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Inequality in the (Post-) Pandemic City: The Paradox of Geography and Vaccine

As the COVAX vaccine rollout begins, we're revisiting an essay by Mosoka P. Fallah on why affordable, equitable access to a COVID-19 is so important.

This blog was originally posted as part of the Global Research Programme on Equality (GRIP) miniseries, Inequality in the (Post-) Pandemic City.

The Paradox of Geography and Vaccine: When the Constructs of Global Health Security and Vaccines as a Global Good are Abandoned

On January 12, 2021 I read with excitement the World Health Organization (WHO) news release, “UNICEF, WHO, IFRC and MSF announce the establishment of a global Ebola vaccine stockpile”. We all owe a debt to the efforts of the “International Coordinating Group (ICG) on Vaccine Provision” to bring this to a reality, with financial support that from GAVI, the Vaccine Alliance.

What does this new development mean in the context of current research, development, manufacture of COVID-19 vaccines? It means that success is possible. Now, when there is an Ebola outbreak anywhere in the world the Vaccine can get there in 48 hours under the right environmental conditions to quickly contain it. It means we will not see the repetition of the devastation of the Ebola outbreak of 2014/2015. We will not see health systems crumble under an outbreak which previously left dead bodies sprawled in the streets of Liberia, Sierra Leone and Guinea.

But what this seemingly great story has not revealed is the sacrifices made by African scientists in the long journey from the phase two clinical trials in Liberia to ring-vaccination in Guinea. It masks the story of the thousands of West African volunteers who took the risk to be tested with one of the two Ebola vaccine candidates in 2015.

Like many other Africans, I have been involved with the Merck, Sharp & Dohme (MSD) single-dose Ebola (rVSV∆G-ZEBOV-GP, live) vaccine from pre-trials up to the current decision for the vaccine stockpile under the ICG. It has been a long arduous journey to overcome the initial hesitancy and resistance of communities in the region. These initial efforts, however, had resulted in the first large scale Phase-2 randomized control clinical trial of two Ebola vaccine candidates in Liberia. One thousand five hundred participants in Liberia were recruited into either of the two vaccine candidates or the placebo control arm. The result of that vaccine impacted the initiation of the ring vaccine in Guinea and its eventual use in the Democratic Republic of the Congo. In 2017, I was invited to Geneva by WHO to attend a special session convened by the Strategic Advisory Group of Experts (SAGE) on Immunization. The combination of data we presented on the leading candidate of the Ebola vaccine (rVSV∆G-ZEBOV-GP) phase-2 trial along with other expert opinion led the SAGE group to approve this single vaccine candidate as a part of the 2018-2020 Ebola virus response in the Democratic Republic of Congo (DRC).

Many African scientists were asked by MERCK to serve on the Experts’ Input Forum on Ebola vaccine. There were many of us from Africa including Professor Jean Jacque Muyembe, co-discoverer of the Ebola virus.  Our inputs informed regulatory, licensure and post-licensure processes. Key among these issues was the stockpiling for immediate distribution to countries facing Ebola outbreaks. The final decision to have the MERCK Ebola Vaccine stockpile managed by the ICG had taken three years. I was there with my colleagues assisting every step of the way. Both the volunteers who received this experimental vaccine as well as those of us who supported the process have never asked for special privileges or priority in the stockpile and the distribution of the single-dose Ebola vaccine (rVSV∆G-ZEBOV-GP).

We were happy to collaborate with our colleagues from the US, Europe, a private vaccine company, WHO, MSF, and UNICEF so that we all can benefit from this global good. This successful coalition resulted in a vaccine that would protect humanity from the scourge of the deadly Ebola virus.

That is why I was shocked when I realized that the research, development, manufacturing and distribution of current Pfizer-BioNTech mRNA and Moderna mRNA COVID-19 vaccines would not be as equitable as it has been with the Ebola vaccine. We are seeing a sadly different narrative. These two vaccines that have demonstrated 95% efficacy would not be equitably access by all human beings. A narrative that is embedded in the hypocrisy of a fair and just world when things are normal and when only the Africans are affected. Every construct we developed for a just world including vaccines as a global good is abandoned when the western world is seriously threatened or massive profit is to be made.

My hope for an equitable distribution of the approved COVID-19 vaccines to end this nightmare was shattered when I read that the mechanisms initiated for the Ebola vaccine would not be repeated for these COVID-19 vaccines. I was shock when I read that in spite of the perilous time the entire human race finds itself in, some big pharmaceutical companies are unwilling to share their intellectual property (IP) for mass production and distribution of the COVID-19 vaccines by countries like India and South Africa that have the technology. For me it was appalling that we could be discussing profits when our very survival as human beings was threatened.

This for me is the greatest paradox when it comes to two major global frameworks- vaccines as a global good and vaccines as the main component of a Global Health Security Agenda (GHSA). The three pillars that the GHSA rests upon are to prevent, detect and respond—that preventing infectious disease in one country is a way of ensuring security for the rest of the world. Hence, the need to invest in vaccine, like the MSD Ebola vaccine, and make it available and accessible. In this way developed countries are prevented from the export of diseases that can be contained by vaccination. Under the current onslaught of COVID-19, we seem to be forgetting the entire framework of the GHSA.

What is even more paradoxical is that these constructs and frameworks hold well when it is to the convenience of the wealthy, but it fails to hold when adhering to them will challenge their economic prosperity and comfort. The exorbitant cost and the failure to release the IP defeats these constructs. Why are we shifting from the fundamental frameworks that we have created for all other vaccines? Why are we making an exception with COVID-19?

I am of the view that our current disregard for these two constructs are underpinned by the great North-South divide or the historical racial divide. We all do know that the quest for economic prosperity has driven the oppression of others over the past 600 years. Slavery as an institution replaced the cordial trade between Europe and Africa with the demands of cheap human labor in the Americas. Advocacy for ending slavery as an institution in England gained traction when the steam engine made it economically viable to replace human muscles. We then saw the transition from slavery to colonialism when the invented engines of Europe became very hungry for the natural resources of Africa. Colonialism has been replaced with neocolonialism because there is need to continuously siphon Africa’s resources while bringing finished products to its vast market at prices that are an order of magnitude above the extracted raw materials.

We are seeing the repeat of history in these perilous times, where maximizing profits from the COVID-19 vaccines supersede whatever ethical constructs we have built. Essentially, all of our moral compasses and normative values seems to crack under the pursuit of profit.

If we decide to proceed with current agenda for the COVID-19 vaccine, let us not ignore these very hard questions:

  1. Can we afford to continue lose 375 billion dollars a month when equitable access to the vaccine will change this?
  2. Can we really have security and protection from this disease if only the rich and the developed countries are vaccinated?
  3. Can we afford to see a world where more the half of the global population in the developing economies become poor by paying for these vaccines?
  4. Are willing to selectively distribute these vaccines until multiple resistance strains engulf the planet again?

If we answer yes to any of these questions, we are simply buying time until the disease takes a more devastating toll. However, we all do know that it is in our best interest to answer no to each.

The developed world has made better choices in past. This was demonstrated through PEPFAR, which saved millions of lives and gave hope to the entire continent of Africa. The HIV/AIDS pandemic once made the developed world to face similar dilemma of making profit through protected patents and IP while the infected people of Africa and Asia gradually rotted to death.  It took the courage of President George Bush who asked Dr. Anthony Fauci to work in utmost secrecy to develop the largest HIV/AIDS response plan that would make antiretroviral treatments available to the developing world. That ambitious plan became the President Emergency Plan for HIV/AIDS Response (PEPFAR). With that plan more than one-half of the world was saved from extinction. Many children would no longer be made orphans. Many people would now lead productive lives. South Africa did not have to train 5 or more people for every job due to the fact that people were dying from the deadly disease.

In the current pandemic, we need a PEPFAR-like plan to stave off impending calamities in the Global South—the harsh reality is that African countries cannot afford to procure the vaccines at current market prices. With a global economic collapse that is seeing more African countries becoming insolvent, any attempts for them to procure this vaccine as it stands will reverse every human development progress they have made.

The poorer countries have options which may not be ideal for our world. They can wait in dreadful anticipation for the virus to devastate their lives, their economies, and their very existence. They can come together through regional bodies like the Africa CDC to amplify the demands for funding for collective purchase of affordable vaccine when they are produced through COVAX. I have just published an article where I delved deeply into the mechanism of COVAX to be the most viable option (No country is an island: collective approach to COVID-19 vaccines is the only way to go). They can join other countries and immunize their people with sub-standard vaccines that have very little evidence of efficacy. But this will have consequences for the world. They can advocate for the IP to be given to them so that countries with advanced manufacturing capacity like India, South Africa and Brazil can make more vaccines. Like I stated in my recent article, I doubt this will come to pass because there have been counterarguments in the last WTO meeting and a flat rejection of this option. Again, maximizing profit to drive research and innovation should not triumph the concept of global good and GHSA. These ideals make us human.

As of now, we know that each of these options have their challenges. Like I said in my recent article, the COVAX platform which is the most viable option for making potential vaccine equitable available to everyone, has some inherent challenges. The needed funds may not raised to manufacture the projected 2 billion doses needed to protect the most vulnerable population in all nations. There are potential risks for low efficacious candidate vaccine being used with safety concerns. To minimize these risk and accelerate our response efforts to protect the entire world, we need to galvanize ourselves under the leadership of the developed world to ensure that the two currently approved COVID-19 vaccines to make the two most advanced vaccines (Pfizer-BioNTech mRNA vaccine and Moderna mRNA vaccine) with about 95% efficacy be equitably accessible to all men irrespective of their geography, color of their skin or economic condition. This can be complemented with the COVAX platform to protect the human race from COVID-19.

Even as I sadly end this essay, my mind wandered to the hundreds of hours we committed to the Ebola vaccine trails that made our world better prepared to contain the virus. Taking the cue from this successful enterprise, will the Global North set aside its greed to ensure that all people, irrespective of their geography, color of their skin, and economic wellbeing, have affordable access to a COVID-19 vaccine? This is our moment and this is our time to show our solidarity as global citizens.

Dr. Mosoka P. Fallah is the Founder and Executive Director of Refuge Place International, an NGO aiming to address the issues of access to quality affordable health care that impacts maternal and infant mortality among poor urban and rural dwellers in Liberia. Mosoka has a PhD in Immunology from the University of Kentucky and he has studied Global Health and Infectious Disease Epidemiology at the Harvard Chan School of Public Health.

Currently, Mosaka is the Principal Investigator in Liberia of several NIH-sponsored studies on Ebola, including a natural history study of the largest cohort of Ebola survivors in the world. In addition, Mosoka serves as a part-time faculty member at Harvard Medical School’s Department of Social Medicine. In June of 2019, he visited the Democratic Republic of Congo as a part of a team of local NGO and York University in Canada to evaluate and advise on the Ebola response. Mosoka also recently served as the Director General of the National Public Health Institute of Liberia (NPHIL). For his work building community-level trust in the Ebola response, Mosoka was named a Time Magazine Persons of the Year in 2014.

Global Research Programme on Equality (GRIP)

The Global Research Programme on Inequality (GRIP) is a radically interdisciplinary research programme that views inequality as both a fundamental challenge to human well-being and as an impediment to achieving the ambitions of the 2030 Agenda.

The miniseries “Inequality in the (Post-) Pandemic City” probes how different dimensions of inequality are shaped, exacerbated, materialized, or co-exist in globally diverse urban contexts. In this series, we provide insights from researchers, scholars and specialists and ask how the effects of the pandemic, including the virus itself or the intervention measures associated with it, are impacting people and communities, particularly in relation to economic, political, social, cultural, environmental and knowledge-based inequalities

Photo: World Bank on Flickr

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