Coronavirus vaccine: How will poorer countries get a fair shot?

It is an unseasonably cold October day in Johannesburg, and Robyn Porteous is following a handful of others up the stairs of a clinic at the Reproductive Health and HIV Institute at the University of the Witwatersrand (Wits).

“I think they have you do this just to prove you don’t have COVID,” quips the 32-year-old digital marketer, as she passes another landing. Three more flights of stairs to go, not that the marathon runner is showing any signs of strain.

The group eventually arrives at a small waiting room. Black plastic chairs are arranged in a neat socially-distanced square. Despite the weather outside, the windows are open and through them the tops of brownstone office buildings and pink and white apartment blocks shrouded in the morning fog are visible.

“Ventilation,” Porteous explains. The drafts travelling through the windows reduce the risk of transmission for airborne infections such as the novel coronavirus.

South Africa has just come through the country’s first wave of COVID-19. A television in the waiting room plays a local news report featuring the country’s health minister, Zweli Mkhize, speaking about the latest cases. A caption below his image reads: “Mkhize warns against complacency.”

Back in June, Porteous had a heated Twitter debate in defence of COVID-19 vaccine trials in South Africa. It eventually brought her to this very room two months later – where she took her first injection as a volunteer in the AstraZeneca COVID-19 vaccine trial, one of four currently ongoing in the country.

“It was as much like a rise to a challenge as it was just wanting to kind of do something,” she says of her decision to join the study. “You feel really helpless in a pandemic. I can’t donate endless amounts of money but can hopefully donate my body to some kind of scientific research that matters.”

Porteous will now be one of about 2,000 people in the study, which follows an earlier UK trial study that found the vaccine was safe and showed promise in helping the body mount a possible defence to COVID-19.

Vaccine nationalism: Many rich countries claim the ‘lion’s share’

More than four dozen potential COVID-19 vaccines are in human clinical trials, according to the World Health Organization (WHO). Four are being tested in South Africa.

But before any of these jabs have been proven to work, there is another looming roadblock: Some parties, including the United States, European Union and the United Kingdom, are staking their claim to what Oxfam senior policy adviser Mohga Kamal-Yanni calls the “lion’s share” of doses.

A recent analysis by Duke University found that countries have already confirmed purchases for 3.8 billion doses and a further 5 billion doses were under negotiation or had been reserved as of late October. Of course, not all experimental immunisations will successfully make it through clinical trials. The US, followed by the EU and India, have so far secured the largest number of potential doses, according to the report.

In September, US Republican Senator Thom Tillis introduced the America First Vaccine Act. If signed into law, the act would prohibit the export of any COVID-19 vaccine developed using government funding until firms had met US demand for it.

“Once that vaccine is developed, Americans should get the vaccine first, before it goes to other countries … ensuring that they receive a return on their investment,” Tillis said in a statement.

The US government has invested at least $11bn in COVID-19 vaccine development, according to US consumer advocacy organisation Public Citizen.

The brand of vaccine nationalism behind Tillis’ proposed legislation is not new. During the 2009 H1N1 flu outbreak, high-income countries able to produce vaccines refused to export them until their domestic needs were met, researchers wrote in 2019 in the healthcare journal The Milbank Quarterly.

For a new pandemic, COVID-19 brings with it decidedly old problems when it comes to vaccines – and the world is looking to a decades’ old solution to help.

COVAX: Subsidies and solidarity

In April, the public-private vaccine partnership GAVI launched the COVAX initiative. COVAX aims to pool nations’ purchasing power – and donor funding – to secure a minimum number of affordable vaccines for participating countries through what is called an advanced market commitment. So far, COVAX has secured a possible 700 million potential doses of COVID-19 vaccines, outpacing even the UK, Japan and Canada, according to Duke University.

As part of COVAX, poor countries will pay a subsidised price of up to $4 for a two-dose vaccine. Initially, COVAX promised free vaccines to low-income countries, but a September decision by GAVI’s board opted to introduce a cost-sharing plan with countries. Still, GAVI says there is some flexibility in this requirement and that countries can make a case for why they cannot afford the discounted prices.

Middle and high-income countries will pay in full for stocks procured through COVAX. Nations that may have already reserved supplies of some vaccines can also opt to use COVAX to buy doses they were not able to secure through bilateral deals.

The US has already said it will not join COVAX.

Ultimately, COVAX hopes to procure two billion vaccine doses by the end of 2021 and guarantee participating countries enough vaccines to immunise up to 20 percent of their populations. As of 19 October, 82 countries had signed legally binding contracts to join the initiative, which has already raised more than $2bn in funding.

COVAX draws on GAVI’s success with a similar 2005 initiative to introduce a pneumococcal vaccine. Pneumococcal disease is a bacterial infection that can lead to fatal conditions such as meningitis and pneumonia; hundreds of thousands of children died from it in lower-income countries before this initiative.

But 15 years later, will COVAX be enough to guarantee countries a fair shot at a future COVID-19 vaccine? The mechanism may not be perfect, say some, but it might be many countries’ best – and only – option.

Vaccine scepticism: ‘People build up what they think a trial is’

Back at the vaccine trial at Wits, a doctor in dark blue scrubs enters the waiting room.

“Number 1403?” he calls out. A young man looks up from the phone he has been scrolling through and rises to meet him before the pair head off down another hallway.

Porteous, the daughter of healthcare workers, grew up watching VHS tapes of surgeries. Medicine, she says, was dinner table talk. Still, it doesn’t mean her parents were thrilled that their daughter signed up for a clinical trial.

“My parents, being medical, understood the need for the trial, but they were like, ‘We don’t necessarily want our daughter doing it’,” she says. “But once I went through the science behind it with them, explaining, it’s not like they’re injecting you with COVID, they were fine with it.”

She adds: “Everyone kind of hears ‘COVID vaccine trial’ and their mind goes to the worst possible result.”

She reflects on the Twitter debate that brought her to the study. Other South African Twitter users had expressed concern that an experimental COVID-19 vaccine was being trialled in Africa. But it had already been proven safe in human trials in the UK, Porteous explained in a tweet.

“So why don’t you volunteer?” came the response from one Twitter user.

“What surprised me a lot from being online and on Twitter was the perception of this vaccine trial,” Porteous tells Al Jazeera. “From the get-go, people were convinced that there were these nefarious intentions involved.”

“I felt like that made it even more important for me to take part so I could say, ‘Look, I volunteered and I’m okay… nothing was done against my will,'” she explains.

“Number 1389,” a nurse calls out in the clinic’s waiting room. Porteous, who has been leaning against a doorway, steps forward and follows her into a small office.

“People build up what they think [a vaccine trial] is and it&#8217#8217;s almost like the truth can’t get through that … and that’s a bit of a problem,” Porteous says before she exits.

A history of medical colonialism

But those who are sceptical can point to a long history of medical colonialism in Africa – some of it in the not-so-distant past.

During the German colonisation of Namibia in the late 1800s and early 20th century, for example, the Herero and Nama people were forced into concentration camps. In one camp, a German doctor injected prisoners with arsenic and opium in a failed bid to study vitamin C deficiency.

German professor of medicine, and future Nazi, Eugen Fischer visited the country during this time to collect what is estimated to be hundreds of skulls and skeletons of murdered Namibians for “research”, writes University of Namibia Professor Vilho Amukwaya Shigwedha in a 2018 book. Germany has begun to repatriate these remains.

Karsten Noko is a Zimbabwean lawyer and medical humanitarian worker who has written about the ways in which colonialism has shaped medicine in Africa.

In the 20th and 21st century, medical colonialism may look quite different but it still betrays what Noko says are double-standards when it comes to medical ethics. What is done to African bodies, he tells Al Jazeera, is not always what would be done to those in the Global North.

In 1996, pharmaceutical company Pfizer tested an experimental drug on 200 Nigerian children without parental consent. Community members eventually sued Pfizer and settled out of court.

Almost a decade later, blood samples taken from Ebola patients during West Africa’s 2014 epidemic were subsequently relocated in secret to laboratories as far away as the UK without patient consent, the Telegraph newspaper discovered.

Noko says that incidents such as these – coupled with a lack of transparency from pharmaceutical companies around trials, medicine pricing and patents – fuels distrust. Meanwhile, there remains a dire need for diverse clinical trial data to ensure that medicines and vaccines work for everyone, including Africans.

“We understand that if people are not willing to consent to clinical trials, then we do not get drugs. That’s not what we want,” he explains. “But what I do think we should be calling for … is much more transparency about what happens and much more protection from states.”

Today, clinical trials in countries like South Africa, Kenya and Uganda are subject to heavy regulatory oversight and must meet stringent national and international standards that ensure that patients are protected, that communities have a say in clinical trials and, in some places, that African scientists play leading roles in local research.

Dr Kathy Mngadi is a clinical research site leader with The Aurum Institute and helps head major HIV vaccine trials in South Africa. As a researcher, she says she understands why some people might distrust and misunderstand research studies.

“I think one of the remnants of apartheid and colonialism has been a deep mistrust by the majority of the population of not just past but even current government structures,” she says.

Allegations of government corruption related to the country’s COVID-19 response and the poor quality of public health services in some areas only add to this distrust, she explains.

But HIV clinical trials like the ones Mngadi leads have also helped spearhead a solution.

HIV activists and researchers have largely led the global push for meaningful community participation in trials. This means that representatives from communities that could be affected by trials or who live in the surrounding area should be involved in the design, running and post-trial follow-up of research trials.

Today, in large part thanks to HIV activists and scientists, community participation is part of international best practice when it comes to all human clinical trials.

“We need to involve the community from the beginning so that we see research is not something that is done to communities, but rather that it’s done with communities,” Mngadi explains.

At least three of the major COVID-19 vaccine trials in South Africa are using existing HIV research sites, which have long-standing community advisory boards comprising community leaders and representatives who ensure community interests are safeguarded during the trial process. Additionally, independent experts monitor trial data and can call for studies to be halted if anything goes wrong.

Still, Mngadi knows scientists have a long way to go when it comes to helping the public understand the ways clinical trials work to ensure volunteers are safe and that communities benefit from medical research conducted where they live.

“When I see a social media posting or article in South Africa about people being used as ‘guinea pigs’ it becomes quite clear to me that people are not aware of all of these layers of protection that are put in place during clinical trials,” she says.

“You can’t blame them because they don’t work in clinical research, but I do think it’s important for researchers to continuously get that message out.”

COVAX round one: Lessons from pneumococcal disease

About 30km south of the Wits clinic in Johannesburg, the sign for Soweto’s Chris Hani Baragwanath Academic Hospital stretches across five lanes of traffic entering and leaving the facility – a testament to how large and busy the township hospital is.

Wits Vaccinology Professor Shabir Madhi’s office sits on the 11th floor of the nurses’ residence at the hospital. From the floor-to-ceiling windows, Soweto stretches out in a patchwork of red, white and sandy-coloured roofs.

By 2005, more than 100,000 children under the age of five were being admitted annually to facilities just like Chris Hani Baragwanath in South Africa with pneumococcal disease.

Globally, hundreds of thousands of children under the age of five were dying annually from the disease. Almost six out of 10 such deaths were in Africa by 2008, according to the WHO.

A vaccine to prevent pneumococcal disease had debuted in the US in 2000 but, eight years later, was still too expensive for countries in the Global South.

Developing a new vaccine is a risky business financially. It can take decades and millions of dollars to produce a new immunisation, according to the US Center for Global Development. If poorer countries cannot afford to pay, firms do not invest in producing vaccines because they cannot be assured of a return on investments.

In the early 2000s, global health experts came up with an idea to overcome this – an advance market commitment. The concept seems simple: If poorer countries pooled their buying power, they could assure would-be vaccine makers of their ability to pay for large volumes of doses upfront.

Vaccine-makers would be guaranteed a return on investment and, in exchange, would promise immunisations at a pre-agreed price for a certain period – much like COVAX.

Activists have long known that markets do not work to provide medicine for those who need it most. That is why in 2016 a high-level United Nations panel of experts proposed advance market commitments as one of a series of innovative funding approaches to ensure that the cost of making a medicine or vaccine did not necessarily determine its price.

In 2007, GAVI piloted the idea with an advance market commitment for the pneumococcal vaccine. As part of the agreement, companies committed to providing doses for a fraction of what countries would typically pay – $3.50 instead of $50 per dose, according to 2008 prices.

Previously, low-income countries had to wait decades before vaccines that were available in the Global North reached their shores, but GAVI’s advanced market commitment changed that, says Professor Madhi.

“With the pneumococcal vaccine, that 20-year lag time was reduced to 10. And it’s all about the funding model,” explains Madhi, who is also the lead researcher on two of the COVID-19 vaccines being tested in the country as of late October through the university’s Vaccines and Infectious Diseases Analytics (VIDA) unit.

Less than a decade after GAVI’s first advance market commitment launched, 54 countries from Afghanistan to Zimbabwe were able to roll out the pneumococcal vaccine, an independent review by the Boston Consulting Group (BCG) found. And by 2015, the deal had saved the lives of almost 300,000 children.

Because South Africa is considered a middle-income country, it did not qualify to get cheaper pneumococcal vaccines through GAVI – and it will not get heavily subsidised COVID-19 vaccines if it signs onto COVAX.

Despite this – and largely through its own efforts – in 2009, South Africa became the first African country to introduce vaccines to prevent both pneumococcal disease and rotavirus, which causes diarrhoeal disease. The move was in part because of research conducted by Madhi and his team at the Soweto hospital, including one of the first pneumococcal vaccine studies.

Personal and public health value: The rotavirus vaccine

The earliest human clinical trials into any new vaccine will test it among a small group of people to make sure a jab is safe but not if it works. Safety data such as this is more-or-less universal from one country to the next, Madhi explains. But genetics, living conditions, and how much of a given disease is circulating in a population can all play a role in how well a vaccine works from one population to the next.

Differences like these may explain why a 2010 study published in the New England Medical Journal by Madhi found that the rotavirus vaccine aimed at protecting children from diarrhoeal disease was less effective in Malawian infants than in South African children.

Why? Madhi and his team believe that it is because of the higher prevalence of rotavirus in Malawi. Babies there are more exposed to the virus by the time they reach five months and develop some natural immunity to it. Adding a vaccine only boosted this existing immunity a little.

In contrast, most South African infants have no pre-existing immunity to rotavirus because there is less of the virus circulating in the country, meaning they are less likely to be exposed to it as babies. For children like these on an individual level, the vaccine made a bigger impact because they had zero immunity to the virus, to begin with.

But on a population level, the result of this looks different. Madhi and his team found that for every 100 babies