davis, in an interview I conducted, much intellectual property (IP) developed for tropical disease, for instance, has been developed on the back of public investment. This tendency is nowhere more clear than the Covid-19 vaccines which have seen all the major candidate vaccines that have been approved, de-risked almost entirely by the initial massive investment by the American and European taxpayer.

Public-private partnerships and philanthropy, while they have proven critically important in the battle against HIV, are wholly insufficient to contain global pandemics such as Covid-19. That is not to say that we don’t require everyone to roll out plans that have the ability to succeed. This is particularly important in a context such as ours, where the state lacks capacity and displays pride and arrogance. What we need is humility and an admission that our political leaders do not have the capacity to deal with this crisis.

Genuine participation by all those who have something to offer must be built into our state-led response immediately.

 The public cost of patents

By the end of 2020, the confirmed global Covid-19 death toll sat at more than 1.8 million people; while most speculate that sadly, the real number sits far higher. Fortunately, given our robust reporting system in South Africa, we have no such need to speculate. For example, SA’s Medical Research Council (MRC) meticulously records all deaths and therefore is able to quantify excess deaths in the time of Covid; many countries, including other members such as BRICS, do not have systems comparative to our own.

South Africa’s own death toll, from 6 May to 8 December 2020, is estimated to have stood at 60,000 when one takes into account excess deaths. The emergence of the new variant that is far more transmissible will undoubtedly continue to overwhelm our health service. My own estimate, given the combination of higher infection rates and a collapsing healthcare service, unless we institute a massive vaccine programme, deaths in 2021 could double, possibly treble, the death toll we have experienced in 2020. This is based on the assumption that we do not get a vaccine rollout that covers at least 50% of the population by June or July this year.

This grim situation could very well get worse if our healthcare workers and the most vulnerable persons do not receive any protection in the coming weeks — or certainly within the first quarter of this year. Phase 1 of the government plan to roll out vaccines, designed to protect healthcare workers, seems possible and likely to happen if the government responds with urgency and vigour. Yet, even this limited rollout will require the involvement of all those with the expertise, direct interest and goodwill to shape the plan, so we can ensure that the state-led rollout with the huge logistics involved happens as efficiently and rapidly as possible.

The major and more difficult task of protecting essential workers, those over 60, the millions with co-morbidities, demanding tens of millions of doses, is physically near impossible to meet within the current constraints.

It is simply out of reach for most of the world at present.

 Civil society mobilises — again

The Treatment Action Campaign (TAC), SECTION27 and others, several years ago launched a coalition to pressure the SA government to Fix the Patent Laws. Success would insure that we would not have to undergo a replay of the long and bitter campaign to get access to anti-retroviral medicines for HIV that saw hundreds of thousands of lives unnecessarily lost in the 1990s and 2000s. The ultimate argument of the campaign is that South Africa needs to adjust its patent laws to the South African Constitution, which provides “everyone with the right of access to healthcare services”.

The logical force of the Fix the Patent Laws campaign has undoubtedly helped to inform South Africa’s joint motion with India that calls for a waiver on the TRIPS agreement to the WTO. In short, this would allow for the sharing of intellectual property around Covid-19 vaccines. The motion has the support of 140 countries, but is being opposed by a club of nations that continue to rule the world and are accompanied by allies such as Brazil’s president Jair Bolsonaro.

Resolution seems unlikely.

At present, all that’s been brought to the table from AstraZeneca for Brazil and India are preferential price deals for the manufacture of vaccines. In similar such deal, Pfizer’s CEO has also apparently (some months ago), offered discounted prices to South Africa. According to some reports, CureVac, another front runner in vaccine production, is exploring a deal with South African-born and raised Elon Musk to establish mini-factories around the world to produce their vaccine according to vaxmap.org.

There is a need to meet global demand in a rational and equitable rollout in early 2021. To do so requires nothing less than manufacturing and supply to be massively expanded to all those countries that have the capacity to undertake such a task.

South Africa, unfortunately, does not have the capacity to manufacture Covid vaccines, despite a public-private partnership established for this purpose over 20 years ago, a story in its own right. Covid will linger for years to come and therefore it would be expedient for us to develop this wasted capacity rapidly.

Resolution of the supply question that is being battled out at the WTO in terms of the TRIPS waiver will need to be rapidly assessed. Countries like ours have the legal (and moral) right, as embedded in our Constitution and past judgments of our Constitutional Court around access to medicines, to protect the right to health and life itself. It will become clear in the next few days and weeks whether this requires our country to issue compulsory government licenses to force the sharing of IP.

In recent interviews, I was informed that a deal with Johnson & Johnson is still on the table and being negotiated. Their application has been lodged with SAHPRA and phase 2 final results have been submitted for consideration, but final local regulatory approval may very well take another month or so. If this is so, then there may be some hope on the near horizon.

We have to start planning for this contingency. A rollout plan that involves key players from across civil society, including distribution logistics from the private sector, needs to begin as of yesterday. It will need to be stress-tested and bulletproofed if we are to stand any chance of finishing all three phases of the planned rollout of vaccinations by 2021.

It would be a grave mistake for this rollout to sit within one department given the enormity of the task and rather poor track record to date.

We cannot leave this fight for access and genuine participation in the vaccine rollout to the health NGOs, social justice organisations and the likes of Oxfam or MSF alone. All our trade unions, democratically run civic organisations, churches and political parties have a huge responsibility to stand up now and be counted at this moment of need for our country and indeed the majority of the world’s population. In such a battle, local and international solidarity will be key to any victory.

An extraordinary effort is required on all moral and political fronts, by the South African government working hand in hand with its citizens. Our efforts to ensure IP is shared will require the active solidarity and support of many millions around the world if we are to achieve some degree of success in 2021.

But first, we need to get the government and others to actively support the call for vaccines to be seen as a public good — outside of the polite setting of the World Trade Organisation — and this requires nothing less than significant pressure from those quarters of our society that have organised constituencies. Efforts are under way, but there is a long way to go. DM/MC

Rehad Desai

This article is informed by and grateful to the following scientists who have been interviewed for my forthcoming documentary, The Time of Pandemics: Mike Davis, Dr Larry Corey of HVTN, Dr Tony Fauci of NIAID, US; Prof Glenda Gray, Dr Aslam Dasoo, Prof Shabir Madhi.

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