Immunity is liberty Vaccine internationalism during a pandemic

The current vaccine crisis in the midst of a pandemic could be a tipping point for the current order of global governance. The global policy response and vaccine rollout have proven too inept to counter the catastrophic moral failure of affluent countries' vaccine hoarding. The WHO Director General’s performative pleas for vaccine equity have done little to move an intransigent system of global governance to address an emergency of this scale. What do these overlapping and related failures mean at national and international levels? 


Longread by

Amitabha Sarkar

AMISOM Public Information/Flickr/Public domain

Airport ground crew load part of the first consignment of COVID-19 vaccines for Somalia onto a waiting truck at the Aden Abdulle International Airport in Mogadishu, on 15 March 2021.

The current vaccine crisis in the midst of a pandemic could be a tipping point for the current order of global governance. The global policy response and vaccine rollout have proven too inept to counter the catastrophic moral failure of affluent countries’ vaccine hoarding. The WHO Director General’s performative pleas for vaccine equity have done little to move an intransigent system of global governance to address an emergency of this scale. What do these overlapping and related failures mean at national and international levels? 

The COVID-19 pandemic is different from the other recent pandemics (SARS, MERS) caused by zoonotic coronaviruses. COVID-19 has spread beyond Asia. It has proliferated around the world, devastating social, political and economic activity. The pandemic’s impact on rights, justice, and entitlements has damaged not just physical health but also psycho-social wellbeing and led to the unprecedented collapse of national health systems, most visibly in affluent countries, causing millions to succumb to the virus. 

In response, governments everywhere leaned on a combination of public health measures and social security supports. While non pharmaceutical interventions (lockdown as the prime example) and test-track-care models proved effective in reducing infections and fatalities (for example in New Zealand, South Korea and Vietnam), many countries, including affluent ones (notably the USA under Trump), were reluctant to fully implement these public health measures because of short-sighted economic concerns. Besides, social security safety nets were inadequate to meet people’s real needs in many countries, such as India or South Africa. As income, food, child education and other basic needs went unaddressed, people’s trust in government – already fragile in many countries – was further eroded. 

Health checks in India.

Gwydion M. Williams/Flickr/CC BY 2.0

Health checks in India.

The ‘social’ link with vaccine nationalism

In the absence of a cure or standard treatment protocols vaccines represent a new hope, not only to prevent infection but also to restore general physical, social and mental wellbeing. The vaccine means social, economic and even political liberation: ‘Access to vaccines’ is not simply a matter of being able to receive a jab, but a complex mix of social, economic, political and technological factors – a sort of ‘culture of cure’. More than a simple medicine to remedy or prevent a disease, this new ‘culture of cure‘ can ‘fix’ all the pandemic-induced abnormalities in our daily lives. The popular perception of the vaccine as a ‘fix all’ has a profound impact on national-level policy making. Since vaccine research began, scientists have been engaged in the development of several vaccine candidates to prevent infection. Politics, meanwhile, has been scrambling to leverage the same vaccine candidates’ potency as a social medicine to cure the social and economic ills brought about by the restrictions used to fight the pandemic. 

Dangling a cure for social ills has helped politicians and national leaders to breathe new life into the social contracts upon which they depend. Access to vaccines for their citizens means an escape from pandemic-produced discontent with the state-market-society relationship. Thus, Vaccine nationalism has become a political programme, particularly in affluent countries, to regain lost trust of their citizens. 

However, such national-level actions contaminate international vaccine collaboration profoundly, as evidenced by the world-wide distribution of vaccine doses. Of the 1.8 billion vaccine doses produced (to 28 May 2021), 85 per cent have gone to high and upper-middle income countries and just 0.3 per cent to low-income countries. Even in India, where more than 60 per cent of the world’s vaccines are produced, barely three per cent of the populations was fully vaccinated at the end of May.

Receipt of the first part of the COVAX vaccine against covid-19.

Présidence de la République du Bénin/Flickr/CC BY-NC-ND 2.0

Receipt of the first part of the COVAX vaccine against covid-19.

The misad(venture) of COVAX

This scandalous inequity in vaccine distribution raises doubts about the efficacy of the global vaccine coordination framework, COVAX. COVAX was conceived as a vaccine pool for the world, from which 190 countries could equally access vaccines, with distribution calculated based on epidemiological risk and progressively covering entire populations in all countries. Free doses were also pledged to all 92 low-income countries. But in reality, against the commitment of delivering two billion ‘free’ doses to low-income countries by the end of 2021, COVAX has so far delivered just 3.4 per cent of this target in the first five months of 2021. 

The problem with COVAX is not its stated intentions, but the diverse interests of the multiple actors it involves. It is a multistakeholder group where the WHO shares space with the Bill and Melinda Gates Foundation-led Coalition for Epidemic Preparedness Innovations (CEPI) and the GAVI (global vaccine alliance). The role and involvement of the WHO in such initiatives is always questionable. In COVAX, WHO is just another partner, providing technical and management assistance but not in charge of financial resource control and without independent decision-making authority. In the absence of an urgently-needed UN-owned response, the countries participating in COVAX are also allowed to separately purchase vaccines from pharmaceutical companies. Consequently governments and companies have struck bilateral deals (approximately 56 by the first quarter of 2021) to procure vaccines outside the COVAX pool.   

Such deals are a win-win for both companies and rich countries. Companies can charge higher prices because of the many contenders for the product and rich countries can ensure fast delivery of doses not only for their own population but also to leverage in diplomatic relations. In reality, countries like the USA or Canada have already ordered more than four or five times as many vaccines as they need to protect their populations. This has three significant consequences. First, COVAX has lost its monopsony power to fix or regulate the vaccine candidates’ prices worldwide, which could otherwise have made all the candidates available at much cheaper rates. Second, pharmaceutical companies are also giving priority to bilateral deals over COVAX to supply the doses, since rich countries have chosen them, instead of COVAX, for advance orders of vaccines. This ultimately leaves COVAX underfinanced and stuck waiting for doses to distribute among its members, especially low-income countries. 

Vaccination Day against COVID-19 for midwives and health personnel in Guatemala.

Victor Sánchez/Pan American Health Organization PAHO/Flickr/CC BY-NC 2.0

Vaccination Day against COVID-19 for midwives and health personnel in Guatemala.

Vaccine citizenship in the land of patented knowledge

The success of a COVAX-like initiative has been in doubt since its inception. Many of the COVAX donors and supporters (such as the EU, the UK, Germany, Canada, Japan and Australia) are blocking a TRIPS waiver proposal at the World Trade Organisation (WTO) to protect COVID-19 related patents. Moreover, the Bill and Melinda Gates Foundation — which incidentally is part of COVAX through GAVI and CEPIpersuaded Oxford University to retract its original assurance of a no-patent vaccine and instead tied pharma giant AstraZeneca into manufacturing a patented vaccine. 

The vaccine shortage could be easily resolved by granting access to the necessary knowledge and technology to manufacturers around the world. However, pharmaceutical companies are fighting any such efforts to share vaccine know-how with other manufacturers. The same reason is also behind another failed attempt by the WHO to create a knowledge pool for access to COVID-19 related technology: C-TAP. So far not a single pharmaceutical company has found enough ‘motivation’ to join the C-TAP pool and voluntarily share knowledge, treatments and technology. It is a forbidding paradox that the invention of the most sought after vaccine candidate of this pandemic (mRNA research) was the product of mostly publicly-funded decades-long knowledge collaboration among various scientists, laboratories and various national institutes. But the innovation of an mRNA vaccine — product development, manufacturing and distribution — is now shackled to knowledge protection for private profit. 

The row over a TRIPS waiver for COVID-19 vaccine patent reflects the role of knowledge in capital formation as well as accumulation. The primacy of knowledge protection as an intangible asset over human lives has instigated a new culture of counter politics, which is not driven by national leaders (as in the case of vaccine nationalism) but ordinary people are questioning the practice of knowledge protection over human lives. Beyond the politics of a TRIPS waiver, this monopolistic knowledge is also instrumental in ideating a socially shared space of pandemic-free territory where vaccinated people can feel they belong. People deprived of vaccines across the world have reckoned with the fact that patented knowledge is the barrier to ‘access to vaccines’ and thus ‘access to pandemic-free territory’. This undeniably triggers the current global outcry against ‘Big Pharma’ and domestic public actions have followed. The leading example may be India, where the Government had to halt vaccine exports, risking diplomatic commitments, after facing public ire in the aftermath of a second wave of Corona and a nation-wide vaccine shortage. 

In global politics, supporters of TRIPS waivers (earlier led by India and South Africa, and now co-sponsored by 62 lower-middle and low-income countries), knowing very well about the exclusivity of any pandemic-free territory in the current order, are in negotiation with the global governance actors, especially the WTO, to win the ‘right’ to manufacture vaccines in the form of a waiver. This negotiation is nothing more than the seizure of vaccination rights from people residing in the Global South. This politics of vaccine entitlement is constructing globally a new social category – vaccine citizenship. Unlike vaccine nationalism, vaccine citizenship is neither limited to any boundary nor capable of making advance deals with the companies, but a just society that transcends borders, intends to break the capital-knowledge chain, and unites people to petition for access to vaccine.

Airport ground crew load part of the first consignment of COVID-19 vaccines for Somalia onto a waiting truck at the Aden Abdulle International Airport in Mogadishu, on 15 March 2021.

AMISOM Public Information/Flickr/Public domain

Airport ground crew load part of the first consignment of COVID-19 vaccines for Somalia onto a waiting truck at the Aden Abdulle International Airport in Mogadishu, on 15 March 2021.

Geo-political governance, and no more global governance

The emerging category of vaccine citizenship is veiled behind the negotiation of a TRIPS waiver. The ills of global governance often lead to such groupings, though usually on a much smaller scale and with limited reach. All over the world, the presence of various patient groups and networks are examples of global health governance injustices. Big Pharma is not challenged by individual national laws thanks to the safeguard of TRIPS provides (or of late TRIPS Plus), contributing to extreme commercialisation of care and treatment and leaving so many people either to die or go untreated. 

The present structure of global health governance is responsible for this hapless situation where non-state actors with conflicting interests pursue their goals while keeping multilaterals in confidence. In the 1990s, international health governance lapsed into global health governance, bringing a sea change in the domain of health. The reduced importance of inter-governmental or multilateral actors over the decades – primarily because of underfunding of the UN system – made non-state actors more powerful in UN decision-making platforms. It is increasingly difficult to find global health mechanisms that is not a ‘global public-private partnership’. In such partnerships, private interests are protected while people’s participation is crippled. Thus the accountability, though always tainted, of global health governance is left in doubt, especially in the aftermath of a pandemic. 

The decay of multilateralism has created a void in inter-governmental collaborations, which is otherwise the need of the hour. Countries are giving priority to more bilateral relations over multilateral alliances. The Global Financial Safety Net (GFSN) tracker reveals that in the advent of COVID-19, countries have used more bilateral channels (disbursed $1.75 trillion) than the International Monetary Fund (disbursed $108 billion) and regional financing arrangements  (disbursed $3.8 billion) to access financial support, as of March 2021. In the case of World Bank, it seems the lending is not matching the COVID-19 crisis. The World Bank disbursements in 2020 increased by just 0.3 per cent of GDP, whereas it predicts a GDP decline of 4.1 per cent between 2019 and 2020 in the median low-income country. The over dependency on bilateral swaps is undesirable as they are less transparent and accountable compared to multilateral lending. These deals are usually run chiefly on the interests of economically powerful countries and often in competitive exchanges. 

Geo-political interests trump inter-governmental collaboration in vaccine donations too. One study found that the majority of donations given by China, India, Israel and Russia were based on the countries’ strategic and economic interests. Apart from New Zealand and France, most countries prefer to donate their excess vaccines through diplomatic channels and not through COVAX. Hence, vaccine diplomacy may address the shortage of vaccines in specific contexts and serve national interests too, but it is unlikely to advance global vaccine equity. In this pandemic, bilateral diplomacy is creating more competition than collaboration. At the moment, the USA and China are at loggerheads over vaccine diplomacy to expand or preserve their geo-political influence. The same is found in bilateral swaps where the US Federal Reserve (US FED) and the People’s Bank of China (PBOC) are way ahead of others in offering financial aid. Hence, the US, which traditionally favours patent conditionalities, support for a TRIPS waiver is undeniably a good thing, but it is also a counter to China’s world-wide vaccine diplomacy. 

This pandemic is the foremost example of why the world needs a state actor- owned and led international system of governance. Otherwise, there will always be truncated forms of crisis management, where transnational corporations, multinational organisations and individual countries (mostly economically dominant) will try to prise benefits from governance systems that are not fit for purpose. Furthermore, these multi-stakeholder approaches fuel the rivalry between member states, forging muscular nationalisms and risking global peace and prosperity. 

Health in public hands

People’s Health Movement

Internationalism, the liberated immunity

This pandemic is indeed a crisis, but it is also a much-awaited opportunity! The pandemic has paved the way for the construction of a new socio-cultural dimension of cure which is hitherto applicable only for the patients (mostly from the lower rung of society) suffering from ‘poor diseases’ (such as HIV, TB, Malaria) – the path of ‘access to’ treatment, medicine or vaccines is a new qualifier in this regard. Current forms of global governance are unable to comprehend this ‘culture of cure’ that has changed the utility function of vaccine from preventive medicine to social medicine. What is more, challenged by a pandemic global governance’s chief development methodology, global public-private partnership, is proving counterproductive: Access to vaccines is now a matter of competitive nationalism and thwarting global alliances. Likewise, COVAX is causing disequilibrium in vaccine procurement and resulting in global public inequity. 

Against the backdrop of these complicated governance outcomes, the debate over support for a TRIPS waiver may appear as a typical North versus South fight. But that is perversely counter-intuitive. Gone is the unipolar world, where a handful of affluent countries, like the G7, monopolise governance space. In this new multipolar world countries with different status, both affluent and emerging economies (such as the G20), share governing platforms with non-state actors. This multipolar world prioritises ‘market-friendly’ governance at the behest of the capital-politics nexus, all over the world. Thus global governance platforms are exclusive to economic giants only (both state and non-state actors), but not to the world’s majority of low and middle-income countries and other international communities. This dearth of inclusiveness constrains global governance from representing ‘the people’ primarily. This gaping void has now given rise to a global identity — people who demand ‘vaccine citizenship’. 

This demand cannot be addressed through geo-political governance. Rather, it will eventually redraw the atlas again into two or three ‘worlds’. This crisis can be solved only by reviving faith in international governance and strengthening multilateral institutes. Neither transnational corporations nor bilateral deals can secure vaccines for all; it is the multilaterals that can energise public procurement of vaccines in cash-starved countries in this emergency.  

The demand for vaccine citizenship is an opportune moment to create bonds between people across borders. This is a time to shoot for progressive internationalism with a call for public vaccines, using public finance for vaccine research, development and manufacturing, an alluring alternative to the incentivised patent-protected profit churning private vaccines. Global solidarity networks and movements (such as, the People’s Health Movement) may align with progressive, non-violent agitations, unions and associations of farmers, students, trade union workers, employees, gender rights groups, and other voices at the national level. Domestic pressure for a global cause — vaccination for all — could forge international solidarity in these times of crisis. 

The world is in need of a ‘politics of solidarity’. The various grassroots-based community initiatives active across the world are breaking the barriers of identities as well as challenging divisive capital-politics linkages to embrace each other. Community collectives in India (Quarantine Students Youth Network), Brazil (favela-based groups) and many other countries are examples of how individuals from various walks of life can come together to help others during the course of the pandemic. This is a lesson for larger politics to realise that people in need always come together on the basis of solidarity. 

The pandemic has devastated the lives of people who have always been at the hard end of the global order of capital’s systematic exploitation. For ever-exploited people, vaccinations are no longer just an immunity from the virus, but an inspiration of liberty from the pandemic related restrictions too. Vaccine equity is a programme of global liberation from the restraints of global public-private partnership for international organisations. 

Vaccine internationalism is the politics of global justice and peoples’ solidarity! 

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