The COVID-19 Pandemic in 2022 – Losing Inspiration Part One

In 2020 and 2021, the global response to the COVID-19 pandemic inspired in me an enthusiasm for the global, multi-stakeholder collaboration that was unfolding through GAVI in the newly formed COVAX Facility. Regrettably, this vision has not evolved into a reality as I had hoped it would. As a result, I have backed off from writing about the scope of global collaboration in this pandemic. Most strikingly, the evolution of collaborative thinking has moved from the basic and worthwhile premise of a global distribution of available vaccines (and diagnostics and therapeutics) to a recognition that regional and locally-based control of manufacturing facilities for these same products is a preferred and alternative objective -at least, under the current circumstances.

What a surprise to me that the Biden Administration would be no different from the Trump Administration in favoring domestic (i.e. America first) production and distribution of vaccines – before any global sharing would occur. But then, it seems that this has also proven to be true of the member states of the European Union, where the initial idea of a COVAX Facility had actually germinated. So OK, we all understand that politics is local. So local must be the first priority.

But above and beyond that, why has the global concept not taken hold? It has indeed been disappointing that the pharmaceutical industry has pulled back from any generosity on its own behalf – at least in terms of the big first-line producers of pandemic vaccines (Pfizer and Moderna). The message is clear. Any corporate “generosity” from one or another pharmaceutical company is unrealistic without its being a shared generosity from all – which essentially means a generosity driven by public policy.  It is true that at one point AstraZeneca (in partnership with Oxford University) did try to go it alone on the generosity front, but it didn’t end up with the winner vaccine. So, so much for that idea. And then, instead of public policy dictating this idea for the world, the governments that could have moved in this direction simply used their bargaining strength to ensure priority access to vaccines for their own citizens.

So what to do instead? The COVAX Facility was premised on a pooling of available vaccines to be shared globally – a commendable notion in and of itself. But it failed miserably. What is more, the original premise of GAVI (for other vaccines long before COVID-19 – back in 2000), to pool resources for vaccine distribution to less developed countries, regardless of this more far-reaching idea of a global pool, also encountered difficulties. Even on this more limited return to its original focus, GAVI’s COVAX Facility suffered from a lack of early funding for the advance purchase agreements that dominated the market for these new vaccines.  Although the original idea of the COVAX Facility distributing some 2 billion doses globally, regardless of level of development but to ensure the coverage of health care workers and vulnerable populations wherever they were located, went by the wayside, so did the later revised projection of getting 1 billion doses out to the less developed countries by the end of 2021!

And what about its multi-stakeholder composition? One could argue that the COVAX Facility has done a better job here.  It remains, of course, under the governance of the  GAVI Alliance itself, whose board does include both civil society and private sector representation. And similar arrangements are in place for the oversight bodies within the COVAX Facility.  One can also see that that widespread support for the COVAX Facility was visible from both of these groups at its most recent April 2022 summit. The main lament, however, is that it has not prevailed as the vehicle for effective global collaboration.

Of course, this is all past history now. After all, the rapid scale that we witnessed in the development of COVID-19 vaccines in 2020 was also replicated by a huge scaling up of manufacturing capacity in 2021 and 2022.  It wasn’t immediate, of course. In the early months of vaccine availability, in late 2020 and early 2021, the unevenness of vaccine distribution took hold through vaccine nationalism, in a way that did surprise me (and many others). It didn’t improve until much later.  But now, in mid-2022,  that we have more than enough doses for global distribution, everyone has shifted their attention to the additional barriers (logistical distribution capacity, lack of skilled health care workers, popular resistance to vaccines, etc)  for reaching the populations in need. Nonetheless, this original and very skewed disparity in vaccine availability has had a long-lasting impact.

Ramifications of the IP Impasse

What we now see as the main thrust for future access is oriented to a diversifying of manufacturing capacity for ensuring at least regionally based control of access to vaccines. The question here, as it was initially in the pooling idea of COVAX, is how to ensure a truly global marketplace. But instead of voluntary agreements for everyone to pool the vaccines  from wherever they are made, the focus has shifted to getting the early  manufacturers of vaccines to decentralize their manufacturing capacity – or, in the alternative, to share their patents and manufacturing know-how to make regionally diversified manufacturing a genuine reality. Clearly this is what the original WTO proposal from South Africa and India had in mind, independently of any COVAX Facility access to available vaccines.

I had thought that Dr. Ngozi Okonjo-Iweala, newly appointed to head the World Trade Organization, would be able to nurture the parties to an agreement on the intellectual property issues related to this redistribution of manufacturing capacity. I was wrong. Early in the year, one had hoped that a resolution of this was on its way. The pivotal WTO ministerial conference, MC12, had been abruptly postponed in late November because of the surprise onslaught of the omicron variant of COVID-19; MC12, after all, was intended to be entirely an “in-person” conference in Geneva, but omicron effectively closed down air travel for participants from key locations like South Africa and elsewhere. Oddly enough, a “hybrid” WHO conference of in-person and online participation went ahead in Geneva as scheduled on roughly the same dates , but the WTO’s MC12 had no back-up arrangement for online participation.  And so it was abruptly postponed.

My thought at the time was that its postponement was advantageous and perhaps serendipitous as a way to allow a bit more time to hammer out any differences in negotiating positions on this particular IP issue. But it turns out that the issue did not benefit from a time delay. The negotiating positions of the EU and Switzerland, on the one hand, and the hundred or more WTO member states supporting South Africa and India on the other, apparently did not budge in the interim – and probably got even more locked in to opposing positions. It ended up being the final issue that led to an extension of MC12’s June 2022 session into an extra day – and into the early morning hours of Friday, 17 June, for a last-minute compromise on the IP issue. And, although MC 12 was rated as a success because of this (and other key agreements), this compromise was roundly criticized both by the pharmaceutical industry and by the NGOs on the other side!

I would say, furthermore, that the noticeably inactive American delegation at MC12 didn’t help the matter.  Early on, it seemed that the Biden Administration was willing to pressure the pharmaceutical companies to share their patents and their know-how on COVID-19,  and it seemed that the new US Trade Representative Katherine Tai was ready to support an IP waiver.  Early on, too. it seemed that President Macron had even showed a willingness to side with the US up on this. But then, one has to assume, the resistance set in, both in the EU but also, most interestingly, within the Biden Administration.  It was obvious to me that the American management of the pandemic probably had a host of policymakers with competing interests – maybe even a rather wild and hostile bunch, if one ever were to get an inside story on the matter.

The Balancing Challenge

One reads about the political sniping directed at the CDC and its relationship with the White House under Trump.  But that seems to be only a part of the messy cauldron of public officials with an interest in public health, whether global or local.  There was (and still is) a very visible Dr. Fauci, for example, but there is also White House pandemic czar, an HHS with an apparently sidelined Secretary, a Blinken-run State Department with its own strategy at pandemic-related summits, a USAID moving into the fray – and a USTR on trade and IP rights!

I am not privy to the internal maneuverings, but I do sense that they contributed to quite a cacophony of public pronouncements. I just sense that it did. It was already there in the long delays for implementing the expectation of a global distribution in early 2021 because of an absolute and conflicting priority for domestic distribution that were clearly controlled from the White House.  But I also suspect that it was in the White House that the interests of the pharmaceutical industry played a role. Dr.  Fauci himself did imply, back in an October 2021 interview, that the administration was still working out a balance to combine the benefits of risk assumed by government and the research capacity of the private sector for both development and for technology transfer. It seemed odd that this was still being debated within the Biden team, but then it seems that they are “still working on it” today. No announcement to this effect has been forthcoming in all of the months since then. And here is it already August 2022!

Meanwhile, there is also the matter of a Congressional role in pandemic financing. In fact, this has brought another aspect of the healthcare debate into the forefront – pharmaceutical drug pricing – and not just on COVID-19 vaccines!  It may be that this broader challenge on the negotiating of drug prices has overshadowed any effort to cut COVID-19 drug prices internationally.

Huge pandemic-driven financial measures were enacted in 2020 and 2021, and another huge package, more oriented to economic recovery, was in the offing in 2022.  But then things fizzled. Pandemic-driven priorities seemed to lose momentum – distracted first by the Russian invasion of Ukraine and then by alarmism about inflation. The Build Back Better Act fell apart, for whatever reason, including the small pieces of it oriented to supposedly fulfilling a US leadership role in the global pandemic efforts through both the COVAX Facility and bilateral aid initiatives. Early in 2022,  this was included in a $22.5 billion package of pandemic recovery proposals – defined as the minimum to meet pandemic management requirements. And yet, this was reduced to some $5 billion (in late March or so) – another “absolute minimum”.  And then this was pared down to a mere $1 billion in or around May.  And not even than has been enacted. And now, oddly enough, one sees no push at all for new funding  to supplement whatever the US had already committed to doing way back at the end of 2020!

The latest legislative maneuver has replaced the Build Back Better Act with the “Inflation  Reduction Act” that is about to pass before the August recess of Congress. The media focus on this new package is on the combination of climate change provisions, but it also has a significant set of changes to drug pricing in the US. This is probably a far more far-reaching set of changes than anything to do with the IP issue at the WTO, and I suspect that the Biden Administration has essentially traded off a visible role on the IP issue with a more comprehensive effort to bring drug prices down in the US itself. Given the fact that the pharmaceutical industry has regularly defended a globally multi-tiered drug pricing strategy (with American drug prices being the highest), this latest effort to control US drug prices is a direct challenge to the industry’s multi-tiered strategy.

More and More Critics of Vaccine Nationalism

To return to the dilemma of what to do about a global strategy for vaccines, diagnostics and treatments in response to a global pandemic like COVID-19, I have been truly discouraged by the way that vaccine nationalism has operated to undercut a global approach. I don’t seem to be alone about this, and I will wrap up this particular commentary by commending some of the people and organizations that are documenting this disappointment and exploring ways to deal with it in the future.

The WHO, of course, continues to be the obvious center of global health diplomacy. The coordination of information about the pandemic has been well managed by the WHO, and I appreciated many of its daily briefings online. Furthermore, it is both where the ACT-Accelerator started and where related GAVI and CEPI initiatives have been linked, including the COVAX Facility. I have been following (trying to follow) the ACT-Accelerator Facilitation Council since its inception from afar.  I note that the WHO website does show that the Council has some 33 governments plus three non-governmental organizations – the Bill and Melinda Gates Foundation, the Wellcome Trust and the World Economic Forum. These three are actually represented on the Council.  Other non-state actors are also “regularly invited” to Council meetings, including two civil society representatives (but no names given), plus Unitaid, IFPMA, National  Academy of Sciences and a host of others (European Commission, Gavi,  FIND, Global Fund, UNICEF, etc).  This may still be very non-participatory, as it were, but it is encouraging to note their presence.

Then, the WHO is also pursuing other changes – amending the International Health Regulations, developing a possible new international instrument to address pandemics, and a reform of the organization itself.  There was an interesting online hearing for the pandemic treaty in April that was widely attended with both oral and written statements. And a second hearing is set for September. The participants came from the multiple non-state actor categories that the WHO has developed – in contrast to many other international organizations and the UN.  So there were speakers or written statements on behalf of charitable organizations (e.g. Bill and Melinda Gates Foundation), private sector organizations (IFPMA), private sector individuals, civil society groups, academic groups  and the likes of GAVI, CEPI and so forth.

The COVAX Facility, too, has been revamped with a new Pandemic Vaccine Pool – launched in January and featured at the  2022 Break COVID Now Summit that GAVI organized with G7 and G20 and African Union support. This adds to existing fund-raising with a focus on pooling funds for the future. And then there is also a COVAX Vaccine Manufacturing Task Force for broadened geographic deployment capacity.  Fair enough. The COVAX Facility still gets a lot done.  Check out these news releases (one on the April summit here and the other on expanding manufacturing capacity here) on the COVAX website that shows both the momentum and the multi-stakeholder support for this initiative.

Other groups are also being mobilized to call for more equitable pandemic responses. The Global Health Centre at the University of Geneva, for example, is a repository of information on what is happening globally. Its founder and chair of its International Advisory Board Ilona Kickbusch works with an excellent team of global health scholars and experts. In a recent G7 publication, Professor Kickbusch listed some eight or ten different initiatives at the global level, starting with the ACT-Acceleratory but encompassing quite a variety of initiatives. My sense here is that these are the many ways in which health experts are interacting and collaborating globally, even where policymakers have otherwise been slow to mobilize.

In the US itself, I have observed a growing number of individuals and efforts that are acknowledging that the US response to the COVID-19 pandemic has failed to live up to its past leadership in global health.  The most obvious cited example of past leadership is the US response to the HIV/AIDS crisis – and especially the PEPFAR initiative spearheaded by President George W. Bush in 2006.  I am impressed with the work being done at the  Global Health Program of the Council on Foreign Relations, directed by Tom Bollyky, and especially the series of articles on global health by David Fidler.  I also like the work being done by the Center for Transformational Health Law at the O’Neill Institute for National and Global Health at Georgetown University.  A survey done by the O’Neill Institute looked at how other international initiatives in the past have facilitated multi-stakeholder involvement without necessarily being included in the official or intergovernmental governance of these initiatives (e.g. forums for dialogue as part of the Convention for Biological Diversity). This suggests an informal evolutionary approach to multi-stakeholder engagement that might be replicated in whatever “pandemic preparedness and response” might be institutionalized in the future.

I suppose the US-driven initiative to establish a FIF (Financial Intermediary Fund for Pandemic Prevention, Preparation and Response) at the World Bank is one of the more formal intergovernmental ways of going about this future path. I know others have suggested (e.g. this article by Emily Boss and Asia Russell in the CFR’s “Think Global Health”) an expanded Global Fund (the one focusing on HIV/AIDS, TB and malaria) as a more credibly multi-stakeholder approach. And, of course, there is the GAVI and CEPI framework as offshoots from the WHO.  And the WHO itself. Plus, I wonder about this business of a Global Health Threats Council or Board or Fund or some such that would conceivably elevate to a higher intergovernmental level than even the WHO the concerns about global health.

I could keep on and on, I guess. I’m almost talking myself back into being inspired, in spite of the appallingly nationalistic way that the COVID-19 pandemic has been handled so far. But not yet. I leave this series of commentaries for now and hope that we are entering into an “endemic” phase of this particular pandemic even as I fully appreciate that future pandemic preparedness must learn from the mistakes of this one.


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