This interview is part of Pandemic Discourses series “Politics of Vaccine Equity: Conversations on the Frontline.” Achal Prabhala, coordinator for the AcesssIBSA project which campaigns for access to medicines and vaccines, discusses the politics and shifting geographies of COVID-19 vaccine access. This interview was originally published in Pandemic Discourses.
Alliances for Policy Change
Fukuda-Parr: Thank you for participating in ‘Conversations on the Frontline,’ our interview series with activists on the politics of vaccine equity. I’d like to start by asking you about AcccessIBSA. In a field that is dominated by civil society groups in Europe and the US, this is a particularly important initiative that brings together activists from India, South Africa and Brazil. Moreover, the group is engaged in cutting edge policy research. What motivated you to launch AccessIBSA?
Prabhala: I had been working in South Africa for about seventeen years and in Brazil for ten years. I had built up a network of people who were working on similar issues… from lawyers, to academics, to activists. And I found – like many other people – that there were striking similarities in many countries we were working in. They are all multi-ethnic liberal democracies where some degree of freedom and progress was possible. I found there has been a great deal of cooperation among not only the governments but among activists. In terms of access to medicines each one of these countries had done something very well that the others could learn and replicate. They had also done a few things badly which could serve as learning opportunities for the other countries. On a personal level, it helped me because if I felt down about something not going well in one country, success seemed possible somewhere else.
Fukuda-Parr: Was your initiative to promote alliances for policy change?
Prabhala: Very much so. We produce original academic research in areas which we feel are missing. So let’s say there are policies that we want and which make intuitive sense. We try to build better arguments, put together better data, or just do better analysis. And then we make sure that all those arguments are made public. Then in cases where governments are willing to listen to us, we begin to work with them. But one important thing is sometimes you can get sucked into this trap of being a sort of confidential government advisor, where you are providing advice, but none of that advice is public. And I think that if we had to solely rely on that mode of work that it would be a mistake. We’re not carrying other people with us.
Fukuda-Parr: Can you give an example where working AcesssIBSA countries have been particularly effective in sharing research, or persuading governments to rethink their policies?
Prabhala: I can provide a few examples. In Brazil, in 2011, there was an effort to create a new patent law, which got about 75% of the way and then got bogged down. At the time, there were two countries – India and to a lesser extent Argentina – which had anything to offer in terms of a new direction that would create better access to medicines. And so it mattered very much that I was from India, and that I was familiar with what had happened there. That worked very well in terms of not just taking what we had done, but improving upon it, and actually creating a better version of what Indian patent law was. We were able to provide similar input broadly to South Africa which is undergoing its own patent reform process.
Another was in India. We created a set of reports that were both complementary and critical of the way the Indian government had handled its own patent law. We had a really good law but the implementation was poor. We put out a comprehensive analysis and that got a lot of publicity. Then I met with the head of the patent office. Fifteen years ago, the conversation would have been “Okay, we’ll take action, we’ll address this, but the US and the EU are going to be very, very angry. And what do we do about that?” But when we met in 2017, he said… “Look, I’m embarrassed that this is my department making these mistakes. But I’m excited because the people I’m spending the most time with are the Russians and the Chinese who are here to learn as much as they can about Indian patent law.” I think that’s the effect of the BRICS process. I don’t quite know how BRICS works in other domains, but often when I needed a meeting with an Indian patent officer, I could catch them in Pretoria, and work sometimes more easily with them there than in Delhi because they were more available.
The Politics of Knowledge Production: New Players in the Global South
Fukuda-Parr: This is really interesting and shows why what information gets to policy makers makes a key difference. Can we explore the politics of knowledge? Where do you draw your information from and how has that changed? How do you see the alliances amongst scientists, activists, academic researchers, and lawyers in this field? And has this shifted?
Prabhala: This is the most profound change that I’ve experienced. Previously you would look for knowledge around western medical products in western journals. Now, I think the net is being cast far wider. Actually, for the first time, I fully understand the limitations of a narrow knowledge universe, which relies on a narrow set of things that you believe are good and true and new, like only relying on Western medicine, data, and information. Let me explain what I mean by that.
So that’s what’s really changed. Middle income countries now have a very high level of infrastructure, and ability, for evaluating drugs and vaccines. And this includes Turkey, Brazil, Indonesia, Malaysia, some of the countries in the Middle East, and many others in Latin America. What they have done is to show that they are fully capable of regulating themselves and deciding what’s best for them, getting what best they can in terms of vaccines. And they do that in a manner that is far more publicly engaging.
I think this is the first time that I have been in a situation where we’re fighting for access to vaccines when there are products that are not solely only from the West. This creates an interesting situation, because I think what you see for these products to be validated – whether it’s Chinese or Russian or Indian or Cuban vaccines – there is still a degree of authorization that does have to come from the West. And the way that typically comes now is through peer-reviewed publication in a reputed journal like the Lancet, the New England Journal of Medicine, JAMA, or by approval from the World Health Organization. But the products themselves and what’s being tested and displayed has been available as information prior to their publication in these journals. It’s just typically that they’re taken more seriously after the WHO has approved them, or the journals have published a paper on them. However, there is data that I have followed very keenly from places like the Turkish regulator, or the Brazilian regulator, or from institutes in Brazil. This is data from the source, which is not taken seriously, for mysterious reasons and would have been taken much more seriously if it came from a Western source. So that’s what’s really changed. Middle income countries now have a very high level of infrastructure, and ability, for evaluating drugs and vaccines. And this includes Turkey, Brazil, Indonesia, Malaysia, some of the countries in the Middle East, and many others in Latin America. What they have done is to show that they are fully capable of regulating themselves and deciding what’s best for them, getting what best they can in terms of vaccines. And they do that in a manner that is far more publicly engaging. In Turkey, the drug regulator is a cherished national institution. It’s really quite touching, many Turkish people I talk to about it have tears in their eyes and describe it with joy and pride. In Brazil, there were a few things about their drug regulator, ANVISA, that I disagreed with. When I talked about these differences to Brazilian researchers, with whom I’ve had vocal arguments, it was almost like I was criticizing the pope in Rome, or something like that.
What I have understood in the pandemic is why people feel so strongly about these middle-income country regulators. They’re very good, they do their job very well, and they do it independently. They do it while being cut off from Western vaccine supplies, as well as Western cooperation, because no one else was interested in evaluating these Chinese vaccines or Russian vaccines. They really took matters into their own hands and I admire them very much for that. And I think what we’ve seen is like a whole layer of certification and authority that is emerging outside the seven richest countries in the world. And that is coming primarily from richer parts of Asia, Latin America and the Middle East. And I appreciate that, because I think that that layer of authority is far closer and more useful to someone like me in India, or someone in, say, the Central African Republic or anywhere else, which lacks the same degree of confidence and ability.
Fukuda-Parr: The scientists and experts who are running these institutions are presumably supported politically by their respective governments. What is the relationship between government policy in this area and the work of the scientists? Are governments giving priority to developing national capacity and listening to their own scientific experts?
Prabhala: This is a really interesting question because, for instance, if you take the case of Brazil and you read the press you would imagine that Bolsonaro has decimated all that was good. But Brazil is a very large country with hundreds of millions of people and you cannot decimate everything overnight. And I think what’s endured is the really strong cadre of bureaucratic excellence. I encountered this over many years. I know this layer to exist. It’s very much like the layer of bureaucratic excellence we had in India in the 50s, 60s and 70s. That layer of bureaucracy has endured, certainly without any help from the federal government.
And so one of the first vaccines that they approved was being trialed by a state organization called the Butantan Institute in Sao Paulo. The governor of San Paolo encouraged the testing of Sinovac, and ran the trials. They then submitted the results to ANVISA, the federal drug regulatory organization, for approval. Despite Bolsonaro saying things like, “you know, you want Chinese vaccines, I oppose it because they’re poison”, it was approved. For many months it was the mainstay of the Brazilian national vaccination program. Even though originally it was intended only for the state of São Paulo, its success there and the lack of any other alternatives spurred its nationwide use.
I think it would be too easy to say that these institutions like the drug regulator are totally politically independent. I don’t believe they are. But I do think that they have a degree of integrity and decades of values and ability that cannot be broken.
I think it would be too easy to say that these institutions like the drug regulator are totally politically independent. I don’t believe they are. But I do think that they have a degree of integrity and decades of values and ability that cannot be broken. And so they might be swayed politically, but it is very hard to see how they would be overturned or, you know, totally just swept up in politics because I haven’t seen any evidence of that. Last year, the Trump administration’s Health and Human Services Administration released a report where they were glowing with pride about advising the Brazilian government – presumably branches of the executive, not the drug regulator – not to place an order for Sputnik vaccines from Russia. They succeeded in what they called “thwarting the intent of malevolent state interference in Brazil.” There’s been an enormous amount of “Cold War style politicking” all over the world this last year and a half with the COVID-19 pandemic which has sort of been swept under the radar. And I think that it’s probably a real effort for any of these regulatory organizations to stay ahead of the pressure. The currents are very strong. And, you know, it’s a” damned if you do” but “damned if you don’t,” sort of situation sometimes. I think it’s been very tricky, but I would say overall, they’ve done a pretty good job.
Fukuda-Parr: This is so interesting. It harkens back to developmentalism and the developmental state. The idea of the developmental state assumes that technocrats and bureaucracies have their own ethos. An interesting comment that a leading epidemiologist in Japan made about the pandemic response was that there is no need for political leadership because the bureaucrats and the professionals know what to do. I think he’s absolutely right, and it has been borne out in Japan, where it was not really “the star prime minister” but the public health system that rolled out the response.
The Politics of Vaccine Access: Big Pharma and States
Fukuda-Parr: Let me turn to the politics of access to medicines. What has been the effect of the pandemic? Do you see changes in government policies or in the behavior of the pharmaceutical companies? How have vaccines from China, India, and Russia, affected the positions of countries and companies?
Astonishingly, what’s happened with the Western pharmaceutical industry is not only that the shift did not happen but that the shift, in fact, went in the other direction. Pharmaceutical companies who have vaccines on the market have been so emboldened by the gratitude of the countries they’ve been able to supply to (I should note the very few countries that they have been able to supply to), they have become supercharged and emboldened. The bad system that didn’t work for anybody, including the rich countries, has become worse.
Prabhala: I love this question. When we spoke towards the beginning of the pandemic, at a seminar that you organized at that time, I believed that the pandemic would cause a shift in the way the pharmaceutical industry business model works. How else would you expect this to work out? Astonishingly, what’s happened with the Western pharmaceutical industry is not only that the shift did not happen but that the shift, in fact, went in the other direction. Pharmaceutical companies who have vaccines on the market have been so emboldened by the gratitude of the countries they’ve been able to supply to (I should note the very few countries that they have been able to supply to), they have become supercharged and emboldened. The bad system that didn’t work for anybody, including the rich countries, has become worse. People publicly thank these companies as though they were just spun out of thin air by ingenuity and enterprise, rather than public money. It is really remarkable. So that shift, I have to say, I didn’t see coming.
Fukuda-Parr: It’s not only the position of the pharmaceutical companies, but also of governments, such as those of the European Union, that has been rather surprising.
Prabhala: It’s not even just surprising. It’s astonishing. As much as Biden’s positive signals towards the TRIPS waiver have been surprising and good, the position of the EU, especially countries like Germany, is really astonishing. In a way I’m actually grateful that Germany and Merkel have come out and said, “We don’t want this and we’re never going to go for it.” In a way, that is clearer and better than some of the other EU countries and the UK who said, “we really, really, really want to help. And we’re interested in considering this.” Which is to say, a ton of really pretty words when really they are trying to say we are never ever going to stand for this.
There have been some real surprises that I would not have been able to predict. I don’t quite know what it’s a failure of. I ran the latest numbers for Pfizer and Moderna which shows that about 85% of all vaccines that Modena and Pfizer have supplied to the world have gone to rich countries. The remaining 15%, by the way, to date, have not gone to the poorest countries. So they’ve gone to very rich middle income countries. But essentially, the supply is so concentrated in the rich world that literally if 85% of the world just dropped off the map, their numbers, in terms of who they were selling to and where they were earning money wouldn’t change at all. Can you imagine?
Fukuda-Parr: But then wasn’t it always the case that those mRNA vaccines would be difficult to administer in the low-income countries because of the requirements for extreme refrigeration?
Prabhala: That’s true for the Pfizer vaccine. It’s not true for the Moderna vaccine. There is a requirement, but it is not insurmountable. And according to recent studies it’s not entirely proven that the strict requirements that they’ve set up for the US and Europe are actually required.
A couple of things with the mRNA vaccines that aren’t widely known. The first is that they seem to be a degree better at protecting people against transmission, but roughly equal at protecting people against hospitalization and death, as compared to the other vaccines like either the AstraZeneca or Johnson and Johnson vaccines or even the Chinese and Indian vaccines.
The second is that they can be made more easily. The process for mRNA eliminated biology, which is really revolutionary, when it comes to vaccines. Vaccines are a class of drugs that are called biologics, because they have biology. Meaning that they cannot be expressed in a simple chemical formula, they are molecule upon molecule, and they also contain some element of an unpredictable thing like a virus or a protein. The mRNA vaccines eliminated the biology part. Earlier, we had chemical drugs, the kinds of things we’re used to taking. And we had these things called biologics of which vaccines were a part. Now we have something that’s in-between. But the thing about them is that they’re very easy to make. They are quicker and easier to make than the other vaccine technologies.
A third thing about them is that you don’t need as specialized knowledge as you need to make the other vaccines. I’ve been spending a lot of time now with vaccine manufacturers because we’re really interested in why technology transfer is not happening. The oldest vaccine technology in circulation is the inactivated virus vaccine. So you take a virus, you kill it, and then that’s part of the vaccine. Sinopharm and Sinovac from China and Covaxin from India are inactivated virus vaccines. But they are also the hardest to make because you have to take a live virus and then kill it. And your lab or your factory has to be certified at something called Biosafety Level-3. Facilities with this certification are very rare. There are few such labs in India. Every country has very few of these facilities, which means that they’re just not enough spaces that can make them. So with the Sinopharm and Sinovac vaccines, and even the Covaxin Indian vaccine, the companies are actually willing to license that technology to more or less anyone who wants to make them, but there are very few places who can make them because of the safety requirements involved in their production. Secondly, it’s a laborious process because it involves viruses. It’s more effort, and it’s more time.
Then you have a layer of vaccines which would be best described as sort of middle-level technologies: the adeno-viral vector vaccines and protein sub-unit vaccines. Novavax, whose vaccine is not yet on the market, is a protein subunit vaccine. So are all the Cuban vaccines. They are super easy to make. They’re the next best thing to make after mRNA, meaning that they are the simplest. The adeno-viral vector vaccines like Sputnik, Johnson and Johnson, and AstraZeneca are more effortful than the protein subunit vaccines, but easier than the killed virus vaccines, because they don’t require fancy facilities. A lot of facilities can make them. This is why the Sputnik manufacturers literally created an open access template. So more or less any manufacturer could apply to get a license to make the Russian vaccine. Which meant that a lot of companies went into vaccine manufacturing for the first time to make this vaccine.
The newest vaccines are the easiest to make, and paradoxically, the oldest vaccines are the hardest to make.
And then finally, you have mRNA vaccines, which are by far the fastest and easiest to make. On the negative side, they’ve never been made before, even in the US until last year, which means that there’s more technical assistance that’s necessary if you want to hand it off to someone else. If you are handing off older vaccines, there’s just less you have to explain because people know how to make them. So there’s a little more to explain with mRNA. On the positive side, though, a lot of people who’ve never made vaccines can make them. So Cipla in India, the world famous generic supply company, has never made a biologic. It’s absolutely interested in a license to make the Pfizer or the Moderna vaccines because it can. It’s a company that deals with chemistry. These are vaccines that also deal with chemistry, primarily, in the sense that they are constituted by routine biochemistry, and are not cell-based. So they don’t require biology. The newest vaccines are the easiest to make, and paradoxically, the oldest vaccines are the hardest to make.
Fukuda-Parr: A lot of arguments offered by the pharmaceutical companies and by the governments against the TRIPS waiver is that it’s technical capacity, not intellectual property, that is an obstacle to expanding production. These are myths that need to be debunked more vigorously in the mainstream press.
Shifting Maps: Global South Collaboration
Let me go back to politics. How have the principal actors in the fray changed? We talked about the manufacturers from Russia and China, particularly, and India. Whom do you see as the main major interlocutors, enablers, allies, opponents and how do you see the political map?
Prabhala: So I think the thing that’s been tragically wonderful in the pandemic – and I say tragically wonderful because both those words are equally applicable – is that the map of where we think we can get good things from has changed. You know, all my activism so far has been for Western medicines, or Western vaccines, or something else developed in the West. I’ve never in my life tried to get a Cuban vaccine, or a Russian vaccine, or a Chinese, or Indian vaccine. The pandemic did two things. The scarcity of Western vaccines made almost every country realize immediately that there was a degree of protection and security in having some access to vaccine manufacturing. It’s not like every country in the world is scrambling to make vaccines; obviously, if you’re a small island nation, you can’t. But every region in the world is trying to figure out a way to have a stable source of vaccine supply. And what that has meant is both a huge involvement of both private capital as well as government interest for the very first time. These are not governments or private capital players who would have been interested in vaccines prior to the pandemic, but they are now. And that’s just led to an almost insane degree of collaboration across governments, private capital, and private industry outside the West.
One example is Iran, which has successfully started producing one of the many Cuban vaccines on offer, which is a remarkable achievement. So Cuba set up a joint production effort with Iran right at the start. Incidentally, along with Carina Vance, a former health minister of Ecuador, I recently chaired a meeting, organized by Progressive International, for the health ministers of Cuba, Mexico, Argentina, and foreign ministers of Bolivia and Venezuela. There, the governments of Cuba and Mexico affirmed that their vaccine projects were available to anybody for licensing anywhere in the world. Mexico is developing one vaccine called Patria. Cuba has two vaccines and advanced stages of trials which have shown excellent results and a nasal vaccine under development. What has happened, I think, is that more and more countries now are looking to places outside Europe and the United States for a supply of vaccines. And what this has meant is a degree of expanding cooperative deals.
None of this could have happened two years ago. It didn’t happen with AIDS drugs; these countries didn’t come together to create their own antiretrovirals. And I think if the trend continues, it shifts the center away from London and New York, and that would be great, because the world can have a more diversified supply of life-saving pharmaceuticals.
Politics still play a role; because India is in a war with China over a landlocked lake which even most forms of wildlife sensibly abandoned 2000 years ago, India will not use Chinese vaccines, but every other country in the developing world will. Every other Asian government and every Latin American is involved in some way or another with the Chinese vaccine effort. A whole host of countries across the world, from Eastern Europe, to the Middle East to Latin America, are involved in producing or buying Sputnik from Russia. The Cuban vaccines have generated enormous excitement as they’re being produced in Iran. You have the oddest sort of new configurations. The nexus of private capital and governments is not in any kind of neat order, but in all kinds of combinations and arrangements, which is to say, it’s people trying to create as many different initiatives as possible. There’s a huge factory that’s going online in Abu Dhabi which will be producing a Sinopharm vaccine. There’s a very promising Thai effort to create a new mRNA vaccine. There’s an mRNA vaccine in advanced clinical trials in India, and there are several mRNA vaccine development projects underway in China.
None of this could have happened two years ago. It didn’t happen with AIDS drugs; these countries didn’t come together to create their own antiretrovirals. And I think if the trend continues, it shifts the center away from London and New York, and that would be great, because the world can have a more diversified supply of life-saving pharmaceuticals.
Fukuda-Parr: Where is the private capital you’re referring to coming from?
It’s a commercial opportunity. Private capital is interested in this because there’s money to be made.
Prabhala: In many countries, vaccines are a business opportunity. I’ve spoken to a large number of companies in India over the pandemic who have all signed licenses either for the Sputnik vaccine or for the Indian vaccine. In all cases, the way that it works is that the risk is entirely with the licensee. So typically, with the Russians, you get the technology, you get technical assistance, and you get help, right. But no money changes hands, you just sign a license. When you start producing vaccines, the onus is on the producer. So the costs, firstly, are entirely borne by the receiver of the license. And then once you start producing vaccines, the onus is on the producer to certify that vaccine and have it regulated and qualified. And then, when they start selling it, a royalty goes back to Sputnik V and they also reserve the right to buy it. It’s a commercial opportunity. Private capital is interested in this because there’s money to be made.
Vaccine Access: The Role of the State, Philanthropy, and Vaccine Contracts
Fukuda-Parr: Where is the role of the state? In the US you had state subsidies and advanced purchases. There was heavy hand of the state in this model, the so-called Western model. Where is the state in these non-Western vaccine development that’s happening?
Prabhala: The funny thing is the Chinese vaccines are called Chinese vaccines, even though only one of them is a public sector company – Sinopharm – and the other – Sinovac – is a private company. The Russian vaccine, you can call it a Russian government vaccine. But we never think of Moderna and Johnson and Johnson as the US government vaccines even though they are, because the US government – and the US taxpayer – fully funded them into existence. And that’s just an odd thing.
We should legitimately credit rich country governments with having had the foresight, very early, to commit money towards the research and development of vaccines. And then the pre-orders of these vaccines provided a further financial boost. One has to have a realistic understanding of the world. None of the governments outside the West scrambling for vaccines now are angels. You know, even countries that are not rich, even the poorest countries, have millions or billions of dollars for anything that they absolutely have to put it towards. And so this idea somehow that only the US government could have funneled you know, $3 or $4 billion in initial research, is nonsense. We could have done that. Any government could have done that. That kind of money is available. It’s really a question of where you see yourself in the food chain. India, Brazil, South Africa, these countries in different ways pretended the pandemic didn’t exist or just sort of sat back for many months, without doing any of these things that other countries are doing. So, you know, there’s a lot of blame to be laid at the doorstep of these countries, which are now suffering. Some of it, I feel, has to do with this history – especially in countries like India, maybe to a lesser extent in South Africa – of having long outsourced one’s public health to Bill Gates. By that, I mean, not just him or the Gates Foundation, but to philanthropy and international organizations in general: an abdication of sorts of your poor and your public health needs, and the idea that this is not something that governments of poorer countries need to worry about, or,in fact, can. It’s absurd. There’s nothing that the US government did that we didn’t have the money to do or could have done.
Fukuda-Parr: What do you think about the initiatives in Africa? African governments have been very proactive in developing domestic vaccine production in Africa. It’s been building up over the years, but now I think there’s a new momentum from the Africa CDC and other regional organizations.
Prabhala: Up to the point of the pandemic, I think many African countries were in India’s boat. This is that they were content to have other people take care of their public health, in many ways. I think that the pandemic did shift things. A number of people who have been working on vaccine issues in Africa have a very clear idea of what they want to do. To their credit, they’ve actually managed to stitch together deals for financing, that involved all African Union members, to place the kinds of advanced purchase commitments that Western countries did. But several months after they did, which means that they get the vaccines several months – even years – after the Western countries do. So because they organized so much later – only towards the end of last year and beginning of this year – to get these orders placed, they are also far behind in the queue.
So the WHO has set up an mRNA vaccine manufacturing hub in South Africa. The hub actually has no technology to work with; they are, in fact, trying to develop an mRNA vaccine from scratch, which is obviously going to take a very long time.
Now, the second thing that they have become very vocal about – especially folks at the African Union – being sidelined in the vaccine access game. Of all the regions of the world, there’s nowhere else that’s been as badly off. And that is surprising, because there are vaccine manufacturing facilities in South Africa and Senegal, and in every North African country. They just went into the wrong agreements and too late. Like Aspen in South Africa went into an agreement with Johnson and Johnson, and it was really the wrong kind of agreement, where Aspen had no say in who their vaccines would go to. Institut Pasteur in Senegal has only made inactivated vaccines and in very small capacities, but still, they got no contracts to make any COVID-19 vaccines. So I think that they’ve been very vocal about the fact that they’re in a particularly vulnerable position. And I think that’s excellent, because that’s getting heard. What they are being met with, however, is false promises. So the WHO has set up an mRNA vaccine manufacturing hub in South Africa. The hub actually has no technology to work with; they are, in fact, trying to develop an mRNA vaccine from scratch, which is obviously going to take a very long time. Pfizer announced that they would give manufacturing capacity to South Africa; actually, what they will do is provide them the vaccine to be put into vials in an arrangement called ‘fill and finish.’ They’re not providing South Africa with the capacity to really make anything, they’re allowing South Africa to literally package the very last step of the vaccine process.
Fukuda-Parr: What about the other countries that you were mentioning? Russia, Cuba, Iran, and so forth? Why wouldn’t Cuba have an agreement for manufacturing with Senegal, Uganda, or Egypt?
Look, I think there’s one inescapable fact, which is that Western vaccines are seen as better vaccines. So there’s a degree of desire that’s pretty uniform across the developing world. It’s what we’ve been trained to think.
Prabhala: This is something that we would want to have happen. The Cuban vaccines especially, would be easy to make, because of the technology platform they use. These can be made in a lot of places, and these are the kinds of vaccines we would want to get. Look, I think there’s one inescapable fact, which is that Western vaccines are seen as better vaccines. So there’s a degree of desire that’s pretty uniform across the developing world. It’s what we’ve been trained to think.
Separating Politics from Science: Preference for Western Vaccines
Fukuda-Parr: I worked in Africa for many years, you know, and there is a kind of a legacy of looking to the old colonial masters. Much as there is a rhetoric of South-South cooperation and knowledge sharing and all that, much of the knowledge that African countries use comes from North America and Europe.
Prabhala: Very much so. And the same is true in India. But I should just say that it is really at that poorest layer of the world where you see this pronounced preference for Western vaccine technology. Whereas the middle income countries – through a combination of necessity, confidence, and independence – have made their own choices. And I think that is an important difference.
But the way Western press generally covers the Chinese or Russian vaccines hasn’t always been fair. There are propagandist outlets in Russia and China, who will say the most intemperate and silly things about their own vaccines, as well as run down Western vaccines and so on. I wouldn’t take any of that seriously. The western press has not glorified itself either.
Fukuda-Parr: What about the international NGO networks for access to medicines? Haven’t they been kind of ambiguous towards non-Western vaccines?
I think that the original sin of those vaccines, in many people’s minds, was the fact that they came from authoritarian states.
Prabhala: Because they are, I’ve had some really difficult discussions. When Chee Yoke Ling and I wrote a piece in The New York Times in February about Russian and Chinese vaccines, we were trying to pierce the veil of ignorance around them. We were also trying to run a rational analysis of why Argentina approved them or Brazil approved them, or Turkey approved them, which is to say, understand why middle income countries with the ability to evaluate pharmaceuticals as well as Europe and the United States chose them. And it’s a complex and fast moving issue but the best summary I can provide of it is that a lot of activists – and I should just say not only just Western activists, but many people in India – were incensed about that piece that we wrote.
I think that the original sin of those vaccines, in many people’s minds, was the fact that they came from authoritarian states. So there was a genuine difficulty in separating the efficacy of a vaccine and the politics of the country it came from. In our minds, we were fairly clear that good science could come out of bad states. If the Chinese toned down the state’s mistreatment of Uighurs, would that somehow increase the efficacy of their vaccines?
But the second point was that both Russia and China put the vaccines into circulation in a limited manner in their countries prior to what are called “interim results” from phase three studies. And that was made out to be a very big deal. But the difference between what they did, and what the US government did, is very small. At the end of Phase 2 trials, you have a full understanding of safety in humans, so you know a vaccine is safe. You also have potential efficacy from something called immunogenicity. So that’s the basis on which you would go into Phase 3 trials. This was the basis on which China and Russia put their vaccines to use. This was late last year, and there were no other vaccines available, while at the same time, they had a crisis in their country – and they decided to go ahead. And the difference between what they did and what the US did is that difference of about two months. The US and the EU gathered interim results from phase three results, not the entire phase 3 results (some of those trials are still ongoing). But that was presented as being a gross human rights violation, and somehow permanently tainted the eventual efficacy of these vaccines. This is not a rational understanding or fair application of science.
Lastly, when the vaccines themselves came out, they were victims to their own distributed model of trials and faced extremely biased media reporting. The Sinovac vaccine could not run phase three trials in China when it was time for them to do so because community transmission had actually been eradicated in the country. So they ran trials in Turkey, Brazil, and Indonesia. China allowed their partner countries to run trials, and each of these three countries ran different trials and came up with different results where the efficacy varied. It was initially reported between 91% and 67%, and then 51%.
The Bloomberg headline made it seem like the Sinovac vaccine was much worse than Pfizer. But American epidemiologists on social media, at exactly the same time, were looking at this study and saying, “how great that this study confirms that Sinovac works.” This whole year has been an Alice in Wonderland experience.
The Brazilian trials came up with the lowest numbers at 50% efficacy, and this result will always be used with Sinovac despite the fact that a Turkish trial showed 91% efficacy. The problem in Brazil was that the trials there were run on a different design, far more sensitive than with other trials, a fact that was ignored when reporting the results. What I saw was that not all, but large sections of extremely respectable Western media – including specialized scientific publications – have a tendency to not give these vaccines any benefit of doubt. The kinds of different headlines you can generate from the same data is truly astonishing. There was a Chilean trial that evaluated Sinovac, which found that the Pfizer vaccine did better by a small percentage in only one metric, which is the prevention of transmission. The Bloomberg headline made it seem like the Sinovac vaccine was much worse than Pfizer. But American epidemiologists on social media, at exactly the same time, were looking at this study and saying, “how great that this study confirms that Sinovac works.” This whole year has been an Alice in Wonderland experience. What you read about a trial or a study is really based upon what side of the bed the person who wrote it woke up on in the morning; rarely has there been a serious engagement with the underlying data. And if you’re not capable of analyzing and don’t have the time to do that yourself, honestly, you could get whiplash reading different headlines about the same thing.
The Future of Vaccine Access: Shifting Dynamics
Fukuda-Parr: What are some of the out-of-box approaches that might shift the dynamics in the stalemate that we’re in? Are there political processes, new alliances, incentives or new kinds of economic, social, and political dynamics that have the potential to move towards a system that prioritizes public health and equity?
Vaccines being developed in other parts of the world now pose a significant alternative and a threat to Western vaccines. In 2000 Western pharmaceutical companies had a monopoly on antiretroviral drugs. They didn’t budge until there was a threat.
Prabhala: There are two interesting things here. Vaccines being developed in other parts of the world now pose a significant alternative and a threat to Western vaccines. In 2000 Western pharmaceutical companies had a monopoly on antiretroviral drugs. They didn’t budge until there was a threat. And that was Yusuf Hamied (CEO of the generic pharmaceutical company Cipla), saying, “I’ll make those drugs for you at $1 a day for $350.” This spawned an entire movement of hundreds of companies joining the fray to make those drugs at exactly that price. This constituted an existential threat to the supremacy of the antiretrovirals from Merck, Pfizer, Boehringer Ingelheim and Glaxo. The way they responded was to give out more licenses and have their drugs made cheaper.
From a business perspective you could not be in a better place than to enjoy a monopoly. This is why Pfizer revised its earnings estimate on their COVID-19 vaccine alone to nearly $35 billion. This is an unheard of amount for any company to make in a single year on a single product. For Pfizer, it is a great position to be in and it will therefore take hell or high water to move them from that position. The only thing that will move them from that position is an alternative and a threat. If non-Western vaccines prove to last the distance by being adequately effective, that itself will shift the positions of the Western companies and their governments. Unfortunately, this hasn’t happened as much as we’d want it to as yet, but given the number of projects in development, there’s a good chance it could – in the near future.
I think this is where the Biden administration can facilitate change. This is a moral question, and it is entirely within their power to say to pharmaceutical companies – especially Moderna and Johnson and Johnson – “we funded you and you made tons of money on us. Now we will mandate that your technology be shipped off to whoever wants to make your vaccines anywhere in the world.” That is truly the only thing that they can do now. Morally speaking, when the US government has funded 100% of a vaccine’s development, it should mean that the US government has legal authority over where that vaccine can be made. Unfortunately, there is no such binding legal obligation in the contracts the US government signed when handing over this money. However, legally, there are a couple of different ways that the US government could claim its right. There’s the Defense Production Act (DPA), by which the US government can command private resources to fit government priorities and needs. They used that to persuade J&J to share their technology with Merck, when J&J realized it did not have sufficient manufacturing capacity for the US. There is also precedent for the DPA to be used to benefit foreign countries when they are US allies. This is all hypothetical and complicated, but legal scholars who have looked at it have said the US government can designate vaccinations in India, or in South Africa, say, as a US government priority. This is because the DPA has been used before to supply arms to US allies; if that has been done, by extension, the same can happen for vaccines.
Fukuda-Parr: A lot of what we’ve been trying to do in the pandemic is to fix some of the faults in the existing system. But if world leaders, especially the ones in the powerful rich countries were willing to implement a new system what would it look like? What’s your vision?
Prabhala: One of the things that I find really surprising is how little we know about monopoly medicine – or the vast inequalities that have been created due to it. My own parents don’t understand this, despite the fact that I’ve worked against it all my life. What’s even more striking is that there are a surprising number of people in favor of universal health care as something that has to be a state priority, who are for the idea of health being treated as a public good that is provided to people rather than something that has to be purchased. Unfortunately in the UK and the EU, where it exists, and even in the US, where people want it, that logic of universal health care has not been extended to medicine prices and medicines themselves. In the UK, I worked on a case just two years ago, before the pandemic, where the NHS couldn’t afford a crucial cystic fibrosis drug. It turned into a huge political issue before the 2019 elections, which resulted in the monopoly owner of that drug, a company called Vertex, dropping their price. But for five years, the world’s fifth biggest economy could not afford to buy a drug that cost more than $100,000 a year, to provide it to children under the age of 10 who faced debilitating lives without it. So, even in countries where universal health care has long been an accepted fact, there is little attention paid to the fact that monopoly medicine can still be a serious problem towards achieving universal health care.
I do believe that we have to think of universal access to medicines as an integral part of universal health care. When we talk about the technical intricacies of medicine monopolies, we lose so many people. Instead, if only we talked about universal health care as also having to crucially involve universal access to medicines, a lot of people would get that. Now, I guess, it’s just a question of finding a way to get that dialogue going.
Fukuda-Parr: Right. A new narrative and a new discourse.
Prabhala: I think so.
Achal Prabhala coordinates the AccessIBSA project, which campaigns for access to medicines and vaccines in India, Brazil and South Africa. He founded the project in 2016 from a Shuttleworth Foundation Fellowship he was awarded in the same year. He grew up in India and trained in economics and public policy management in the United States. Through the pandemic, he has worked on a range of initiatives to increase vaccine access, including through public media and an interdisciplinary research project on the policy frameworks that restrict access to biologic drugs and vaccines.