Emma Ross
Good afternoon, and thanks for joining us again for the Chatham House COVID-19 webinar series, with our Distinguished Fellow, Professor David Heymann. Today, we’re going to be talking about what’s going on with access to vaccines, with a different focus than we had when we talked about the COVAX facility a few months ago. We’re going to cover a broad range from what countries are doing outside of COVAX to buy or make their own vaccines, how that’s going, and what’s getting in the way, to vaccine nationalism and vaccine diplomacy.
With us to share their insights into these issues are Helen Rees and David Ellwood. Helen’s a Professor at the Witwatersrand University in Johannesburg. She’s one of South Africa’s powerhouse women Scientists, and the list of her senior advisory roles and board appointments in global health is huge, so I won’t go into that, but what I do want to highlight here is that she’s been actively involved in the COVID response at the national, regional and global level and is involved in almost all levels in the development of the vaccine. [Audio cuts out – 02:27] European and Eurasian Studies at Johns Hopkins University, based in Turin. He is a Historian who specialises in the politics of modernisation in Europe and in the last decade, in the study of soft power. During the pandemic, he’s been looking at how countries are using their vaccine supplies as geopolitical instruments to exert influence around the world. So, welcome to you both, this should be a really great discussion. Thank you so much for joining us.
Professor David Ellwood
Thank you.
Emma Ross
I’ll deal with the housekeeping first, the event’s on the record, as always, and if you’d like to ask questions, please write them in the ‘Q&A’ function on Zoom. Upvoted questions are more likely to be selected. You can put the questions in at any time you want, and it can be on any topic, it doesn’t have to only be on this topic, so if you have science questions or anything, please do go ahead. So, Helen, I was hoping we could start with you by getting an overview, access to vaccines has been a major focus of discussion at the highest levels around the world and we have the COVAX Initiative, which we are told is the game in town for global access that everyone should get behind as the vehicle. But what’s actually happening in reality on the ground, with people’s experience of accessing, countries that didn’t do advance deals, and is COVAX the only thing that’s going on, what else is going on, and how are we doing?
Professor Helen Rees OBE
Well, you’re quite right, I mean, COVAX is very important, but COVAX hasn’t gone at the speed that it would have really liked to go at, because of being able to access the vaccines, and also, some of the complications, such as the liability requirements that countries are required to satisfy. So, at the moment, COVAX had only got as far as 39 million, but, I mean, the prospects remain good, but there are problems there. There are several problems.
One is the impact of something that we’re seeing at the moment in India where this huge surge of infections has meant that the Indian Government has said, “Look, we need to close our borders to the export of vaccines.” So, the issue of exporting vaccines and vaccine manufacturers, we saw it right at the beginning of the pandemic, when the US wanted to prohibit and buy up products that were made, both vaccines and other products, that were made in the United States, thus limiting access to other countries. So, that is one of the problems.
Secondly, you’re quite right, that because countries are scared, even low middle-income countries, that they’re not going to get access in the way that they really feel they need, there’s a lot of bilateral negotiations going on and the problem with those is that they’re often shrouded in secrecy. So, we don’t know what the cost of the vaccines are when there are bilateral negotiations, but we do know, in one case, for example, the AstraZeneca purchased in South Africa was more expensive than that negotiated by the European Union. So, it doesn’t necessarily follow, in bilateral deals, that if you’re a low middle-income country that you’re going to get a more competitive price, that that is, sort of – and that’s really not clear.
The third thing is, and we often neglect this, I think, is that it’s one thing to buy the vaccines and to get the vaccines into the country, through whichever route, but the third thing is how – what is the ability of countries to be able to rollout a programme? These programmes are very different to the childhood immunisation programmes that many countries are familiar with and are good at doing, the EPI programmes. These are to adults, to specialised groups, to target populations, perhaps over 60s, these are not people that people have traditionally targeted in many settings, and the cost of those programmes is very expensive. In some cases, it can be as much as actually purchasing the vaccines, if not more, because you’re putting in place just a new, sort of, infrastructure. So, I think countries’ readiness and countries’ abilities to rollout, not only in low middle-income countries where this is just starting, we’ve seen it in Europe, the struggles to actually rollout the vaccines, even if you have the vaccines. So, I think that at the moment I would say, on a score of one to ten, ten being very good, where is the world? I think we’re about three. Some countries have done extremely well, as we know, but I don’t think that we’re anywhere near yet where we want to do, and just to reinforce what you said, COVAX is incredibly important for low middle-income countries.
Emma Ross
Thank you, Helen, that’s quite sobering and quite a poor score. David Heymann, would you agree with that, or what’s your take on where we are and whether the world in general is delivering on, you know, what we’ve said we all commit to? Those who have committed, not everyone’s committed, I guess.
Professor David Heymann CBE
You know, Emma, if you look throughout history, in recent years, the world has rallied behind access to vaccines for those who need them. This happened first in the smallpox eradication programme, which was the first real programme to get 100% access to a vaccine that was necessary for the risk groups. And then the polio eradication programme came along, and then there was a glitch in the getting the availability to pandemic influenza vaccines and a group at WHO, a, intergovernmental group, developed the Pandemic Influenza Preparedness Framework, which has provided vaccines for pandemic influenza, which will provide them, from companies to WHO at no cost, about 10% of their production capacity, to use in developing countries. So, we’re making progress and, of course, routine childhood immunisations have always been available through an effort of UNICEF and WHO and many donor countries, including the UK, which has been one of the major contributors to getting vaccines out to children in need. So, the world has always rallied behind, and I believe that they will rally behind again vaccines for COVID, but it’s not easy.
Production capacity, as Helen said, is quite low. We’re not able to get the production that we need because there have been pre-purchase commitments already by many countries to get that vaccine. So, production is having trouble meeting global needs, but I think that gradually, as time goes on, people are going to see that countries are taking advantage of getting vaccines to people for one of three reasons. Number one, either, because the country has humanitarian goals, which many countries do have in their development assistance. Number two is that if they should see in any way that getting vaccines to countries and getting them effectively used decreases the emergence of strains, which might be variants that escape vaccines, they would then see an interest nationally in doing that and they might contribute even more. And then, finally, I know you’re going to talk about this with David later on, is soft power, countries are actually giving vaccines for soft power. So, a short answer to your question, Emma, is that throughout the recent history, there has been a rally behind getting vaccines out to the people who need them, and despite the glitches early on in COVAX, I’m sure that that facility is a step forward in making sure that this will happen over time. Remember, these vaccines have only been available since, really, January.
Emma Ross
Yeah. Okay, thank you, David. Helen, I just wondered, particularly in Africa, since that’s your area, I’m just wondering for countries – low and middle-income countries that are going to be dependent, that haven’t done these advanced deals to secure their vaccines, are they happy to wait for COVAX to deliver to them as and when it’s their turn, or as and when they can get it, or are countries taking action for themselves, or regional blocks, outside of the COVAX? I’m interested in what’s going on outside of COVAX facility, is there a lot of activity or are pretty much most people just waiting ‘til COVAX gives them something?
Professor Helen Rees OBE
I mean, I think that’s a really important question and if we look at the African region, in fact one of the – if there are good things out of COVID, and I think there will be wonderful lessons learnt for global health as we go forward, one of them has been in the African region a real, sort of, call to action around a number of things. One is that, unlike when we had pandemic flu in 2009, we don’t want to be the region that’s left behind with no vaccines. I mean, we’ve learnt that lesson. So, the African Union has really taken up leadership and really started to make demands on a number of fronts. One is to say that sort of, vaccine nationalism, the buying up of vaccines, I think it’s about 16% of countries own 53% of vaccines, that that is not acceptable, that there has to be vaccine sharing.
Also, a demand for manufacturing, that there’s very, very little vaccine manufacturing capacity in the African region, which leaves the region extremely vulnerable, and also, some challenges on intellectual property from the African Union as a leader saying that we would like to see, through the TRIPS Agreement, some of the concessions that are provided for by TRIPS that would allow more rapid transfer of technology into the regions. From that point of view, the AU, the African Union, has really taken a very strong leadership role and in addition, they are planning to purchase vaccines and they’re doing it in collaboration with COVAX. So, it’s not a competition, it’s to say how do we do this together, and in fact, COVAX and they are making sure they’re not competing for the same vaccine base and making sure that we have rollout. So, I think that this is an extremely positive, sort of, development.
Emma Ross
Okay. Speaking of they’re trying to buy – where does the World Bank come into this actually, ‘cause aren’t they a player in the access thing, outside of COVAX, in COVAX, where do they fit? I’m not quite sure.
Professor Helen Rees OBE
In fact, both, so they’re working with the COVAX facility and with the ACT Accelerator, so they’re a partner to WHO in those matters, but they also have put forward, I think, about $11 billion worth of money that will support countries. And in addition to vaccine purchasing, I think there’s also a discussion about vaccine programmes, as I say, because that’s an area where we probably globally haven’t actually focused enough funding to say to countries, you know, how much is this actually going to cost? What is required, you know, in terms of cold chain, supply chains, vehicles, etc., what is actually required, and how are you going to pay for that? Because there’s a real dollar sign at the end of a vaccine programme.
Emma Ross
No, I guess getting it in was only the start. I mean, there was one African – what was the African country that was going to destroy unused vaccine ‘cause they didn’t use it? Is that because they couldn’t roll it out or they didn’t have the capacity or people didn’t want it? I mean, how much is that a problem?
Professor Helen Rees OBE
Yes, no, that was actually probably I think you’re referring to what happened in South Africa. So, we had imported a million doses of the AstraZeneca vaccine and were ready and getting geared up to distribute it, and it is a very good vaccine, and then we had two pieces of data that emerged at a time – at the beginning of when we were starting to see variants, and at the beginning of when we were starting to ask questions about how will those variants impact on the effectiveness of vaccines that were developed for the original Wuhan strain? And so, we had two pieces of data, one was from the laboratory, that said that the vaccine appeared to be much less effective against the new variant that had emerged in South Africa, and the other was, and I guess this is a danger of science, it was a very small clinical trial that suggested that the vaccine was not going to be effective against mild to moderate disease. We didn’t have data on severe disease in the context of the emerging variant, but based on that, and this was, remember, at the early stage of trying to understand the impact of variants, the Health Minister felt that it wouldn’t be wise to proceed with a vaccine with uncertainty about whether it was going to be effective against the variant. So, this vaccine was then redistributed.
Emma Ross
No, I think I was thinking of a vaccine that was expired and it sat around and didn’t get used and it was expired, and they were going to chuck it. David, do you know anything about that?
Professor David Heymann CBE
Yeah, Emma, that happened in Malawi and it happened in a few countries in fact, and the reason, I believe, and Helen may be able to say more about this, is the fact that this vaccine is a vaccine for adults. And most countries in Africa have only, in the past, been giving vaccines either to children or to pregnant women, in order that they can prevent neonatal tetanus. And so, getting vaccines to adults is a whole new game and it’s very difficult for many countries to figure out how to do this in a way that the adult populations are in fact receptive to the vaccine. But, Helen, you may be able to add more to that.
Professor Helen Rees OBE
No, I think that that’s very true, and we might talk about this later on, but in terms of vaccine hesitancy, I don’t think that we know how – what the demand will be from the population. We’re talking very much programmatically how do we get it out to people? But the other question is, how will people, who in many cases might never have had a vaccine in their life or might not be aware of that, how receptive will people be to that? So, I think that that’s a very important question. But on the question of expiry dates, the other thing that I think we haven’t – at a country level, wasn’t necessarily fully appreciated to begin with is that early expiry dates were – early batches are, kind of, as long as you can go at that point and then you keep looking. Because many of these vaccines are very likely to have a shelf life much longer than was initially anticipated, these are new vaccines, unknown shelf lives, so the manufacturers are looking all the time, and we’ve already seen that, in many cases, those – that expiry date is then extended. So – but I think that understanding that is people are catching up very quickly, but it wasn’t necessarily well understood at the beginning of the pandemic, when vaccines were first received.
Emma Ross
Yeah, it sounds like a bit of a chicken and egg is, do you give the countries the vaccine if they’re not ready to do something with it, or do you get them ready to receive it before we give it? And so yeah, that’s an interesting dilemma. I wanted to move on, bringing David Ellwood in here, talking about another route of access to vaccines, and coming back on what, Helen, you were saying about African Union working in co-operation inside and outside COVAX, trying not to compete with them, I’m wondering if some of those vaccines are coming through vaccine diplomacy, are they Chinese vaccines? But, David, I was hoping you could tell us, David Ellwood, what does soft power mean in the context of the COVID vaccine, and how good are vaccines as an instrument of soft power? I mean, talking about the history of soft power as a strategy in general, are vaccines a good candidate for soft power, and basically, what’s going on at the moment in this field? And who are the big soft power wielders and what are they up to?
Professor David Ellwood
No, I use the metaphor of ‘currency’. They are a currency of soft power, like all currencies they have hard and soft variations and they’re liable to inflation and deflation, and in fact we’re going through a very severe period of deflation, when it comes to the currency value of vaccines as soft power. Soft power, for me, is about the connection between hard power and influence. Hard power being military, economic, political, and influence being something, which is extremely magmatic and extremely difficult to define. I’ve got 20 synonyms for influence. It can – they can be credibility, they can be legitimacy, they can be authority, and they can be trust, they can be reputation, goodwill, standing, all these type of stuff, they all come into the mixture. In the case of soft power, I believe that, in the old days, nations used to enjoy levels of prestige and prestige is the antecedent of soft power. But now nations, corporations, churches, and universities, institutions, they all try to manipulate. They all try to manage their reputations. They try to manage their prestige in the world in ever more conscious ways and using ever more conscious array of instruments, and the very latest of these is the vaccine.
Where does the vaccine fit into this picture? My belief, over many years of study, is that the most effective, enduring and incisive form of soft power is your model of modernity, your models of change, of innovation, of progress. And usually, these models function over many decades, so that’s why I talk about the American century, I still believe in the concept of the American century because America has continuously produced models of innovation and change and modernity, which the rest of us have always had to come to terms with. And the latest dramatic case, of course, is the super leagues, pushed in football, pushed by these American billionaires and the JP Morgan Bank. It’s a classic case, for me.
The vaccines are different, and different from the Super League in fact, because they are tactical. They are an innovation, which has come up extremely rapidly, and now we know there is a background, especially in the very interesting Russian case, there is a background to them. They don’t come from just nowhere, but they come to consciousness and they’ve come into circulation. They’ve been applied in a very, very short space of time. So, the question is whether the soft power mechanism, and the soft power idea, can be applied in the tactical sense. That is the name of the game.
The key – the people who really believed in this idea that the vaccines could be a currency of soft power and in a tactical sense, they were first of all the Chinese, then the Russians, and then there were the Indians. You could also include the British in this because at the time that Boris Johnson was proclaiming that Britain should be a science superpower, along comes the AstraZeneca vaccine and he embraces it and pushed it exactly as a confirmation of his idea of Britain as a science superpower. He also launched, it should be said, back in 2016 that Britain should be a soft power superpower and there is quite a lot of people who still believe in that. In fact, there are much better reasons for believing that than Britain is a science superpower, but that’s another story.
Now, the key players have been China, Russia and India, because they’ve always accompanied the distribution of vaccines in gratis or low cost in emergency situations. They’ve always accompanied these efforts, with highfaluting principles, with high-sounding principles of morality. This is humanitarian. This is the hand of friendship. This is our gesture to world wellbeing. We’re only safe if we’re all safe. This is the language they use when they subscribe to COVAX. It’s the language they use when they give vaccines to underdeveloped countries, including, it must be said, South Africa, as I understand the vaccines that came to South Africa were in fact Indian, AstraZeneca, and I’m sure Helen can confirm or deny that. But the point is this, they were always accompanied by these very high-sounding principles of humanitarian interest and wellbeing. And in fact, the Chinese have gone furthest in this by apparently shifting health diplomacy, the health diplomacy in the wider sense, to the centre of the famous Belt and Road Initiative, and so, wherever the Belt and Road Initiative is – has taken root, there you will also find the Chinese making big gestures and big displays, on their efforts with vaccines, for instance in Northern Africa, North East Africa, in parts of Central and Eastern Europe, parts of Latin America, and so on and so forth.
The question is whether these tactical manoeuvres will work. Right now, there are no – these are competitive games, make no mistake, this is a competitive game for influence. The question is, who’s winning now? My answer is nobody’s winning right now because shadows have come over all these efforts in all kinds of ways. Above all you need to have a vaccine, which is guaranteed to be effective, and that means not simply in medical terms, but, as Helen made very clear, rollout, your rollout has to be effective. To what extent the Russians and the Chinese can actually influence rollout on the ground, that’s something which is not entirely clear.
Certainly, the Chinese have been trying to do that in places like Ethiopia and other zones in North East Africa, and I think the Indians probably did it in the early phases when they were handing out vaccines to all their neighbourhood, all the way round from the Maldives to Myanmar, to Nepal, even to Pakistan, at one stage, Sri Lanka and so on and so forth. I don’t know to what extent they…
Emma Ross
Yeah, no, yeah, and I wanted to ask you what are they really after? I mean, are we talking about – what can we look forward to as the consequence of all this soft power, if it works, and they do – you know, what’s the quid pro quo, are we talking about access to mines, support at the UN, you know, what kind of favours are being exchanged or deals are being made in exchange for these vaccines, and if this goes at a big scale, you know, what impact will that have on geopolitics and the whole balance of power? I mean, surely this is – they must be focusing on areas or locations where Western influence is waning or is a little bit disabled or weak, so they can move in there. You know, where – how do they decide who to give it to? I understand the Russians are planning to supply vaccine to about 70 countries, the Chinese to about 90, how are they selecting them and what do they want in exchange and what is – what’s the world going to look like, as a result of this vaccine diplomacy?
Professor David Ellwood
Well, quite frankly, it’s too soon to tell. I’d have given you a different answer if you’d asked the question in January or February. It would have been much more specific and much more precise, because it seemed as though the vaccines were working, first of all, that they were effective. Now, a shadow has come over all of them, in one way or another, and there are doubts about the effectiveness of the Chinese vaccine, as the population of Chile has discovered. The Russian vaccine is in a special category because not only do they push their vaccine, which isn’t, compared to the others, isn’t available in such huge numbers, compared to what China and India promised in the early stages, it’s also accompanied by huge disinformation effort. And so, they kind of haven’t been able to resist the temptation to accompany their vaccine diplomacy with disinformation efforts against other people’s vaccines, and the State Department has now recognised this and denounced this. The trolls, the fake news, the bad mouthing of other people’s vaccines, that’s not going to help the Russians, either in the short, medium, or long-term when it comes to having soft power influence.
When it comes to India, obviously, their effort in this direction has collapsed in flames, almost literally, and that has completely undermined their authority and their possibility for gaining influence in this sense. Where does this leave the others? It should be said that there is certainly a lot of risk among the experts that where India is failing right now, the Chinese will move in and the Chinese will take advantage of India’s chaos in places where they’re already established, in Pakistan, that they may even try to move into places like Nepal and places like Myanmar and establish a health presence there and take advantage of India’s disarray.
Where does that leave the others, the Europeans, the Americans? The Americans are playing a very strange game, it’s not clear, and they don’t have a strategy of vaccine diplomacy right now. They seem to be improvising initiatives as they go along. They’ve given vaccines to Mexico, they’ve given vaccines to Canada, they’ve given vaccines to COVAX, now they’re talking about a special emergency effort in favour of India, and so on and so forth. Now, that’s not clear at all. The Europeans, they too, well, you see Europe is a special case because everybody considers the EU to be a soft power operation, far more than anything else, in the grand strategic picture, and people talk about the Brussels Effect and the lead they’re trying to establish when it comes to green – the greening of the world and on the battle against the regulation of tech giants. All this is in areas where the Europeans have been making strategic efforts, the EU has been making strategic efforts, but when it comes to the vaccines, they’ve been caught short and the EU has shown it’s completely unprepared to tackle an emergency like this, procure large, huge quantities of stuff, in a very short space of time.
But the question you asked is, what do these countries expect to gain from these kind of efforts in the short, medium or long-term? What kind of influence are we talking about here? What kind of soft power? Well, if you establish a permanent presence of health diplomacy, you can also – the image and the standing and authority of your nation in the world, especially in this setting. Cuba is a classic example. Cuba has been doing health diplomacy for over 60 years, well over 60 years, and they have an established presence and an established authority in this area of doing – of sending medical teams and sending medicines and sending Nurses and sending bits of hospital equipment, to various places in the Third World, and they have an established authority and status and prestige in that area and built up over many decades.
If the others, the other players in the game, the Chinese, the Russians, the Europeans, the Americans too, want to build up this kind of status and this kind of authority, this kind of prestige, they will have to prove that they are willing to commit resources, over the long-term, to change the picture, the health picture, the balance of power in health sectors, in the various countries that they decide to move into. Central Europe, you know, Central Europe is a fascinating case, and this is where my colleagues have been active, who is going to win the battle for influence in Hungary, in Bulgaria, in the Balkans, in Poland, in Belarus and the Ukraine, these are contested areas, probably the area which sees the most intense competition for geopolitical influence. So, any instrument that can be useful in this sort of confrontation is embraced with enthusiasm by the various protagonists, and so Hungary, the Hungarian Prime Minister, Orbán, he got himself injected with the Chinese vaccine, and the Serbian Prime Minister, President, is saying, “I can offer my citizens the Chinese version, the Russian version, the Western – any Western version you want,” you see, this is him offering, you know, a great offer.
The Western Balkans are looking very weak, in Bosnia and Herzegovina and Albania and so on, and complain very bitterly that the EU is letting them down and the amount of stuff that is being sent is tiny. So, naturally, along come the Russians and along come the Chinese and everybody else, in a zone of very intense geopolitical competition where that sort of currency of power can really make a difference. Over the long-term, it’s very hard to say right now. It really depends on whose vaccines turn out to be the most effective, in terms of fighting the disease and covering the large majority of the population.
Emma Ross
Okay, so that’s a lot to think about. David and Helen, I just wondered whether either of you are at all concerned about vaccine diplomacy as a practice, I mean, as far as from a public health point of view, does it really matter why countries are engaging in this way or doing vaccine diplomacy, you know, if they’re giving access and they’re building manufacturing facilities and teaching the recipient countries how to make vaccine, as public health practitioners, do we care that they’re getting some influence for it? It must be good for public health, I mean, other than the reports of disinformation. Do you have any concerns about vaccine diplomacy and how it’s playing out, from a public health standpoint, or an access standpoint? David, do you want to go first?
Professor David Ellwood
Which David?
Emma Ross
Oh, Heymann, Heymann.
Professor David Heymann CBE
Yeah, I think Helen can speak better to this than I can, but, you know, there is a World Health Organization and they do review all vaccine information and they give emergency use licences, if necessary. And as long as the vaccine goes through that process, I think we can be sure that that vaccine is a vaccine, which is suitable for use in most countries. I think I’m going to defer though to Helen to talk about that process, it’s done in the Sage, and where things stand with that, because that, to me, is the key. If WHO has said yes, this vaccine is a vaccine which is useful and effective, then the next step is to make sure that it’s available by any means. So, I’ll defer to Helen on the rest. Helen?
Professor Helen Rees OBE
Thank you. No, I – so, I – it’s not only WHO, but, I mean, again, you know, if good can come from this pandemic, one of the things that is emerging is the importance of national regulatory authorities and also, some regional efforts between regulatory authorities. And this is becoming even more important when you think about the emergence of variants that come to dominate subregional areas quite quickly, because what everyone wants to know is, you know, is the vaccine safe and effective? But is it going to be effective in my context, with my particular pattern of variance, whatever that might be, and that’s a regulatory question?
The other thing that’s a regulatory question is the quality of manufacturing, and I think that this is, you know, now coming out, a lot of people are talking and understanding the importance of the quality of manufacturing. So, in terms of your question, does it matter, at a national level if the national regulator and if it’s an empowered and well-resourced national regulator, many are not, and they benefit from regional collaborations with other regulatory authorities. But if that is approved and seen as something that’s good, good manufacture, it’s sufficiently effective, safe, within the parameters that we’re looking at for safety, if all of those things are ticked, then a country will say that’s fine. And I think we should actually be very, very open to this, I really don’t think that we should be in any way closed. I hear about the soft power, but at the moment the world needs vaccines. We need to have a level playing field and to look at all vaccines, you know, through the same lens of WHO, regulatory authorities, programmatic suitability, can we roll them out, is it a single dose, is it two doses? And that’s what we need to be asking at a national level, and the rest, I think, Politicians will be sensitive to and of course there will be the soft diplomacy behind it, but I think that the real question is, do the vaccines work? Are they fit for purpose?
Professor David Ellwood
And can I just come in here?
Emma Ross
Yeah, sure.
Professor David Ellwood
No, I completely agree, and in fact that was my conclusion too in the end. But we just had a very interesting case, there are two cases I would like to mention. First of all, Serbia and Belgrade, the biggest Confucius Institute in Europe is going to be built in Belgrade, Confucius Institute, and it’s going to be built on the site of the US Embassy that was bombed by NATO in 1999, huge symbolic meaning. Does it matter that the Chinese are penetrating Serbia in this way? Well, certainly if they get together with the Russians in that part of the world and really start making trouble, then it does matter. That remains to be seen. So, there, vaccine diplomacy, in that part of the world has a very significant, obvious geopolitical meaning.
A more interesting case is what happened in the Rome region, Lazio, there was an article about this on Politico.eu yesterday, in which they demonstrated the success of the vaccine rollout in that region of Italy, and there’s been enormous disparity between the regions, which was largely because the key people in Lazio, in Rome, consulted the Israelis. They consulted the Israelis and they brought in Israeli experts to show how it can be done, ‘cause Israel has obviously had one of the more successful rollouts anywhere, and that transformed their idea of how to carry on, how to get organised and how to make it work.
Well, that – the government in the Lazio region is a centre-left government, but you cannot imagine the regional authorities in Northern Italy, which are run by a right-wing populist government ever turning to a foreign government, a foreign agency for advice. It doesn’t matter whether it’s Israel or whether it’s talking about Ecuador or anybody else, that populist impulse, we do it alone, we are, ourselves, alone. That has consequences, even in this kind of sector, and we had Francis Fukuyama on the Johns Hopkins platform on Monday night, and he produced a piece of research, which he said, “There’s a definite correlation between the domination of populist politics, in any particular region or country, and the weakness of the vaccine rollout, the weakness of the vaccine strategy.” And one of his political science colleagues has been able to demonstrate fairly conclusively that conclusion, that correlation, and that’s certainly the case in Northern Italy, which is run by the populist, the one single populist party, normally from the Western Alps, all the way through to the Dolomites.
Emma Ross
So, it sounds like it can be good for public health, but also have far-reaching other effects that are very important as well. I’m going to move on to audience questions now, and the most upvoted question is from Ashleigh Furlong from Politico actually, you having just mentioned an article on Politico, a question on India and, David Heymann, I was hoping you could take this one first, “Are vaccines the way out of the crisis in India and should other countries be donating vaccines to India, or instead be giving them to places where hardly any jabs have been distributed?”
Professor David Heymann CBE
You know, the answer to that is that we have seen an incredible development of vaccines, of diagnostic tests, and of some understanding on how to best treat people with infection. So, all of these play a role in India, as they do elsewhere. India has not been able to vaccinate its population, its population at risk of serious illness, and as a result, they’re having serious illness. It’s too late now to vaccinate those people. What’s important in India now is, number one, to get the oxygen, the ventilators and the dexamethasone if not available and other drugs, which can be used to treat the people who are infected, understanding that in areas where that crisis is not occurring, and it’s only major in urban areas right now, from my understanding, they need to begin to setup the infrastructure to deliver vaccines in the future. And of course, they need to be using testing, and in areas where there isn’t a lot of transmission, begin to do some contact tracing, to do good epidemiology and stop the small outbreaks that are occurring, so they don’t spread into larger community transmission. So, there’s no one answer for India, it depends on where you are, but the major urgency now is to get the disease under control because the prevention measures have not worked. I think Helen might have some other additions to that. Helen?
Professor Helen Rees OBE
So, I mean, I think there’s no doubt that had India had the capacity to rollout vaccines, it might well not be in the situation that it’s in now, but, you know, that wasn’t to be the case. I do think that now, with the request by the Prime Minister, Modi, that Serum Institute, for example, should not export until the Indian population has got substantial coverage, in terms of vaccination. This is going to have a global impact. I agree with David though, that the rules of epidemiology still apply and even in a big country like India, you know, you are getting these different patterns in different areas, and the response should be tailored to that, but at the moment the urgency is certainly treatment. That’s the urgency, but vaccines need to follow very, very closely.
The other thing we should just remember that is an unknown for India at the moment is, there is a variant there that’s been identified with three major mutations. It’s called the B1617, but what we don’t know is, is that the dominant variant in the country, or are there lots of different variants playing out? And we also don’t know what the response of the vaccines that will be used, you know, what will be the immune response to those vaccines, in terms of this emerging problem? So, once again, you know, there’s a mixture of programme, science, readiness, but also, the challenge of this emerging science that shifts the goalposts all the time. But I certainly think that I agree with David, in a parallel to treatment, I would be strongly and rapidly trying to prepare for a really accelerated vaccine rollout.
Professor David Heymann CBE
Emma, just to add onto that, India has been one of the major countries that’s been sequencing, that’s doing the genetic sequencing of polio virus, and they have a great understanding of genetic sequencing, they have all the skills that are necessary in a country to do a very good job with this. The problem is that there’s a lack of co-ordination, it’s a very big country, as we all know, it’s – a lot of the power in health has been decentralised to the state level, and it’s very difficult for a central government to co-ordinate state governments when they have a decentralised power. So, there are many…
Professor David Ellwood
Same in Italy, absolutely the same in Italy, exactly the same.
Professor David Heymann CBE
Yeah, and that’s what happens when these decentralisations occur, and you lose the lever that you had earlier on when you were centralised to make things work in harmony. So, it’s a big issue for India.
Emma Ross
David, I don’t know if this is going off – is related to what you’re saying, but I’ve heard you say, many times before, that fighting the pandemic shouldn’t be a centralised top-down thing, it has to be a bottom up and a very local thing. Shouldn’t that be an advantage in India and a place like that?
Professor David Heymann CBE
Yes, it should be an advantage everywhere. The good response comes from community level, and communities need to understand how to help their people do their own risk assessment and how to protect others and protect themselves. What we’ve seen in this outbreak, surprisingly, is a top-down approach where physical distancing has not been instilled in populations, so that they’re empowered to do this themselves. It’s been a centralised lockdown, forced physical distancing, which disempowers people, and which makes them ill-fit when the lockdown is over to really do their own risk assessments and to begin to contribute to stopping transmission.
Emma Ross
Okay, thank you. I’m going to take the next question now, the next most upvoted question is from Charles Clift and it’s going back to intellectual property again, “Is the TRIPS waiver proposed by India and South Africa a good solution to expanding production and global access to vaccines?” So, whoever wants to take that first, if, for this audience, who are not all as – may not all be as up on TRIPS flexibilities, etc., as Charles is, could we start by a little bit of introduction on what’s TRIPS and how it relates to this, just to – for a bit of inclusion in a broader audience? Thanks. Who wants to take this first? Helen, you’re looking right for this question.
Professor Helen Rees OBE
I’m certainly not a TRIPS expert, but I will share with you what I know and what I think. So, under the World Trade Organization is the TRIPS Agreement, which is Trade Related Intellectual Property Rights, but written into that, and this is really to have global standards around, amongst other things, around respect for intellectual property, etc. But under that there are waivers that can be put into place, so, those waivers are particularly when there is something like a global emergency. And so, India and South Africa, and I think they were supported by about 100 countries in this request, asked that these waivers should be enacted, to allow a freeing up of exchange of technology, and in particular with things like copyright, industrial design, patents, these were some of the things that they said, and only for the duration of the pandemic and particularly around – I think particular concern was vaccines, but in fact, I mean, it went broader and obviously would include other therapeutics and medicines.
Now, the counterargument is that it won’t do anything at the moment, we’re in the middle of a pandemic, and even if we did that, would we be able to transfer IP in the sort of speed that’s required and is this, you know, kind of the wrong moment to have this discussion? That’s one of the arguments that’s coming from the pharmaceutical industry. The counter-counter to that is, well, actually, we’ve already seen that there are examples where having intellectual property has had an impact on things like access to diagnostics, on access to therapeutics, such as remdesivir, so there are counterarguments that are saying “But we’ve already seen that IP, the conservation of IP and the failure to share has had an impact.”
I think that, you know, whether it’s now or in the longer-term, one of the things that we did with this – with the conservation of intellectual property around the HIV/AIDS crisis was in fact to look at some waivers and the transfer of intellectual property to low middle-income country manufacturers, so that antiretrovirals could be made much more widely available. I’m not sure that we’re going to win this particular argument now, in the context of this pandemic, but I think it’s am extremely serious argument because if we have waivers for a global emergency in the TRIPS Agreement, and we fail to put them into place, and big countries with big pharmaceutical – the home to big pharmaceutical manufacturers are the ones that are saying we don’t want to do this, we have to then re-ask ourselves what is the point of having these global agreements, if we’re not going to honour them, particularly in the context of the pandemic? And if they’re not fit for purpose, what would be fit for purpose that would allow a freer exchange of technology, of access, of manufacturing, if this isn’t fit for purpose, what would be? And I think that’s going to be a medium-term discussion.
Emma Ross
And also, if you’re not going to enact waivers for something like this, how desperate does the situation have to get? I guess that’s related, may be similar flipside of what you’re saying, that, you know, if this doesn’t do it and make the case for, we really need to do this, do any of you know what is actually going on and what are the prospects of this actually happening? How much progress? You said we’re probably not going to win on this, but is it being taken seriously, or is it being dismissed, or where are we with it? David?
Professor David Heymann CBE
Well, there has already been licensing of the AstraZeneca vaccine to producers in India and those producers are producing the vaccine under standard good practice and in a vaccine that’s licensable, so it has occurred, to a certain extent. Whether it will occur, I think Helen has been clear, whether or not it will extend to other vaccines, especially those vaccines with the newer technologies, is not clear. And if it doesn’t work, then there has to be a re-examination of why it didn’t work and how we can make it work better in the future.
You know, WHO, one time, tried to have a Commission, I think some of the people who are listening in were leading that Commission, to try to see if there could have been a replacement for intellectual property that would ensure the innovation that occurs from intellectual property. And to my understanding, that never really did result in another mechanism, but there’s still work on that being gone underway to make sure that we don’t let this problem just fall by the wayside. There’s the patent pool, there are other areas of work also, there’s work on taking away the marketing of products from the development. So, all of these things may, in the future, lead to a better way of doing research and development, maybe the public sector taking a risk, while the private sector putting in its innovative skills, with the risk funding from the governments, to make things work in a better way.
Emma Ross
Okay, before I bring David Ellwood on this, ‘cause I would imagine that opening up intellectual property rights would not be good for those holding vaccine soft power, because that kind of dilutes their power, if everyone can make their own vaccines. But, David, I’m not sure the question’s clear, maybe I’d kind of zoned out, I hope not, of is a TRIPS waiver a good solution to expanding access to COVID vaccines or not?
Professor David Ellwood
Are you asking me?
Emma Ross
No, sorry, David Heymann, before I move on to David Ellwood on the…
Professor David Heymann CBE
If it works, it’s a good mechanism.
Emma Ross
Helen, is it a good solution?
Professor Helen Rees OBE
Yeah, I mean, it’s there for a global emergency and this is a global emergency, and David’s quite right, AstraZeneca have done this. So, it can be done, and clearly one of the big challenges at the moment is vaccine manufacturing capacity and that’s a big global challenge and, you know, we’re slowing up, in terms of our ambitions of vaccine coverage, partly because of manufacturing capacity. And so, if this will help that, I don’t see why, if AstraZeneca can do it, why it cannot be considered, and it can be limited, it can be for the duration of the pandemic, and it can be very targeted, for example, at vaccines.
Emma Ross
Thank you. David Ellwood, what I wanted to ask you, and maybe this is a tiny bit of a stretch too far but are there interests for the vaccine soft power wielders to oppose something like this. So, say China or, not necessarily India, but China or Russia, that may not want countries widely, far and wide, to be able to make their own vaccine? Do they have an interest in opposing this, or is it really a minor…?
Professor David Ellwood
I haven’t seen any evidence on that question in the media I’ve been reading. Intellectual property rights, copyright and patents are obviously currencies of soft power and there are great large lobbies, which are organised in order to defend them and to protect them as such. What needs, I think, what needs to be said in this context is one of the great bugbears in the relationship between the US and China, between the West and China, is because the Chinese appear to systemically steal intellectual property, in all kinds of fields, in all kinds of – over all kinds of periods, and whether – and how and when their vaccine has been developed, that, to me, still remains a mystery, how they actually did it, and with whose technology and their own native or whatever. And so, what they’re attitude to this would be, a waiver, would be extremely interesting to see.
This is not the case in Russia, at least I don’t expect it to be the case in Russia. There’s a fascinating podcast on The New York Times website, which talks about the Russian history of vaccines, and it’s the most detailed description I’ve seen yet of just how strong the Russian tradition in vaccine production is, going all the way back to the beginning of the Revolution, when the country was faced with an outbreak of bubonic plague. And ever since then they have been developing, over many decades, a very strong capacity for developing and producing and distributing vaccines. So, I wouldn’t have thought that they would be caught up in this question about intellectual property, not on this front, perhaps on others, but it’s worth checking out. I do not – I can’t tell you whether…
Emma Ross
It would be interesting to see if it comes to anything.
Professor David Ellwood
China’s the key question, China is the key to this.
Emma Ross
China’s the key, okay, and we’re getting quite close to time, so I think, David Heymann, I’m going to give you the last question, and it’s the most upvoted, by quite a mile, from Sonya Marie, “What risk does vaccine diplomacy pose to long-term global health security?” And anyone else is welcome to come in after that, if we have time. David Heymann?
Professor David Heymann CBE
Well, vaccine diplomacy with vaccines that are effective and properly regulated can be a great boon to health security. They can help countries develop their own health security by using those vaccines and they can also, if countries are able to, provide some production facilities to produce vaccines, should they need them. So, my answer to that, and I’m going to turn to Helen, but my answer is that vaccines can only strengthen health security in the long run.
Emma Ross
Does anybody else want to come in for a last word before I wrap up?
Professor Helen Rees OBE
Well, perhaps just one thing. You know, if diplomacy, if vaccine diplomacy in this case improves public health in the short-term during a pandemic, then, provided all those caveats about quality are in place, then it should be welcomed. And I’m just reminded we shouldn’t forget one of the most powerful vaccine diplomacy efforts has been the PEP programme for HIV and AIDS, which has been done through the United States, and we often don’t think about that in the same manner. But I think in the long run, what we’re looking for, I think, is more autonomy and more ability to manufacture locally and a much more equitable distribution of manufacturing ability, and of science by the way, we shouldn’t forget science. I mean, we shouldn’t just say LMICs and low middle-income countries, are always the recipient of science, they can also be the inventor of science and that’s what we should also be encouraging.
Emma Ross
Okay, thank you. I’m going to give one more question to David Ellwood and this is from Richard Lucas, “When low and middle-income countries accept soft power gifts of vaccine, could this undermine their national security – or this could undermine their national security, should COVAX consider national security, when deciding which countries, they distribute vaccines to?” So, I guess that is in order to counteract any nefarious vaccine diplomacy that may be going on. The first part of the question for David Ellwood, second part for David and Helen, that’ll be the last question.
Professor David Ellwood
Yeah, well, the virus doesn’t respect national security at all, and I would say that everybody can – all nations must now realise that their health security depends on other people, just as much as it does on themselves. And we’re all in favour of autonomy, but the global nature of this pandemic, I think, has been absolutely extraordinary and has struck everybody, and has reinforced the need for much stronger global government, reinforcing the WHO, that part of the UN, the COVAX, whatever, COVAX should not be just a one-off event. It should become, to me, institutionalised through WHO or whoever, it’s never been clearer the need for some form of world – ever stronger world government to manage these emergencies.
Emma Ross
Okay, thank you. David, should COVAX be selecting countries, should national security or international security be at all a part of how they select who’s turn comes first, as far as getting vaccine to fend off other influences in that country?
Professor David Heymann CBE
Well, I think that COVAX has a governance mechanism, which reviews the plans of countries, when they submit them for vaccination, and that’s taken care of in those governing selection process, the governing body and the selection process. I’ve spoken with people who have done that selection process and they’re very sure – they try to be very sure that when vaccine requests come in, there’s government commitment behind those requests, as well as a strategy that is feasible in getting the vaccines to the people who need them. So, I think we can be sure that, with COVAX, and maybe Helen will say a little bit more or some other point of view on this, but that’s my view, that there is a mechanism in place to make sure that when countries request vaccine, it’s a legitimate vaccine with government backing and the possibility of success.
Professor Helen Rees OBE
So, just to build on that, you know, COVAX – I think the success of COVAX is going to be very strongly around its ability to deliver vaccines to the 92 what are called AMCs, these countries which are the poorest or the most vulnerable, the smallest countries, that don’t have muscle and negotiating power, or finances themselves, and will be supported by development aid. And it’s an incredibly ambitious programme, but it is – we shouldn’t forget it’s built on the back of Gavi, and Gavi has been truly one of the most successful global programmes, in terms of ensuring access to vaccines, particularly for childhood immunisation programmes, for the, again, for the poorest countries. So, I must say I think that COVAX has to be backed with finances and with vaccines. It has to be backed with support for programme delivery, and we shouldn’t – and we haven’t discussed it, but we shouldn’t forget that it has to be backed by community demand. So, we have to do our work to actually persuade communities that these are vaccines that they understand and that are beneficial for them.
Professor David Ellwood
And it should be permanent, it shouldn’t just die away when the pandemic finishes.
Emma Ross
Oh, that’s a whole other webinar, David, we’re not going there right now. So, on that note, I’m going to wrap up, but that is a very interesting point and I know I’ve discussed that with Helen before as to, you know, decisions to be made as to whether we keep COVAX going, or what do we do with it, or, you know, how do we leverage it and build something for the future. But we’re going to stop now because I’ve gone over time, naughty, but thank you very much, all three of you, and particularly to our guests, David Ellwood and Helen, for joining us and sharing your insights, a great conversation. I feel there’s so much I wanted to dig up more that we didn’t get to on, you know, the spread of counterfeit vaccines, and more on nationalism and Europe, and anyway, hopefully, another time. But thank you so much for joining us and David and I will be back again, I’m not quite sure our dates, but we’ll be back discussing more hot topics, so just look out for what’s coming up, and thank you all for joining us, and bearing with me and letting me go over by four minutes. So, have a great rest of the day, and thank you all very much.
Professor David Ellwood
With pleasure.
Professor Helen Rees OBE
Thanks, bye.
Professor David Ellwood
My pleasure, bye. Bye, bye. Thank you, Emma.
