Editorial
Global vaccine equity demands
BMJ Global Health: first published as 10.1136/bmjgh-2021-006504 on 21 June 2021. Downloaded from https://gh.bmj.com on 12 December 2024 by guest. Protected by
reparative justice — not charity
Sophie Harman,1 Parsa Erfani ,2,3 Tinashe Goronga,4 Jason Hickel,5
Michelle Morse,2,6,7 Eugene T Richardson 2,6
To cite: Harman S, Erfani P, INTRODUCTION THREE LIMITED ‘SOLUTIONS’ TO VACCINE
Goronga T, et al. Global By late April, more than 80% of the world’s INEQUITY
vaccine equity demands
reparative justice — not
COVID-19 vaccines had gone to people in There are currently three approaches to
charity. BMJ Global Health wealthy countries, with just 0.3% to people reduce inequity in COVID-19 vaccine distri-
2021;6:e006504. doi:10.1136/ in low- income countries.1 This reprehen- bution: bilateral charity, multilateral charity
bmjgh-2021-006504 sible imbalance is no accident. High-income and temporary waivers or suspensions of IP.
countries have used neocolonial negotiating The first is the most straightforward.
Received 2 June 2021 power, global policy leverage and capital to States that stockpile COVID-19 vaccines have
Accepted 4 June 2021 procure enough doses to cover 245% of their committed to sharing their leftovers with
copyright.
citizens while leaving few doses for poorer low-income and middle- income countries.
countries.2 As a result, lower- income coun- Norway was one of the first nations to accede
tries may not be able to vaccinate their popu- to donating doses to poorer countries in
lations until 2023.3 parallel with its vaccine programme.10 This is
Such inequity is yet another example of the weakest form of equity as it is unclear if
how the interests of racial capitalism run this will be done for free, at a lower cost, tied
roughshod over the golden rule of global to diplomacy or conditionality, or crucially,
solidarity—attend to the highest risk first.4 when these vaccines will be made available,
Currently, older and medically vulnerable where they will go, or how many will be deliv-
© Author(s) (or their
individuals are dying from COVID-19 dispro- ered. The bilateral charity approach has little
employer(s)) 2021. Re-use portionately in poor countries, while young, to do with equity and more to do with geopol-
permitted under CC BY-NC. No healthy individuals are getting vaccinated itics, wealth and aid dependency.11 12
commercial re-use. See rights in wealthy ones.5 Vaccine apartheid is a not The second is multilateral charity, best
and permissions. Published by
BMJ. novel phenomenon. The notion that only exemplified by COVAX. In 2020, COVAX
1
Politics and International
certain corners of the world get to benefit emerged as an international collaboration
Relations, Queen Mary from life- saving treatments is an everyday by the World Health Organisation (WHO),
University of London, London, reality of a global health system driven by United Nations Children’s Fund, Gavi and
UK
2
a capitalist, philanthropic model.6 7 But in the Coalition for Epidemic Preparedness
Department of Global Health times of crises—and as new variants threaten Innovations to ensure equitable global access
and Social Medicine, Harvard
Medical School, Boston,
the vaccination plans of wealthy countries— to COVID-19 vaccines.13 Rich countries can
Massachusetts, USA these inequities and their solutions come to access doses for 10%–50% of their popula-
3
University of Global Health the forefront of global debate.8 tions, depending on how much they have
Equity, Butaro, Rwanda Policy-
makers in rich nations are aware paid in, and poor countries can access doses
4
Centre for Health Equity of these issues. But the solutions they have for 20% through the scheme. It is the 20% for
Zimbabwe, Harare, Zimbabwe
5
Department of Anthropology, proposed so far do nothing to address the poor countries that has come to be COVAX’s
London School of Economics, underlying structural problems. They offer unique selling point: here is a mechanism that
London, UK charitable donations and partial, tempo- ensures every country in the world can get the
6
Department of Medicine, rary fixes that are designed to deflect the vaccine regardless of ability to pay. This is the
Brigham and Women's Hospital,
substantive demands for reform that global first time such an initiative has been trialled.
Boston, Massachusetts, USA
7
New York City Department of South countries are fighting for, including The shortcomings of COVAX are numerous.
Health and Mental Hygiene, New challenges to unethical intellectual property If vaccines are delivered as planned, COVAX
York, NY, USA (IP) regimes.9 This approach will not work, may reach 27% of the population in lower-
because it is not designed to ‘work.’ If we want income countries by the end of 2021—a
Correspondence to
Dr Eugene T Richardson;
to end vaccine apartheid, we need to target depressing goal compared with the estimated
eugene_richardson@hms. the root causes of global health inequities. We 70% coverage needed for herd immunity and
harvard.edu need reparative justice. the open vaccine access currently granted to
Harman S, et al. BMJ Global Health 2021;6:e006504. doi:10.1136/bmjgh-2021-006504 1
BMJ Global Health
Americans.14 15 Furthermore, COVAX is still significantly to ramp up production by repurposing existing manu-
BMJ Global Health: first published as 10.1136/bmjgh-2021-006504 on 21 June 2021. Downloaded from https://gh.bmj.com on 12 December 2024 by guest. Protected by
underfunded and there are concerns regarding supply facturing capacity.25 In addition, an IP waiver can and
chains. should be supplemented with technology transfers, logis-
While capital and resource transfer from wealthy tical support and financial investment to facilitate this
countries to poorer ones is surely needed in the current repurposing process. And the most important point is
pandemic response, any system that solely relies on aid that such a waiver could drastically reduce costs across
will ultimately fail to achieve equity. In the setting of the board, making vaccine imports more affordable for
vaccine scarcity, in which suppliers are unable to deliver poor countries.
doses as scheduled and countries are banning exports Opponents of the waiver also claim that IP- related
to keep vaccines at home, there is a risk that COVAX obstacles can be addressed through existing arrange-
aid-recipient states will fall further down the priority ments for ‘compulsory licensing’ under the WTO’s
list, awaiting the leftover vaccines from the rich country Agreement on Trade- Related Aspects of Intellectual
stockpiles.16–18 Property Rights (TRIPS).26 But the past evidence suggests
What may be most pernicious about the COVAX that this process is slow, cumbersome and subject to
scheme, however, is that rich countries and their phar- various shaming practices by the international commu-
maceutical companies have repeatedly used it as a shield nity.27 28 Some point instead to the possibility of volun-
to deflect demands for IP waivers. This is an enduring tary licensing. But voluntary licenses are often executed
problem with aid: it papers over and distracts our atten- secretly and are limited to companies or governments
tion away from the underlying structural violence. And that can afford them. The University of Pennsylvania,
in so doing, it maintains and perpetuates inequalities. which owns IP rights relating to the mRNA vaccines, is
Over 50 years ago, Kwame Nkrumah observed how aid helping Chulalongkorn University in Bangkok develop a
is a ‘revolving credit’ which returns to countries of the vaccine production facility. This partnership was possible
copyright.
global North in the form of increased profits.19 To the because Thailand—unlike other middle- income coun-
extent that COVAX is being leveraged to protect corpo- tries—was able to put up the money.29 Poorer countries
rate patents and profits, Nkrumah’s words continue to be are left out. Sharing of IP and technology transfers can
germane. and will accelerate global vaccine production. The ques-
The third approach is focused on pooling, temporary tion is on whose terms. Organisations such as the WHO
waivers, or suspension of IP. In May 2020, the WHO and African Union are currently mobilising support and
created the COVID-19 Technology Access Pool for resources to accelerate production in low-income and
companies to share IP and transfer technologies in a middle-income countries.30 31 But these efforts will be
coordinated manner. But to date, not a single company to waste unless IP for COVID-19 technologies is shared
has utilised the transfer process—likely because such broadly and quickly.
forms of global IP sharing would quell profits, even if
royalties are included.20 Pharmaceutical companies
and universities prefer one-off transfer deals because it VACCINE COLONIALITY
enables them to set their own terms with non-disclosure Donor-based approaches to vaccine equity are grounded
agreements. Given that they are accountable to share- in old, even colonial ideas of aid and dependency, which
holders and boards—not patients—financial incentives have failed to serve the health needs of the Majority
will drive transfer decisions, not public health demand. World or deliver on health equity. This failed model has
Following the blockages at the WHO around IP, not promoted health equity in the past and is clearly
attention shifted towards the World Trade Organisa- inadequate in the present, on account of dependency on
tion (WTO). In October 2020, India and South Africa donor whims (the bilateral ‘leftovers’ approach), persis-
proposed a temporary waiver of IP rights to COVID-19 tent funding gaps and shortfalls (COVAX), and time-
technologies for the duration of the pandemic, so that consuming diplomacy and filibustering over what is or is
all manufacturers with sufficient capacity and shared it not within current trade rules (WTO).
know-how could start production.21 Although backed by Once again in the political economy of global health,
over 100 countries within the WTO and a global campaign the charitable model of COVAX becomes the smoke-
for the ‘People’s Vaccine,’ the proposal has been repeat- screen for inequitable systems. When states are asked
edly blocked at every committee meeting since then by about their stockpiling, they point to COVAX. When
select wealthy countries with large pharmaceutical indus- pharmaceutical companies are asked about IP, they point
tries, including the UK, Japan and EU states.22 23 to COVAX or their low-cost commitment. The focus on a
Those who oppose the IP waiver argue that it will not donor-based model of aid in achieving vaccine equity has
do anything to solve the problem: even if you were to distracted leaders from the ideologies, economic systems
liberate the recipe for the vaccines, low- income and and trade regulations that leave access to medicine to
middle- income countries do not have the capacity to the forces of the marketplace rather than global health
produce it.24 But this argument is specious. For one, priorities.32 Achieving global vaccine justice requires a
several middle- income countries—including India, rapid shift in trade regulations and contract transparency
Brazil, Senegal and South Africa—do have the ability that streamlines IP sharing and technology transfers.
2 Harman S, et al. BMJ Global Health 2021;6:e006504. doi:10.1136/bmjgh-2021-006504
BMJ Global Health
The resultant collaborations across economies will not ORCID iDs
BMJ Global Health: first published as 10.1136/bmjgh-2021-006504 on 21 June 2021. Downloaded from https://gh.bmj.com on 12 December 2024 by guest. Protected by
only accelerate vaccine production but will also increase Parsa Erfani http://orcid.org/0000-0002-5738-0556
Eugene T Richardson http://orcid.org/0000-0001-8437-0671
competition and push vaccine prices down.
Finally, old models of vaccine equity have not kept
pace with changes in discourse and thinking around
global health governance, equity and justice. 2021 is REFERENCES
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4 Harman S, et al. BMJ Global Health 2021;6:e006504. doi:10.1136/bmjgh-2021-006504
