In January 2021, Winnie Byanyima, Executive Director of UNAIDS warned, “We are witness to a vaccine apartheid that is only serving the interests of powerful and profitable pharmaceutical corporations while costing us the quickest and least harmful route out of this crisis.” With the recent news of Omicron’s emergence as a variant of concern, these words and the countless others informing us of the dangers of vaccine apartheid could not be more prescient.
Vaccine apartheid as a concept calls attention to the effects of inequitable vaccine distribution policies on historically subordinated peoples. Vaccine apartheid has meant that people living in many countries in the Global South are being denied significant doses of vaccines. Some reports indicate that “for every 100 people in high-income countries, 133 doses of COVID-19 vaccine have been administered, while in low-income countries, only 4 doses per 100 people have been administered.” Using vaccine apartheid to characterize this state of affairs is important because it troubles, and renders suspect, the use of terms like vaccine nationalism to describe countries hoarding enough supplies to vaccinate their populations several times over.
The euphemism of vaccine nationalism conveniently papers over the racialized distributional consequences of vaccine inequities. In “Disposable Lives: COVID-19, Vaccines and the Uprising,” I analyze how racialized notions regarding which lives are expendable are reflected in inequitable vaccine access and how COVID-19 has heightened the visibility of the disposability with which society views the lives of people of color. This presumed disposability is reflected in the paltry number of vaccinations, with only about 7% of vaccination completed for the entire African continent. That this meager percentage represents just over half of the entire supply of vaccines to African countries to date is abysmal.
Fatima Hassan, founder and director of the Health Justice Initiative in South Africa poignantly remarked:
I grew up in apartheid. I know what it means to be a second-class citizen or even a third-class citizen. And this is what we saw in this current pandemic. Black and brown people in Latin America, in Asia and Africa were told to wait. We were told that the knowledge wouldn’t be shared with us. We should participate in clinical trials. We should contribute to scientific knowledge, but we should wait, basically last in line, like we did during apartheid, for access to any kind of service, whether it was education or health, before we could get our vaccine.
Some have sought to locate the reason for these delays in the lack of production facilities and other impediments, such as the need for vaccine storage at subzero temperatures requiring the development of a cold distribution chain for vaccine administration. Notwithstanding these issues, the root causes of vaccine disparities lay in legal and policy barriers to access.
The Lack of Global Solidarity
Instead of a recognition that global solutions are needed to address the COVID crisis, many countries have prioritized and competed for bilateral deals, which have driven up prices. Additionally, rich countries have not sufficiently supported and funded global health initiatives such as COVAX, which is the principle vehicle that the World Health Organization (WHO) is utilizing to deliver COVID-19 vaccinations to people in low- and middle-income countries.
The WHO developed a recent strategic plan to address critical disparities in access to COVID-19 tests, treatments, vaccines and personal protective equipment in low- and middle-income countries. An estimated $23.4 billion (USD) funding is needed until September 2022 to implement a plan which would only deliver sufficient doses and support “vaccination campaigns to achieve 43% coverage” in the targeted countries. While this is ultimately aimed at contributing to the global target of 70% coverage in all countries by mid-2022, the arrival and spread of the Delta variant has already indicated what the dangers of haphazard and lackadaisical vaccination programs are. Low global rates of vaccination allow space for the virus to mutate and propagate into potentially more dangerous forms. Moreover, even if COVAX were fully funded, relying on the munificence of others to donate money or share vaccine surpluses is fundamentally flawed as a public health strategy given the need to vaccinate entire populations.
Philanthropy Cannot Buy Equality
In October 2020, India and South Africa made the case that an intellectual property “waiver should continue in effect until widespread vaccination is in place globally, and the majority of the world’s population has developed immunity.” The proposal seeks to reshape the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) regime in significant ways by enabling substantial technology transfer for effective COVID-19 vaccines, therapeutics, and diagnostic tests. The joint submission covers not only patents, but also copyright, industrial designs, and undisclosed information including know-how and trade secrets.
South Africa and India modified this proposal in May 2021 to instead request a three-year waiver. They also revised the proposal because of “the concern of continuous mutations and the emergence of new variants and consequently the many unknowns with respect to SARS-COV-2 and its variants and the global need for access as well as the importance of diversifying production and supply.” The waiver proposal is co-sponsored and supported by the African group of states as well as several other countries in the Global South. Notably, China, France, and the United States have all expressed support for the waiver proposal. However, the United States has limited its support of the wavier proposal to vaccines.
The pharmaceutical industry opposes the waiver proposal along with several others primarily based in the Global North, like Canada, the United Kingdom, and the European Union. The European Union has even gone so far as authorizing countries to limit exports of vaccines. Those that oppose the waiver proposal contend that intellectual property rights are necessary to incentivize research and development. On their view, equitable access to vaccines can be achieved through voluntary licensing and technology transfer arrangements. But, as South Africa forcefully argued at a WTO General Council Meeting, “[T]he problem with philanthropy is that it cannot buy equality . . . the model of donation and philanthropic expediency cannot solve the fundamental disconnect between the monopolistic model it underwrites and the very real desire of developing and least developed countries to produce for themselves.” The waiver proposal has been stalled between these competing positions as the TRIPS Council operates on a consensus model for decisions. This impasse will likely not be resolved soon as the next World Trade Organization ministerial conference has been postponed indefinitely in light of Omicron.
Meanwhile, vaccine apartheid persists. Pharmaceutical companies have exercised their monopoly power to artificially limit supply and to prevent others from accessing the publicly funded technologies needed to create the vaccines. Some companies like Moderna, one of the most efficacious vaccine manufacturers, have promised not to enforce their patent during the COVID-19 pandemic. Yet, it also does not own all the patents in its vaccine and cannot make credible commitments that bind other patent holders.
More importantly, the non-enforcement promise is a red herring since one would also need more than a patent to bring a vaccine to market, which is why the waiver proposal also covers copyright, industrial designs, and undisclosed information including manufacturing know-how and trade secrets. The CEO of Moderna, Stéphane Bancel, said the quiet part out loud when he commented that “If someone wants to start from scratch, they would have to figure out how to make mRNA, which is not in our patents.” That process could take years to reverse engineer and Moderna has made clear that it is only willing “to license our intellectual property for COVID-19 vaccines to others for the post pandemic period.” In other words, the company will not share its vaccine recipe when the world needs it most. The multibillion dollar company also has demonstrated unwillingness in the past to distribute its vaccine to countries on the African continent during the pandemic. The WHO had to hire Afrigen Biologics to work on reverse-engineering the Moderna vaccine.
Moderna is by no means the only vaccine manufacturer that has refused to share its knowledge with the world. For example, in 2020, the WHO created a technology access pool to encourage pharmaceutical companies to share their knowledge with manufacturers in other countries that need to develop vaccines, but no company has done so to date. Even the somewhat encouraging news about a licensing deal involving Aspen Pharmacare in South Africa is limited to the packaging and selling of Johnson & Johnson’s COVID-19 vaccine in Africa. The deal does not entail a technology transfer that would allow Aspen to manufacture its own drug substance and raise capacity.
Our Current Trajectory
If the current course is not corrected, vaccine apartheid will only deepen, and the resulting mal-distribution will render historically subordinated groups even more disposable. This apparent dispensability was made abundantly clear with the swift decisions by countries in the Global North to cut off southern African countries following South Africa’s genomic sequencing of the variant. Instead of being rewarded for tracing and alerting the world to a variant that was already circulating in Europe, the United Kingdom, the United States, the European Union and others were hasty to make decisions informed by “Afrophobia” as the President of Malawi aptly termed it.
As I argue elsewhere, responses to the coronavirus continue to be informed by “outdated but persistent settler-colonial conventions that have mapped illness and disease on to racialized peoples and certain geographic regions.” The response to Omicron reflects the racialization of diseases and embodies the tendency to attach racial meaning to ailments based on the racial groups that tend to be socially associated with a given illness. We witnessed this with the Ebola epidemic, which similarly “resuscitated historical images of Black African bodies as uncontainable and disease-ridden and sparked racialized fears.” This fear of other and their diseases reminds us quite powerfully how the history of diseases and responses to diseases is linked to politics of racial exclusion and racial subordination.
Disease carrying microorganisms are certainly not differentiating amongst people based on race, nationality, ethnicity, or other categories, but SARS-CoV-2 is discerning between the vaccinated and unvaccinated. At the time of writing, the Omicron variant is present in at least twenty-four countries and may be circulating elsewhere undetected. Yet, unfair travel restrictions targeting Africans has lamentably prevented the ministerial meeting to discuss redressing vaccine inequities. The sheer magnitude of the coronavirus pandemic in deaths and illness concomitant with the scale of vaccine redlining make evident that a significant level of legal reform and restructuring is required to meet the challenges of the current moment. If the ongoing pandemic and the emergence of Omicron and other variants is going to teach us anything, the lesson must be that until we are all safe, none of us are safe.