Poverty makes innovation useless in a pandemic – COVID proves OR Capitalism makes their Internal links inevitable, only by doing away with capitalist inequality can we prevent pandemics

Announced within a year of the discovery of SARS-CoV-2, the news of several efficacious COVID-19 vaccines was met with great hope of some return to pre-COVID normality and set a new bar for the speed of knowledge generation and the production of life-saving vaccine technologies ([46]). However, the logistical and scientific challenges of developing an effective vaccine were not the end of the difficulties many would face in accessing a vaccine. As with previous novel technologies, inequities in vaccine access rapidly became a major obstacle, reminding the world of the divisions between the haves and the have-nots ([28]). This concern was captured by a comment from UN Secretary-General António Guterres at the UN General Assembly in July 2021: "We passed the science test. But we are getting an F in Ethics" ([61]).

Under enormous pressure, science delivered highly effective COVID-19 vaccines in record time. This unprecedented effort in science required global collaboration. For example, the first clinical trial to show that a COVID-19 vaccine was effective in preventing clinically evident infection was conducted by Pfizer-BioNTech—in the United States, Turkey, Germany, South Africa, Brazil, and Argentina ([46]).

Since private and government-owned pharmaceutical companies had developed and manufactured their own COVID-19 vaccines, each took responsibility for their sales and distribution. This meant that countries that could not afford vaccines or whose pharmaceutical markets were of little interest went to the bottom of a company's list of countries to prioritize. This problem was anticipated, and COVID-19 Vaccines Global Access (COVAX) was created jointly by the WHO, the Vaccine Alliance (GAVI), and the Coalition for Epidemic Preparedness Innovations (CEPI) to secure vaccines and distribute them to low-income countries ([57]). COVAX invited all countries to join it, in an attempt to distribute the first 20 percent of all vaccines equitably. However, most wealthy countries either bypassed COVAX or secured vaccines directly from pharmaceutical companies in addition to orders placed with COVAX. In response to the multiple demands for COVID-19 vaccines, pharma mostly prioritized their preferred markets. As a result, countries across the globe secured their first vaccine doses using these five approaches (for a timeline of approaches, see figure 1 below):

( ). Development of vaccines: countries that developed their own vaccines were vaccinating their citizens within about a month of the announcement of vaccine efficacy results. These included the United States, Germany, China, Russia, and the UK.

( ). Advanced market commitments: countries able to secure doses through advanced market commitments obtained doses next. These countries purchased vaccines before the outcomes of efficacy trials were known. They were willing to risk losing their money if the vaccines were not effective. These countries included Israel, Denmark, Canada, and Australia. Some countries bought vaccines from multiple companies far in advance of trial results; Canada secured more than nine doses for each citizen in this way.

( ). Vaccine diplomacy: next to receive vaccines were countries, like the United Arab Emirates, Turkey, Egypt, Morocco, and Chile, that secured doses through diplomatic initiatives, mostly with China and Russia. Some purchased doses before clinical trial results were finalized by issuing early local regulatory approvals. These diplomatic initiatives likely involved quid-pro-quo-type arrangements.

( ). Bilateral agreements with pharmaceutical companies: the majority of countries bought directly from companies via agreements, mostly secret, often involving collateral to ensure payment. The collateral could include valuable national assets and even offshore assets ([41]). Not all companies were willing to sell their vaccines to every country seeking to purchase them; for example, Moderna initially chose not to license or sell its COVID-19 mRNA vaccine in Africa. As a result, some countries had limited options, skewing the market in favor of companies willing to sell to less privileged countries.

( ). COVAX arrangements: Countries reliant on COVAX were most often at the back of the queue. Since many of these countries could not afford to purchase COVID-19 vaccines, they were entirely dependent on donations from COVAX.

Note that many countries used more than one of the five mechanisms over time after their first doses were secured.

Graph: Figure 1. Timeline for the five approaches used by countries to secure COVID-19 vaccines.

In February 2021 an analysis by the Economist showed that there were enough vaccine doses for all countries if rich countries were willing to share their doses ([17]). However, the bulk of the world's supply of vaccines was reserved for and administered to just 15 percent of its population, largely, but not solely, in the wealthiest countries.

Politics and panic affected the distribution of vaccines, diverting them from the neediest to favor those practicing vaccine nationalism. This involved buying more vaccines than necessary, striking deals with pharmaceutical companies that redirect doses away from equity groups such as COVAX, negotiating bilateral deals and queue-skipping by paying more and thus pushing prices higher, rushing local regulatory approval of vaccines despite inadequate data, and banning the export of vaccines by the manufacturing countries. This diversion of vaccines away from poor countries exacerbated global vaccine inequity.

Even though African countries participated in several vaccine trials undertaken by pharmaceutical companies that demonstrated the initial efficacy of their vaccines, these nations were not provided with early purchase orders or access to these vaccines after completion of clinical trials. For example, the initial clinical trial that demonstrated the efficacy of the Pfizer vaccine included participants from South Africa. Similarly, initial trials of the vaccines developed by Johnson & Johnson ([53]) and Oxford-AstraZeneca ([40]) included participants in South Africa. Despite this, equitable early access to COVID-19 vaccines was not available to South Africa.

While some African countries secured initial doses through diplomacy, most had to join the end of the queue for access to vaccines. Most depended on donations from COVAX. When they did purchase vaccines directly from pharmaceutical companies, in several instances African countries had to pay a higher price than wealthier countries. African countries received their doses months after they had been purchased and sometimes close to the expiration dates. Even today some vaccines tested in African countries, such as the Moderna vaccine that was studied in the SHERPA trial in South Africa ([54]), are not licensed or available in Africa to the people who helped demonstrate their efficacy.

~~~~~~~~

By September 2021 over 6.2 billion people had received at least one dose of a vaccine; the majority of these doses were distributed in industrialized countries, while African countries received less than 5 percent of the administered vaccine doses (Our World in Data 2022). This inequity has meant that three years into the COVID-19 pandemic, poor countries are lagging in vaccine coverage (figure 2).

Graph: Figure 2. COVID-19 vaccine doses administered per 100 people, October 1, 2022.

Vaccine inequity exists not only between countries but also within countries. For example, although New Zealand has one of the highest vaccine coverage rates in the world, its Māori and Pacific people have substantially lower vaccination coverage rates. In the United States differences in coverage between Whites, Blacks, and Hispanics are also stark, and concerted efforts are underway to bridge these gaps ([44]). Vaccine inequity is associated with wealth at not only the country level but also the individual level within countries.

The challenge of equitable access extended beyond the first vaccine doses (figure 3). Despite over a quarter of the world's population not receiving their first vaccines yet, countries like the United States started rolling out third doses as boosters ([65]). The rollout of boosters saw vaccine manufacturers redirect their supply back to wealthy countries while the need for first doses was dire in many poor countries.

Graph: Figure 3. Share of people vaccinated against COVID-19, November 20, 2022.

To compound the inequity in vaccine access, wealthy countries at times had more doses than they could use, leading to wastage ([35]). While shortages of vaccines were widespread in Africa, several countries that had secured early access faced this problem of wastage, mostly due to the short expiry date of vaccines. Some wealthy countries sought to donate their soon-to-expire doses. However, this created the problem of large numbers of doses being dumped in poor countries without the capacity to store, distribute, and vaccinate large numbers of people in a narrow window before expiry. Moreover, since vials can contain up to 10 doses, wastage occurs when there are not enough people to vaccinate from the opened vials, especially since vials brought to room temperature have to be used within a specified period. This second source of wastage has been more difficult to mitigate.

Even where there are bilateral and public-private agreements for the production of COVID-19 vaccines in Africa, African-manufactured doses are not finding their way into the arms of Africans. In 2021 the New York Times reported that 90 percent of Johnson & Johnson vaccine doses produced in South Africa were shipped to Europe, though South Africa could not access enough doses for its population ([49]). These actions by Johnson & Johnson were contrary to its preproduction commitments made to the South African government in its export permit applications. Such actions have sown distrust of the pharmaceutical industry among the public and governments.

Global solidarity efforts have been unable to address vaccine inequity due to nonparticipation by high-income countries or, in some instances, opposition from industry. In 2020 the WHO launched the COVID-19 Technology Access Pool, a voluntary effort to support the collaborative development of a COVID-19 vaccine ([68]). While several low- and middle-income countries joined the pool, almost no high-income countries did. Countries producing their own vaccines and major pharmaceutical companies were entirely absent from this collaborative initiative.

In October 2020 South Africa and India submitted a joint application to waive intellectual property protections for health technologies related to COVID-19 ([72]). Though the waiver was widely supported and drew many cosponsors, high-income countries with access to vaccines such as the UK, Norway, and Canada opposed the waiver ([73]). After extensive delays, a watered-down version was passed in mid-2022. It did very little to address the challenges of vaccine inequity, being substantially weaker than the initial South African proposal. The final waiver relied on the use of existing emergency provisions in the TRIPS waiver, and countries producing their own vaccines were asked not to use the waiver ([25]).

There have been instances of success in equitable access, such as the COVAX mechanism that delivered doses to low-income countries, albeit with delays. COVAX was established specifically to address global equity in COVID-19 vaccine distribution, with modest success: it had distributed over 1.8 billion vaccine doses by November 2022 ([62]). It was constrained by its delay in negotiating with pharma, its budget, and its insufficient leverage.