This interview kicks off Pandemic Discourses new series “Politics of Vaccine Equity: Conversations on the Frontline.” This series will feature conversations from the frontline – interviews with advocates for access to life saving medicines and innovation to hear their perspectives on the politics of the struggle for increasing availability to medicines. We start this week with a conversation with Mohga Kamal-Yanni, a public health expert and activist from Egypt who resides in Oxford. This interview was originally published in Pandemic Discourses.
Fukuda-Parr: Thank you for agreeing to this interview with Pandemic Discourses. You have been on the frontlines of the battle to expand access to medicines, diagnostics, vaccines for many years, or rather decades. We want to hear your thoughts on the Politics of Vaccine Equity.
To start off with, what is the difference in the politics of COVID-19 compared with that of 20 years ago, when there was a massive mobilization for access to antiretroviral medication to treat HIV? What do you think has changed? How have the politics changed?
Kamal-Yanni: Well, some of the fundamental politics, unfortunately, are still the same. There have been some adaptations over time, and there are differences between the two viruses. The key issue is lack of access in developing countries. And basically, rich countries are focused on sorting out their own problems individually, and when they start caring about the others, it’s charity. It’s not equity, it’s charity.
That happened with HIV. And that’s happening now with the COVID-19 vaccine. So fundamentally, in both situations governments are content to leave decisions in the hands of pharmaceutical companies. This, for me, is the key policy approach that has not changed, and I don’t know when it will change. So if you look at the HIV/AIDS 20 years ago, the medicines were highly priced in the North – $10,000 a year – and totally unaffordable in developing countries, and governments in the North and South both accepted it with the mindset, “well, it’s highly priced. Sorry, guys.” They accepted the companies’ mantra of charging high prices to cover the costs of R & D. And it could have stayed that way for god only knows how long except when Dr. Hamied, the CEO of Cipla (pharmaceutical company) from India said, I’m going to sell it at price for $1 a day. So that really changed history. And to be honest, if the world were fair, Dr. Hamied and Jamie Love would share a Nobel Prize. They are more deserving than many of the people who got the Peace Prize.
The problem at that time was that Pharma was in control and the central issue was the price. With COVID-19 vaccines, Pharma is still in control, but the problem is not price but supply. Shortage of supply is the big elephant in the room that nobody wants to sort out. It is a simple fact that not one, two, or even five companies can produce enough for the whole world. And everybody says, “Oh, this is a problem we never faced before.” True. We never have had to produce 10 billion vaccine doses. But how do you reach this 10 billion? Governments think, “Oh, by relying on the same companies to expand supply.” No, you’re absolutely not going to produce enough vaccines that way. So fundamentally governments are leaving vital decisions about how many doses are produced and where they go in the hands of Pharma. In the old days, they were scared that Pharma would move its headquarter or its operation out of the country. This time the main fear is that the companies will not prioritize their country for the doses.
Fukuda-Parr: So the fear is because the governments are all beholden to the pharmaceutical companies for when they will actually get the supply? Countries have pre-purchased, but when that supply is delivered, is in a sense at the whim of the pharmaceutical companies?
Kamal-Yanni: Exactly! So let’s just take an example; let’s say AstraZeneca has contracts with the EU, and contracts with the UK. Now, if a specific agreement is 100 million for the UK and 300 million for the EU, they’re not going to be able to produce 400 million tomorrow, are they? No, they will produce far less. It’s up to AstraZeneca to decide how many of these doses will go to Europe and how many will go to the UK. There is a battle over who gets the vaccines and the EU is not even getting the vaccines that are produced in Belgium. The UK is getting the AstraZeneca vaccines produced at Serum Institute in India, which were meant to be for developing countries.
Fukuda-Parr: That is totally outrageous.
Kamal-Yanni: This bit is driving me nuts. I tell you, I enjoy listening to the news in the morning. And when I heard this news, I jumped out of bed and I wanted to break something because I was so angry.
Fukuda-Parr: If Western governments are dependent on the pharmaceutical companies, how do you see the advent of vaccines from Russia, China and India shifting these dynamics? Have they broken the monopoly of the Western pharmaceutical companies?
Kamal-Yanni: Not yet. One reason is data. The data on the Russian vaccine has been published in The Lancet but there is no public data on the Chinese vaccines. So it makes it very difficult to advocate for Chinese vaccines. The other issue is the WHO emergency authorization. This is really a sticking point. Why haven’t they been authorized until now – I can’t wait for the end of the month because that is when the WHO is expected to make a decision on what vaccines have emergency authorization. If they say Sinopharm, or Sinovac, or preferably both are good vaccines then the negotiation can begin. COVAX would be obliged to buy these vaccines. If they don’t, I think civil society would make a fuss. That would begin to weaken the monopoly. Another thing eating away the pharmaceutical companies’ monopoly is the countries – especially in Latin America – making agreements with companies in China, Russia, and India.
COVAX is another piece of the story. They made a big deal of their first delivery to Ghana but that was only enough for 2% of the population and nowhere near the 20% which is the COVAX target. There’s no plan for how to reach 20% percent. Or to reach the other countries that they haven’t delivered to, let alone the second dose. COVAX so far is totally dependent on AstraZeneca, the Serum Institute, and a little bit on a South Korean company. They are facing a severe constraint. But they never talk about this. The only problem you hear from COVAX is lack of money.
Fukuda-Parr: One of the things that I have heard you say is that the current situation was all predictable. Could say something about the way that COVAX was negotiated and why this has left such a supply gap?
Kamal-Yanni: Anybody who has a little bit of brain would say, “how do we vaccinate the whole world?” Nobody talks about that; the British Prime Minister asks “how do I vaccinate the British people” as do all other leaders. Especially the wealthy countries that have hoarded a huge portion of doses… they ask companies how much they can produce for themselves, not for the whole world. You could have predicted the shortage – and now they are surprised. Hello where were you a year ago?
Fukuda-Parr: The People’s Vaccine Alliance, to which you serve as an advisor, has always argued to take on the challenge of mass manufacturing in order to scale production necessary to meet the needs of the entire world. And that means sharing of technology, this is the other big elephant in the room that is hiding in plain sight.
Could I switch to a slightly different topic? What is the way forward? As you describe it, governments are thinking about their own national interests. The decision making about production and allocation is in the hands of the pharmaceutical companies. And then you get trapped, because national governments are beholden to the pharmaceutical companies to serve their own populations. So what can break this vicious circle?
Kamal-Yanni: Maybe vaccines from China and India, and Russia will actually erode the Western companies’ monopoly. Although it may take a long time before any western country will actually take a Chinese, Russian or an Indian vaccine, especially with public opinion being what it is. Nonetheless, when they see the rest of the world being served by companies from these three countries – Chile has something like 60% of their population vaccinated with Chinese and Russian vaccines – opinion might change.
But to be honest, I think what would change the political dynamics and what will start to make countries talk about the rest of the world is the nature of the virus itself. I think they’re afraid of mutations. Pharma is saying that we can tweak the vaccines. But the more variants we have now, like this latest Brazilian one, the more fear there will be. So they will start thinking, maybe we need to vaccinate the rest of the world and start doing that.
The third thing is that the European regulators are looking at Sputnik. You can imagine if Europeans approve it, it will be very odd if WHO doesn’t approve it. Hungary is already using it. So again, this will bring a gradual erosion of the monopoly, erosion at the edge of the EU.
So once Sputnik is approved, the EU will buy it and that is a huge market. The problem then would be scaling up production. So Russia will have to make deals – like AstraZeneca did with the Serum Institute – with several companies in India, Indonesia, Korea, and perhaps Brazil to scale up production. Then you will be able to compete with the others. Without sharing technology with other companies, the Russian factories may not have enough production capacity to compete and actually export millions. But at least if they get approval, that would be a huge step, because we can guarantee that Europe will just take every single vaccine that is produced.
But ramping up production isn’t easy; we’re talking about technology transfer. Access to technology doesn’t mean that you will suddenly have all your production lines working. And just remember that for Merck to produce the Johnson and Johnson vaccine, the U.S. government funded something like $150 million. Although there is a lot of talk about technology transfer, it is still about keeping monopoly on technology in the hands of Big Pharma so that they can control what technology can be transferred. This is evidenced by the fact that not one single company joined the WHO COVID-19 Technology Access Pool (C-TAP) which acts as one stop shop to facilitate technology transfer and license intellectual property. Even multilateral bodies like COVAX which will clearly benefit from increased supply, at best ignore C-TAP! What is needed is enabling all capable companies to access technology, not worry about intellectual property and have the money needed to modify their production lines to use this technology.
Mohga Kamal-Yanni is a senior health advisor with forty years of experience on access to medicines and healthcare. She has done extensive work with international organizations including WHO, The Global Fund, Medicine Patent Portal, and the World Bank. Since 2020, Kamal-Yanni has been a senior policy and technical advisor to UNAIDS and the People’s Vaccine Alliance on access to COVID-19 health technology.