By Zain Rizvi
By December 2020, the world had astonishingly powerful tools against COVID-19. New mRNA vaccines, underpinned by decades of public investment, had been authorized by global regulators. Yet the promise of the vaccines was unevenly realized: deep fault lines emerged between those who were able to secure vaccines and those left behind, or what South Africa’s president Cyril Ramaphosa called “vaccine apartheid.”
Dose shortages elevated the role of pharmaceutical executives. Fielding calls from heads of state, they decided what vaccine deliveries to prioritize, shaping which countries could protect lives and livelihoods. The answer to one of the most important public health questions of our time — who gets access to vaccines? — was mostly determined neither by political representatives nor scientists, but by corporate executives.
Private decisions did not match public health need. Pharmaceutical corporations hoarded technology that could have helped alleviate scarcity. Some also extracted contractual commitments that led to accusations of bullying, charged low-income countries more than high-income countries, and delayed deliveries to initiatives supplying developing countries.
At the end of 2021, Thomas Cueni, the head of an international pharmaceutical trade association, acknowledged that everyone was “ashamed and embarrassed” by the inequity. “We also have to admit we dismally failed in terms of equitable rollout, equitable distribution, and that is something we really need to do better in 2022,” Cueni said.
Underpinning this private power was intellectual property (IP). Patents and trade secrets empower private actors to make decisions about pricing, production, and supply of important medical technologies — in short, about public health. Monopoly control presents profound questions for public health governance.
This ascension of private IP holders in the pandemic was accompanied by a retreat from the global stage by powerful public actors. Consider the United States, for example, which made the unprecedented move to leave the World Health Organization (WHO) during the pandemic. Around the same time, it poured billions of dollars to accelerate vaccine development, without obtaining a single contractual commitment to protect global access. Months later, the U.S. rejoined the WHO, supporting a global vaccine initiative by delivering dollars and doses, but not at the ambition and scale required. Efforts at the World Trade Organization to waive global IP rules during the pandemic similarly floundered after the U.S. failed to back a historic shift in policy with real political resources. Finally, Congress failed to fund global vaccine assistance, turning its back on the world.
Together, these decisions had a profound impact on global public health. The vaccines were first authorized in December 2020. Since then, millions of deaths have been recorded around the world — with many people unable or unwilling to get shots that could have saved their life.
No one was left unaffected by the inequity. The story of how the U.S. reached one million deaths cannot be told in isolation from how the virus spread globally. Sustained global SARS-CoV-2 transmission, along with deep inequalities in vaccine access, led to the emergence of new variants that were able to spread faster, cause more serious disease and/or escape the immune response. In a pre-print published with researchers at the Yale School of Public Health, we analyzed the burden of mortality from each variant as the U.S. reached the one million death mark. By May 12, 2022, over 40 percent of national COVID-19 deaths were caused by WHO-designated variants. Alpha, Delta and Omicron — which were first detected in Europe, Asia, and Africa — had led to 430,000 deaths. The analysis provided fresh evidence for what global health advocates had been saying all along: no one is safe until everyone is safe.
Yet beyond charity-driven initiatives, exceedingly few parts of our response to the worst global public health crisis in a century were either globally-organized or publicly-led. The failure to rapidly vaccinate the world underscores the urgent need for a new approach. What could that look like?
We could start by reclaiming the role of the public in the development of new health technologies. Public dollars should come with obligations to serve the public interest — from pricing to technology transfer. IP should not stand in the way of ending epidemics. We could also organize and fund global health in a way that recognizes its centrality to our own health.
Most fundamentally, we need to develop new understandings of what it means to keep people safe; to reconceptualize how we structure the production of knowledge, so as to not allow patent holders to erect fences around lifesaving knowledge; and to resist the idea that private economic interests can be left in charge of global public health.
Zain Rizvi is a research director at Public Citizen. He has provided technical assistance to governments, investigated public rights in taxpayer-funded technologies, and analyzed neglected legal authorities to increase access to medicines.