We are in the midst of a global shortage of supplies of covid-19 vaccines. We are reliving the saga that happened early in the pandemic around access to PPE, where each country fought for its own patch. Getting the vaccine doses we require for South African health care workers is the most we can hope for in the coming weeks. Obtaining anything more within the next six months will be almost impossible for the majority of countries in the global South that did not, or were unable to, make pre-orders or payment commitments. South Africa might just possibly be the exception.

Understanding why we have got to the place where access to life saving vaccines is out of reach to billions of people bears some scrutiny. But perhaps it would be relevant to start with some comments on the role that vaccines have played in bolstering public health systems. The echo of denialism around their importance is prevalent across society, infecting even some in government and, judging by the recent comments by Professor Barry Schoub in the Daily Maverick, some members of the Medical Advisory Council too. Prof Barry Schoub says that vaccines are not a silver bullet. Nobody is arguing that they are. But herd protection rather than herd immunity for the global population is not only possible but particularly urgent given the emergence of new variant strains that are significantly more transmissible. Whether the South African strain creates more severe disease is still to be determined by our scientists. What we do know is that before the advent of the new variant it was estimated by studies cited by OXFAM that equal access globally to Covid vaccines can save 50% of all anticipated deaths.

We are facing a global threat in the league of the climate crisis, if you like, an early warning system of ecological breakdown. And like with the climate crisis, only solutions that are global can provide the protection needed to save lives. This requires a high degree of international burden sharing, solidarity and cooperation. This I believe is the emerging consensus by leading public health officials around the world. Herd protection without a wide vaccination rollout in South Africa would only be possible if we closed all our borders for the next few years. This is not an option for many reasons, not least the utter lack of humanity involved in shutting out people from bordering nations who are also victims to unequal access to drugs and treatment. In this sense, I would argue we need a regional plan that puts vaccine acquisition and rollout front and centre and brings all those to the table who have the experience and expertise to make this happen, within the shortest possible time frame.

The argument for vaccines

Vaccines of one form or another emerged early on in the development of natural sciences. Only in one instance has a vaccine completely eradicated a disease, Smallpox, which claimed hundreds of millions of lives. That said, they have largely controlled many other diseases worldwide, Rubella ‘German Measles’, Polio, Hepatitis A and B, Influenza. The list is long and the reach of vaccine technology has been global.

Vaccine research and development began to take off in the late 1800 and early 1900s, with major outbreaks of disease wrought by squalid housing conditions in the advent of industrialisation. It then leapfrogged further in the post WW1 period, in the wake of the devastation of the Spanish Flu. In the post WW2 period, the charge was led primarily by the United States, followed closely by Northern Europe. Nation states that had the capacity manufactured vaccines for diseases that presented a global health threat and did so in cooperation with each other.

But by the 1980s things began to change. Neo-liberalism saw the outsourcing of such vaccine research, development and production to big pharmaceutical companies, whose massive profit levels resulted in perhaps the strongest political lobbying power worldwide, a lobby designed primarily to protect the patents they registered. TRIPs, ‘Treaty on Intellectual Property in Respect of Integrated Circuits’ is one outcome of this lobby (the proposed Waiver to this can be found here).

Consequently, one and half million people die annually because of lack of access to vaccines, while tens of millions of children still do not have access to immunisation. And yet, as recently as 2017, Low to Middle Income Countries accounted for 79% of the global market vaccine sales volume, and yet only 20% of the actual total value. Effectively, despite the level of need, we simply do not present a profitable enough market to drive the investment and production required. The reasons may seem obvious given the high price demanded for many vaccines, but it is not.

Mike Davis has shown that big pharma largely only enters into vaccines and therapeutic treatment research and development [R&D] for diseases that are either more prevalent in richer countries, and/or require repetitive treatment. These medicines are often very expensive and limited to those with private health care, or to those public sector hospitals where nation states can afford the stock. Davis concludes that big pharma, in this context, has acted to put the brakes on the revolutionary bio-medical technological advances within society’s reach. Into the breach have stepped the universities, the National Health Institutes and Centres for Disease Control. These have pioneered medical R&D, perhaps most prominently within the US. Yet while biomedical R&D at universities has been partially funded by medical corporations, this is not the case for research capacity within the state.

State funding for medical research around infectious disease has been eroded drastically over the past decades, and in terms of pandemic preparedness programmes in the US, have been sliced to the bone by Donald Trump. It’s time to jettison the rhetoric on incentivising innovation when it comes to medicine. Big pharma has largely been relegated to the supply and distribution of vaccines and treatments required globally. Much intellectual property developed for tropical disease, for instance, has been developed on the back of public investment*. This tendency is nowhere more clear than the Covid 19 vaccines which have seen all the major candidates recently approved, de-risked almost entirely by the initial massive investment by the American and European tax payer.

Public Private Partnerships and philanthropy, while they have proven critically important in the battle against HIV, are wholly insufficient to contain global pandemics such as Covid 19. That is not to say that we don’t require all of everyone to roll out plans that have the ability to succeed. This is particularly important in a context such as ours, where the state lacks capacity, and displays pride and arrogance. What we need is humility and an admission that our political leaders do not have the capacity to deal with this crisis. Genuine participation by all those who have something to offer must be built into our state led response immediately.

The public cost of patents

By the end of 2020, the confirmed global Covid-19 death toll sat at over 1.8 million people; while most speculate that sadly, the real number sits far higher. Fortunately given our robust reporting system, in South Africa we have no such need to speculate; many countries, including other members such as BRICS, do not have systems comparative to our own*.

South Africa’s own death toll, from 6 May to 8 December 2020, is estimated to have stood at 60, 000, when one takes into account excess deaths. The emergence of the new variant that is far more transmissible will undoubtedly continue to overwhelm our health service. My own estimate, given the combination of higher infection rates and a collapsing health care service, is that this will likely set to double, possibly treble, the death toll we have experienced in 2020. This is based on the assumption that we do not get a vaccine roll out that covers at least 50% of the population by June or July this year.

This grim situation could very well get worse if our health care workers, and most vulnerable, do not receive any protection in the coming weeks – or certainly within the first quarter of this year.Phase 1 of the government plan to roll out vaccines, designed to protect health care workers, seems possible and likely to happen if the government responds with urgency and vigour. Yet even this limited roll out will require involvement of all those with expertise, direct interest and good will to shape the plan, so we can ensure that the state-led roll out with the huge logistics involved happens as efficiently and rapidly as possible.

The major and more difficult task of protecting essential workers, those over 60, the millions with co-morbidities, demanding tens of millions of doses, is physically near impossible to meet within the current constraints. It is simply out of reach for most of the world at present.

In response to the global health crisis now facing our country, the Treatment Action Campaign, Section 27 and others, relaunched the 20 year old campaign to Fix the Patent Laws in mid 2020. Success would ensure that we would not have to undergo a replay of the long and bitter campaign to get access to ARVs that saw hundreds of thousands of lives unnecessarily lost in the 1990s and 2000s. The ultimate argument of the campaign is that South Africa needs to adjust its patent laws to the South African Constitution, which provides the right to health.

The logical force of the patent campaign has undoubtedly helped to inform South Africa’s joint motion with India that calls for a waiver on the TRIPS agreement to the World Trade Organisation. In short, this would allow for the sharing of IP around Covid 19 vaccines. The motion has the support of 140 countries but is being opposed by a club of nations that continue to rule the world and are accompanied by allies such as Brazil’s Bolsanaro. Resolution seems unlikely.

At present, all that’s been brought to the table from AstraZeneca for Brazil and India are preferential price deals for the manufacture of vaccines. Pfizer’s CEO has also offered to enter into such deals and apparently has, some months ago now, offered discounted prices to South Africa. Curevac, another front runner in vaccine production, is exploring a deal with South African born and raised Elon Musk to establish mini factories around the world to produce their vaccine.

We need to meet global demand in a rational and equitable rollout in early 2021. To do so we require nothing less than manufacturing and supply to be massively expanded to all those countries that have the capacity to undertake such a task. South Africa unfortunately does not have the capacity to manufacture COVID vaccines, despite a public private partnership established over 20 years ago, a story in its own right. Covid will linger for years to come and therefore it would be expedient for us to develop this wasted capacity rapidly.

Resolution of the supply question that is being battled out at the World Trade Organisation in terms of the TRIPS waiver will need to be rapidly assessed. Countries like ours have the moral right as embedded in our Constitution to protect the right to health and life itself. It will become clear in the next few days and weeks whether this requires our country to issue compulsory government licenses to force the sharing of IP.

I am informed that the Johnson and Johnson deal is still on the table and being negotiated, their application has been or but that final local regulatory approval may very well take another month or so. If this is so, then there may be some hope on the near horizon.

We have to start planning for this contingency. A rollout plan that involves key players from across civil society, including distribution logistics from the private sector, needs to begin as of yesterday. It will need to be stress tested and bulletproofed if we are to stand any chance of finishing all three phases of the planned roll out of vaccinations by 2021.

We cannot leave this fight for access and genuine participation in the vaccine rollout to the health NGOs, social justice organisations and the likes of Oxfam or MSF alone. All our trade unions, democratically run civic organisations, churches and political parties have a huge responsibility to stand up now and be counted at this moment of need for our country and indeed the majority of the world’s population. In such a battle, local and international solidarity will be key to any victory.

An extraordinary effort is required on all moral and political fronts, by the South African government working hand in hand with its citizens. Our efforts to ensure IP is shared will require the active support of many millions around the world if we are to achieve some degree of success in 2021. But first we need to get the government and others to actively support the call for vaccines to be seen as a public good – outside of the polite setting of the World Trade Organisation – and this requires nothing less than significant pressure from those quarters of our society that have organised constituencies. Efforts are underway, but there is a long way to go.

Rehad Desai is a Honorary Research Fellow at the University of Johannesburg, a Johannesburg based filmmaker making a documentary at present called the Time of the Pandemics. He is also the convenor for C19 Peoples’ Coalition in Gauteng. This article is written in his personal capacity. This article first appeared in the Daily Maverick in South Africa.