Comment: The route to global vaccine equity is not through the status quo

As the two-year anniversary of the announcement of the Covid-19 pandemic rolls around and just as the world is rocked by yet another disaster, Bernard Mallee, a spokesperson for the Irish Pharmaceutical Healthcare Association, writes in these pages of the need to vaccinate the entire world: “We must maximise community protection, no matter where people live”.

As members of Access to Medicines Ireland and academics working on vaccine equity and alternative pharmaceutical innovation models with accessibility as the core value, we could not agree with this statement more. An Oxfam Report, published on March 3, has reported that the pandemic death toll has been four times higher in lower-income countries than in rich ones. Where we differ substantially from Mr Mallee’s assessment of the situation is in his interpretation of who should shoulder responsibility for achieving this goal, and how this should be done.

Mr Mallee brings up three well-rehearsed and equally well-debunked arguments: his first is that production is not the bottleneck for vaccine coverage; rather, the ability of what he calls “developing countries” to absorb and distribute these vaccines on the ground is the problem. His second argument is that “building manufacturing sites across multiple continents is impractical and unnecessary” and that local skillsets are not available to manufacture vaccines with “up to 280 raw ingredients” in low- and middle-income countries. His third argument follows logically from the first two – at least in the logic of a pharmaceutical industry spokesperson: that any messing around with the existing intellectual property system, for instance through the Trips waiver proposed by India and South African as far back as October 2020 can only have a detrimental effect on pharmaceutical innovation.

It is intriguing to see that the pharmaceutical industry has been availing of such a small range of arguments, even though all of these have been thoroughly deconstructed by civil society and academic research. It is unsurprising that this pharmaceutical representative does not mention the fact that nine new “Covid billionaires” have been created among his industry while millions of children in low- and middle-income countires have lost their caregivers and even more people have been plunged into poverty. We refer to the Oxfam report “A pandemic of greed” which presents detailed research on these issues.

Here, we wish to make three points, in direct response to Mr Mallee’s arguments: firstly, there is substantial capacity and capability in many lower and middle income countries for vaccine manufacturing to reach the stringent quality standards the WHO rightly sets out and maintains. Médecins Sans Frontières and AccessIBSA identified more than 100 manufacturers in Asia, Africa and Latin America that are capable of making mRNA Covid vaccines if they were allowed.

Secondly, the pandemic has provided ample evidence that geographically diverse pharmaceutical production is not just possible, it is in fact essential to safeguard citizens’ health everywhere. In Europe, for instance, the European Union are currently formulating an entire strategic approach to shorten pharmaceutical supply chains and boost local production as part of their Health Emergency Preparedness and Response Authority deliberations. It is simply not tenable to deny this right to lower and middle income countries.

Small steps toward decentralisation have already taken place, for instance through the WHO-backed African mRNA hub. It would be essential that current mRNA manufacturers, who have benefitted from billions of public money for the development of their vaccines, contribute to these efforts at building local capacity through knowledge exchange and technology transfer. Finally, and perhaps most importantly, a temporary waiver of patents strictly related to Covid-19 vaccines and treatments would absolutely not have the earth-shattering and innovation-chilling effects that Mr Mallee predicted.

It is well-accepted business knowledge that open source technology, if anything, stimulates innovation rather than blocking it – the latter is what patents do. Given the fact that the waiver would be very narrow in scope and only in place temporarily, it would also have minimal if any effects on the research and development trajectories of pharmaceutical firms.

The pharmaceutical industry sees this waiver as a frontal attack on a business model that has served them so well for decades: a business model based on monopoly rights, which are extended and abused through what is known as a ‘patent toolkit’, including the evergreening of patents and other ways to block competition well beyond the formal duration of a pharmaceutical patent.

Mr Mallee silent over the fact that while this business model has undisputedly contributed to the production of innovative and life-saving medicines, many of these are now priced so highly (often amounting to six-figure sums per treatment) that even the healthcare systems in high-income countries will not be able to provide access to all who need them. This model is fundamentally broken, and the pharmaceutical industry is best placed to know this fact. They should ask themselves this question: if pharmaceutical innovation cannot not be used to save lives and prevent suffering in a global pandemic, then what is its purpose?

Prof Susi Geiger and Dr Ciara Conlan are members of Access to Medicines Ireland