COVID-19 Vaccination Politics: (In)equalities and the Role of Europe

A talk with Caroline Meier zu Biesen and Stuart Blume based on the IFES Lunch Lecture from 24 May 2021
Questions by Anja Hennig and Marian Burchardt
June 10, 2021

This IFES Lunch Lecture aimed to give an insight into the global context of vaccine development, production, and distribution–more generally and with a particular focus on the role of Europe. Moreover, following the major research rationale of the Viadrina Institute for European Studies to raise critical questions concerning our understanding of Europe or the EU, to address power asymmetries, ambivalent developments, or questioning stereotypes we particularly asked for a pattern of inequalities.

The conversation aimed to shed more light on the global conditions of development, production, and distribution of medical resources and their underlying asymmetries and power structures. 

The Lunch Lecture took place online on May 26, 2021. It was conceived and moderated by Anja Hennig (EUV/IFES) and Marian Burchardt (University of Leipzig) and counted with the contributions of Stuart Blume (Professor emeritus of the University of Amsterdam) and Caroline Meier zu Biesen (University of Leipzig).

Below you will find a revised and summarized transcript of the podium discussion, along with an update on the situation since the lecture. You can also watch the entire Lunch Lecture on the Viadrina media portal here.​

Marian Burchardt: In the age of globalization unequal access to healthcare and uneven distributions of diseases and the pharmaceutical and technological means to fight or prevent them are a major axis of disparity between countries and populations. In this context of COVID-19 as well, unequal resources play a major role but there are also global efforts to combat the pandemic. How do global inequalities and global solidarities affect societies’ abilities to combat the pandemic? Inequalities and asymmetries have surely existed before the Coronavirus crisis. But how exactly does the Corona crisis challenge our views on these asymmetries and the way we think about global health? What continuities and ruptures did corona engender, or make visible?

Caroline Meier zu Biesen: Global health can be conceived of as both an assemblage of various actors, agendas, institutions, technologies, epistemological models, political choices, or forms of knowledge that produce a powerful field of concern, and as a series of processes of health globalization, for example the circulation of pharmaceuticals, people, or regulatory norms. In order to understand how global health interventions cross-cut levels from the local the global, it is indispensable to address these entanglements. 

COVID-19 and current attempts to “vaccinate a planet” exemplify the intertwining of these epistemological, political and ethical predicaments in global health. The biggest vaccination campaign in history implies multiple challenges, not just related to scaling up (i.e., manufacturing), but also the global rolling out (i.e., including more production sides). Important challenges are the fragility of infrastructures/logistics allowing medical commodities to travel and distribute, and, from a global health perspective, a test ground for solidarity – old problems in new guises. 

Historians of pharmacy in the Global North have shown how drug making, the world of pharmaceuticals and their distribution radically changed after the Second World War, leading to the emergence of the patent and innovation-centered proprietary regime of “Big Pharma”. As historians and anthropologists (including myself) have argued in the forthcoming book “Global Health for All: Knowledge, Politics, and Practices”, this industry is characterized by several main features. For example, the changing scale of a market supported by health insurance, turning drug purchase into collective spending; the introduction of new classes of drugs, opening the door to chemotherapy in new health areas; the rising importance of administrative regulations; or the generalization of chemical-biological-clinical screening as the dominant path to drug invention. It enabled the discovery of new active substances, thus legitimizing massive investments in research and development infrastructures. The combination of these factors (among others) radically altered the construction of drug markets, placed the search for “innovations” center-stage, and created a “proprietary regime” of market construction. This further fed into the expansion of scientific marketing and of its correlate: the monopolistic control of clinical trials, which increasingly fell to Euro-American firms. The control of global epidemics – such as HIV, malaria and TB – are powerful examples associated with the circulation of pharmaceutical objects, invented, produced, and sold by these capitalist firms. Even though this monopolistic regime of market construction has in the past decade been challenged as a consequence of the massive globalization of pharmaceutical production, medical monopolies continue restricting access to health technologies in pandemic situations, as we now also observe with coronavirus vaccines. Besides the important question of production and distribution, further facets such as the intricate relationship of (inter-)national standards, commercial and health considerations, or il/licit trades are relevant to the globalization of pharma-markets.

Anja Hennig: To help us better understand current inequalities Caroline provided some insights into the transformed economic context of pharmaceuticals. Similarly, but more specifically you talked about the current situation of vaccine shortage and the difficulty, or lack of political will, to distribute doses equitably between countries. You said that to understand this we have to focus on the transformation of the market in which vaccine development takes place. You suggested that this transformation has to be seen in the context of neoliberalization and globalization processes. Because of these processes, where and by whom vaccines are produced was becoming more and more significant. Could you explain this in more detail?

Stuart Blume: From the end of World War I right through until the early 1980s, some countries (Germany, UK, US) relied almost totally on private industry for the vaccines they needed. By contrast, the Nordic countries, the Netherlands, plus many countries in Asia and Latin America – and then later the whole Socialist bloc – relied on public sector institutions. Collaboration between public and private sectors was relatively easy, and knowledge exchange occurred in the interest of public health. The lack of patent protection, so hotly debated nowadays, remained the norm in the vaccines field until the 1980s and was not a barrier to innovation. Moreover, despite the East-West ideological divide, vaccine researchers had little difficulty in co-operating. This was especially visible in the smallpox eradication campaign.

In the 1980s the vaccine system began to change radically for at least three interrelated reasons: First, because of the triumph of neoliberal economics, facilitated by the collapse of communist regimes. Second, new technologies of manipulating genetic material pointed the way to new ways of producing vaccines. Many scientists who had been working on the manipulation of genetic material moved out of their universities into small high tech ‘spin off’ firms. The expertise they took with them had to be carefully safeguarded through comprehensive patenting, at least until a profitable product, or a take-over, had appeared. Unlike the traditional vaccine manufacturers, the new biotech firms had no established links with the world of public health, and they had no interest in sharing their knowledge. Vaccine development and production had become ‘privatized’. Knowledge had been reconfigured as ‘intellectual property.’ by the turn of the millennium the vaccine market was growing far more rapidly than that for pharmaceuticals. Vaccines became a major source of growth for the industry.  This was part of the problem. The economic importance of vaccines to the pharmaceutical industry dominated their importance for public health

At the same time, globalization also implied that vaccine producers were coming to be regarded as elements in a global system of supply. This shift of perspective implied a dramatic shift in how the importance of national – often public sector- vaccine producers were looked at. In an age of fiscal belt-tightening, as cost-saving came to outweigh more expansive notions of state responsibility, local vaccines producers were becoming a costly irrelevance

M. B.: Stuart referred to the transformation of the vaccine market. You mentioned in more general terms  the existence of medical monopolies and the fact that pharmaceuticals are commodities – how does this Global Health context shaped the complex processes of the development, production and global distribution of vaccines against the coronavirus?

C. M.: During the first months of the pandemic, we could observe a sense of possibility of an “open-science, cooperative pandemic response” within the global research community. Vaccines have been developed and approved at record speed because of years of previous research on related viruses, faster ways to manufacture vaccines, unprecedented scientific cooperation, or enormous funding that allowed firms to run multiple trials in parallel.

One year later, however, hopes of replacing a global drug system (which actually predates COVID-19) based on proprietary science and market monopolies have been shattered. The global – or rather not so global – roll-out of vaccines highlights once more the configurations of power that have defined global health as a political enterprise. Patent rights and trade secrets protecting the bottom lines of pharmaceutical companies have hampered efforts to manufacture vaccines at scale, and wealthier countries have used bi-lateral deals with Big Pharma to pre-purchase supplies that cover more than their populations. Pharmaceutical companies and their allied governments still hold the main decision-making power through commercial deals regarding where vaccines can be produced, what prices to charge, or who gets them first (among others, we have seen in particular racial disparities in vaccination rates).

Globally, according to the Bloomberg Vaccine Tracker, by today, more than 3.5 billion shots of the Coronavirus vaccine have been administered across 180 countries. Close to 80% of these doses have been given in just 10 mostly high-income countries (such as the European Union, the US, China, and the UK). According to the WHO and public health activists, the vaccine gap grows by the day. While vaccination rates are quite impressive in the North, the disparity between rich and poor has become severe. About 130 countries – accounting for about 2.5 billion people – have yet to administer a single dose, not to mention marginalized groups, particularly refugees and other displaced populations, who face barriers to vaccine access—in both policy and practice. The timeline for supporting marginalized groups, poor and middle-income countries with vaccines to achieve herd immunity, meanwhile, has been delayed. This artificial scarcity creates another global crisis, making room for the virus to mutate (as we now see with delta) and potentially grow more contagious and vaccine-resistant. The mantra repeated so often throughout the pandemic – “no one is safe until everyone is safe” – remains in force.

A. H.: In the light of economic and strategic interests, and global health structures, at the beginning of the pandemic you anticipated some fundamental problems arising even after vaccines had been developed. You referred to a likely shortage of vaccines, and the possibility of rich states monopolizing the supply. You also showed how the race to produce the first effective vaccine, most notably between China, Russia and the US had been highly politicized. For strategic and commercial interests rival vaccines were being discredited. Another context fuelling political conflicts was Brexit, with the European Medicines Agency (EMA) accusing the British, who approved the first vaccines first, of prioritizing speed over public confidence. Given this complex context under conditions of permanent vaccine shortage, how would you describe the role of “the West”, of European states and the EU in particular, especially vis-à-vis the Global South?

S. B.: First of all, we should note that for politicians in Western Europe and North America (and elsewhere) it was speedy and efficient organization of a vaccination campaign, not vaccine development, which soon became politically important. In pursuit of popular support and votes, politicians wanted to boast of successfully vaccinating large swathes of their populations. This is why wealthy countries claimed limited initial supplies through Advance Market Commitments (AMCs) signed with manufacturers. These AMCs incur an annual fee, which poor countries cannot afford.  When it came to Covid-19 vaccines, the 27 agreed very early on, under the leadership of Berlin and Paris, to pool procurement. All agreed to guarantee that each would have equal access, proportionate to their population size, and above all, that each would apply the same vaccine purchase conditions. Otherwise, how would, say, Luxembourg or Finland have fared in negotiating with the pharmaceutical giants? The EU together set out the demands it wanted met in exchange for financial support aimed at speeding up development and production. But from a global perspective, things look different. From this perspective, as the WHO is now emphasizing, accumulating scarce vaccine by pushing poor countries to the back of the queue is not at all praiseworthy. It is selfish and shortsighted.  The UK’s speedy rollout was critiqued on the grounds both that it represented a sacrifice of inter-national solidarity and that it meant accepting all conditions imposed by manufacturers, including freeing them of liability in the event of any serious side-effects emerging. 

A. H. and M. B.: To both of you, what would be alternative ways to develop, produce and distribute vaccines?

C. M.: Treatment access campaigns are currently targeting governments that – until recently – continued to block a landmark waiver of certain Intellectual Properties (IPs) for the duration of the pandemic. The waiver proposal provides a policy option that could facilitate better collaboration in development, production, and supply of COVID-19 medical tools without being restricted by private industry’s interests. Even though in response to a shift in US policy in which Joe Biden called for the patent waiver on COVID-19, wealthy countries such as Germany argue that production capacity and, in particular quality control were the key impediments to widening access to vaccines — not intellectual property rights. Likewise, public-private partnerships influenced by philanthropic foundations (with their long-standing commitment to the rights of drug companies to have exclusive control over medical science) leave little doubt about their opposition to the waiver proposal. 

The potential of the waiver to act – in the medium to long-term – as a catalyst towards a structural rebalancing of monopoly market power for pandemic situations and to encourage changes in global pharmaceutical production and capacity, remains to be seen. The HIV/Aids crises taught us that alternatives can be possible if public health, equity and access prevail over intellectual property. HIV/Aids Treatment Action Campaigns, with the assistance of the humanitarian rights framework and generic drug manufacturers, provided alternative ways to distribute life-saving drugs. Patents should not be a hurdle for manufacturing, however, regarding vaccines, this seems more complicated. Even the largest vaccine manufacturer in the world (e.g., India) is not capable of producing enough doses. Hence, an important pillar will most probably remain importing vaccines from wherever they are in insufficient numbers. Entering year two of the pandemic, the COVID-19 response has in any case been defined by a vaccination battle that has left much of the world on the losing side, thus reinforcing the very inequities philanthropic efforts seek to overcome, as sociologist Linsey McGoey reminds us.

S. B.: Let’s remind ourselves that in late 2020 India and South Africa proposed to the World Trade Organization a temporary waiver of certain TRIPS (Agreement on Trade Related Aspects of Intellectual Property Rights) obligations, such as patents and intellectual property rights, covering treatments and tools related to Covid-19, including vaccines. This would facilitate an appropriate response in countries which lacked the muscle to push to the front of the queue. Patent free medical treatments, vaccines and devices would also allow manufacturers to begin producing Covid-19 essential medical products. Countries which are home to major manufacturers, including the US and the UK, opposed these initiatives. So too did the European Commission. In how far they were motivated by ideological commitments and in how far by lobbying is difficult to know. 

In the US the newly-installed Biden Administration then changed sides, as Caroline says, and began to support the initiative… On the one hand there can be no doubts as to the moral standing of the claim that the profit motive is incompatible with so existential a struggle. On the other hand it really is not clear that patent waivers in themselves would lead to a substantial increase in global supply of effective and reliable Covid-19 vaccines. Unlike simpler drugs, new vaccine production lines require expensive clinical trials and inspection of each batch by a competent regulatory authority. This has to make sure that they are safe and effective. But it must also ensure that they are being produced to agreed standards of good manufacturing practice. Many countries, and regions, still have no such regulators. Now, in place of patent waivers, the EU is proposing to support local vaccine production, especially in Africa. At present matters have reached an impasse, still to be resolved

A. H.: In April 2020 the Director-General of WHO, and the Presidents of France and of the European Commission, organized an initiative which would support and coordinate global effort to fight the pandemic. To that end COVAX was established to ensure rapid, fair and equitable access to Covid-19 vaccines worldwide, regardless of a country’s wealth. How do you evaluate COVAX?

S. B.: COVAX is supposed to mitigate the impact of bilateral agreements by encouraging rich countries to cooperate and to support low-income countries as well. Like individual countries, and through investment and its own Advance Purchase Commitments with pharmaceutical companies COVAX sought to speed up the development of effective vaccines. Its goal was to have 2 billion doses to distribute by the end of 2021: enough to help countries vaccinate all of their highest priority populations. As of December 2020 COVAX involved 190 participating and eligible economies. 92 low income countries would receive their shipments of vaccine without charge. Whilst the European Union was a major source of support from the start, there was concern that Member States were still prioritizing their own interests, so reducing the supply of vaccine available to COVAX. 

The start of 2021 saw disputes within Europe too, as Member States began to criticize what some saw as the incompetence of the European Commission, which had negotiated on their behalf with manufacturers. Some countries began to negotiate their own side deals, and some of those to the east (Hungary, Slovakia) began importing the Russian Sputnik-V vaccine though this had not been approved by the EMA.  

A. H. and M. B.: Stuart concluded that just as previously vaccines had become economically too important, by 2021 they had become politically too important. Public health concerns have slipped into the small print. In the lecture, Caroline pointed to a blurring of traditional North-South boundaries, pointing to the fact that COVID 19 rendered the “West” vulnerable and itself in need of help. Our lunch talk was at the end of May 2021. In the meantime a G7 meeting took place at which member states agreed to donate nearly one billion doses. With what feelings do both of you look to the future in regard to inequalities and vaccination politics? 

C. M.: With mixed feelings…partly disillusioned, uncertain, but also hopeful. Regarding vaccination politics, I was moved, relieved, but simultaneously also quite shocked to witness how fast vaccine development can proceed – but only when there is “a true global emergency”, including wealthy countries. So, while the pandemic will probably change the future of vaccine science, there is most probably no guarantee that such success in terms of vaccine development can be repeated over and over again. The massive funding for its development is only likely to continue if a sense of social and political urgency remains, and I am uncertain that this is the case as long as we continue following the motto “first come, first serve”. 

I was also struck (through not much surprised) by the overconfidence in and strong focus on magic-bullet approaches such as vaccines…meaning targeting one single disease with little regard to the social or economic factors that influence health outcomes. For decades, it has been a core mission of scholarly work on health/global pandemics to complicate the assumption that this focus on vertical approaches to healthcare based on technical fixes (less community-based) is the best solution. Because lost in this calculus on medical technology are on-the-ground as well as historical, social and political realities, and difficulties with which people must contend. And COVID-19 reveals in very dramatic ways these difficulties, such as the fragility of healthcare systems or people´s skepticism towards certain health interventions (in particular in resource-poor settings, which are attractive “sites of experimentality”). 

Finally, regarding inequalities and health: Social science has played a significant part in unearthing the harsh and brutal dimensions of human suffering, and the structural conditions producing ill-health. At the same time, we should not dismiss people’s strategies for action, weapon of the weak, or “technologies of the self” developed through the confrontation with pandemics, in short: a stronger focus on how healthy futures can be envisioned – or actually “done” in radically novel ways – despite and in response to multiple constraints.

S. B.: To be honest my dominant feeling is one of anxiety. I think what’s become apparent over the past 18 months is that despite the remarkable scientific achievements the world is unable to cope with a threat of this magnitude. Institutions of global governance, systematically undermined for years, have lost authority and are no longer up to the job. The success of COVAX is questionable. Governments are neither willing nor able to learn from past mistakes. You mentioned my – it should be our – prediction of all the problems which wouldn’t be solved by the mere existence of a good vaccine. They were predictable on the basis of what had happened in the past. There was zero political interest in even considering them. These problems haven’t gone away and cannot be avoided. Even now politicians are reluctant to take responsibility for protecting the health of refugees and asylum seekers. They are unwilling or unable to understand the extent to which their words, their deeds, and their omissions have fed – and continue to feed – vaccine hesitancy. Just as there’s little doubt that we will have to learn to live with the SARS-CoV-2 virus, so there is little doubt that other pandemics will follow. Since it is impossible to predict their viral cause it is impossible to start work on a vaccine. Are our political leaders able to think beyond vaccines? Though of vital (and commercial) importance, vaccines can only ever be part of the solution. The impact of Covid-19 has been highly unequal, both in terms of rates of infection at the community level and in terms of the seriousness of an infection for an individual. To be sure, we have to extend the capacity to produce vaccines, insulated as far as possible from commercial interests. But that is not enough. At least as important is reducing the environmental damage which leads to the emergence of zoonotic disease…and the social inequalities which determine their impacts. The real focus of attention and investment, in preparing for what is to come, must be public health infrastructures. Alas, I am not hopeful.

Thank you very much!

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