By Tlaleng Mofokeng, Daniel Wainstock, and Renzo Guinto
In recent years, there have been growing calls to “decolonize” the field of global health. Global health traces its roots back to colonial medicine when old empires sought to address tropical diseases which, if not controlled, could be brought by colonizers back home.
Today, many countries in the Global South may have already been liberated from their colonizers, but the colonial behavior of global health continues to manifest in policies, funding, research, and operations.
Unlike the tropical diseases of the past, SARS-CoV-2 has affected rich and poor countries alike, but the tools for putting this pandemic under control — most notably vaccines — remain unevenly distributed across the world. As of October 27, 2021, 63.5% of individuals in high-income countries have been vaccinated with at least one shot of the COVID-19 vaccine. Meanwhile, in low-income countries, only 4.8% of the population has been vaccinated with at least one dose.
To make sure that COVID-19 is the last pandemic of its kind, the international community is considering the creation of a new pandemic treaty. The goal of such a legal instrument is to enhance the world’s capacity to predict, prevent, detect, assess, and respond to future disease outbreaks.
This treaty cannot become another agent of the perpetuation of global health’s coloniality. One of the ways to “decolonize” the treaty is to ensure that vaccine equity is at its very core.
There is still an opportunity to achieve vaccine equity for this current crisis, but cementing it in a pandemic treaty will ensure that this goal remains should another pandemic emerge in the future.
Promoting vaccine equity between and within countries
Vaccine inequity is occurring between and within countries during the COVID-19 pandemic. A future pandemic treaty must ensure this does not happen again.
In order to ensure vaccine equity globally, actions must be taken through international cooperation and assistance. A statement of the UN Committee on Economic, Social, and Cultural Rights emphasizes this imperative. International cooperation with respect to vaccines is vital because many low- and middle-income countries (LMICs) do not have the financial resources to guarantee the vaccination of their population. According to the United Nations Development Program (UNDP), low-income countries have to increase their health care spending by around 56% to afford to immunize 70% of their citizens.
To ensure that vaccine equity exists not only between countries, but also within them, it is crucial to uphold the principle of non-discrimination. As noted by the UN Special Rapporteurs on the human rights of migrants and on the right to health:
“In times of crisis, the focus should be given to international solidarity, equality, and inclusiveness. We call on world leaders to refrain from discriminatory discourses that may lead to the exclusion of certain groups (…). The prioritization of vaccines within countries should include all those who qualify under a priority group, regardless of who they are.”
Reforming intellectual property rights
The TRIPS Agreement, which establishes global intellectual property standards, has caused an adverse impact on the availability of vaccines. Therefore, the UN Committee on Economic, Social, and Cultural Rights argues that States should use, when necessary, all the flexibilities of the Agreement to ensure universal access to vaccination.
The Doha Declaration, enacted in 2001, attempts to address global inequities stemming from intellectual property protections by allowing countries to grant compulsory licenses for the production of pharmaceuticals for international exports. However, the Doha Declaration has not been capable of ensuring vaccine equity during the current pandemic. Accordingly, the delegations of India and South Africa, co-sponsored by many developing countries, submitted to the WTO TRIPS Council a proposal for a temporary TRIPS waiver in response to COVID-19. The World Trade Organization (WTO) members should endorse the waiver proposal, which will expand licensing agreements and facilitate technology transfer.
Another vital measure to promote vaccine equity is building vaccine manufacturing capacity in the Global South, as argued by The Independent Panel. The African continent, for instance, has less than 1% of the world’s vaccine manufacturing capabilities. To address this issue, the World Health Organization (WHO) created the COVID-19 Technology Access Pool (C-TAP), a platform for developers of COVID-19 vaccines and other health products; which enable them to voluntarily share their scientific knowledge, know-how, and intellectual property rights with manufacturers, especially from LMICs.
Though the “paragraph 6 decision” regarding the Doha Declaration already addressed the issue of manufacturing capacity in 2003, it has not effectively solved the problem. In light of this, the UN High-Level Panel on Access to Medicines recommended that WTO Members should revise the decision to find a solution that enables expedient exports of pharmaceutical products produced under compulsory licenses. The pandemic treaty can incorporate this revision to allow accelerated vaccine production and distribution in the case of future pandemics.
Reshaping the COVAX Facility
The COVAX Facility was created to avoid vaccine monopoly by wealthy countries, as what happened during the swine flu pandemic. Still, during the COVID-19 pandemic, the consortium has faced the drastic consequences of “vaccine nationalism.” For example, the U.K., U.S., and Israel have decided to roll out booster shots in times of vaccine scarcity, when doses are much needed by COVAX for developing countries. Moreover, the lack of inclusive governance, little financial support, poor transparency, and supply constraints have impaired COVAX’s capacity to promote global vaccine equity.
Therefore, the COVAX Facility should increase transparency by publishing contracts and procurement prices. Moreover, stakeholders must monitor commitments by suppliers to reducing profit through third-party audits, the results of which must be publicly shared. Accountability mechanisms are also imperative to ensure the facility’s effective functioning.
Given COVAX’s supply shortages, the WHO should consider supporting other actors as well, such as the African Union Vaccine Acquisition Task Team (AVATT) — an initiative that aims to provide access to COVID-19 vaccines for Africa. These reform measures for reshaping COVAX must be taken into account by a pandemic treaty to ensure a sustainable global supply of vaccines during future pandemics.
Decolonizing starts with vaccines
There surely are many other aspects of the pandemic response that will need to be reformed and “decolonized” – for instance, pandemic policy and guideline development, knowledge and information sharing, and global health financing flows. But putting vaccine equity at the center of a pandemic treaty will already be a huge step towards global health’s decolonization.
Tlaleng Mofokeng, MBChB is the United Nations Special Rapporteur on the Right to Health.
Daniel Wainstock is a law student at Pontifical Catholic University of Rio de Janeiro (PUC-Rio) and Research Assistant to the United Nations Special Rapporteur on the Right to Health.
Renzo Guinto, MD DrPH is Associate Professor of the Practice of Global Public Health and Inaugural Director of the Planetary and Global Health Program of the St. Luke’s Medical Center College of Medicine in the Philippines and Chief Planetary Health Scientist of the Sunway Centre for Planetary Health in Malaysia.
The authors are grateful to Catarina Vallada, Mariana Torquato, Julie Huffaker, and Bianca Carvalho for their thoughtful research assistance in developing this article.