Geopolitics of COVID The Unprecedented Challenge of Coronavirus Vaccine Distribution
João Doria had long been waiting for this shipment, and it finally arrived last Thursday. At shortly half past seven in the morning, a Turkish cargo plane landed at São Paulo’s international airport in southeastern Brazil loaded with refrigerated containers. They contained 120,000 viles of Coronavac, a vaccine candidate developed by a Chinese company. The precious cargo was transported directly from the airport to a secret location.
Doria is the governor of the state of São Paulo. Over the past few months, he has done everything in his power to gain quick access to the Chinese vaccine from Sinovac. The 120,000 units are the first batch that will be available to the Brazilians as soon as approval is granted, possibly within just a few weeks.
The governor had placed his bet on the Chinese pharmaceutical company early on in the pandemic. Sinovac has been testing the vaccine in the Brazilian state for several months. And if the planned vaccination campaign ends up being successful, the conservative politician will be able to use it to burnish his reputation in the presidential campaign he is expected to mount in two years.
That could help explain why Brazilian President Jair Bolsonaro is stirring public sentiment against the "China vaccine,” as he disparagingly calls it. He has sought to torpedo Doria’s vaccination plan because he considers him a dangerous rival. The health authority, which is under the control of Bolsonaro’s government, already delayed the arrival of the vaccine from China once, with Bolsonaro preferring the one developed by the Swedish-British company AstraZeneca and the University of Oxford, even though it is unlikely that it will be available for large-scale use before March 2021.
The wrangling in Brazil highlights the politics of the monumental project now facing the world: the fastest possible production, distribution and administration of COVID-19 vaccines to billions of people around the globe – from major cities with excellent hospitals in the industrialized world to townships, favelas and beyond, including many hard-to-reach areas. It will be a logistical challenge, a project of a dimension humanity has never had to face before.
The article you are reading originally appeared in German in issue 48/2020 (November 21, 2020) of DER SPIEGEL.
The countries that get the vaccine first will also be the first to end their lockdowns, open up schools and restaurants and restart their economies. And those who control access to the best vaccines will gain power. "The pandemic offers an opportunity for some countries to establish themselves as producers of public goods and thus gain more influence than they were able to acquire in the 20th century by way of ideology," predicts Dmitry Trenin, head of the think tank Carnegie Moscow Center.
Other countries, meanwhile, will have a difficult time acquiring any vaccines at all. "If COVID-19 has shown one thing, it’s that the world is selfish and self-centered,” Karline Kleijer, emergency coordinator for the aid organization Doctors without Borders, said back in July. "I have never seen such a dirty, mafia-like street fighter mentality as I have seen in the past few months in the procuring of masks." And the logistics behind mask supplies were relatively simple by comparison.
But at least there is some cause for hope right at the moment. It looks as though the world won’t just have a single coronavirus vaccine at its disposal in the near future, but a whole range of them. According to the World Health Organization (WHO), some 48 vaccine candidates are currently undergoing clinical trials. Eleven of them are in decisive Phase III trials. The producers of these vaccine candidates hail from China, the United States, Russia, India and several European countries.
A vaccine delivery in Brazil: "One thing wrong about the Western countries, it’s all profit, profit, profit."Foto: Nelson Almeida / AFP
In early November, Chinese pharmaceutical company Sinopharm announced that hundreds of thousands of Chinese had been vaccinated by emergency decree, including 56,000 Chinese traveling abroad, of whom none have allegedly fallen ill with COVID-19. The company said there haven't been any significant side effects. At the end of the month, Sinopharm and Sinovac are expected to publish the official results of their clinical trials, after which approval could be granted quickly, at least in China.
Other developers have also reported initial success. The German-American consortium BioNTech and Pfizer recently announced that its candidate is 95 percent effective, and the U.S. company Moderna has said that its vaccine candidate is 94.5 percent effective. Russia has reported 92 percent effectiveness for its Sputnik V vaccine from the government’s Gamaleya Research Institute of Epidemiology and Microbiology. Moscow approved Sputnik V in August and a second vaccine in October, although Phase III testing is still ongoing for both.
Russian President Vladimir Putin would like to see mass vaccinations begin this year in his country. First, though, he has to convince his population that it is safe: According to surveys, 59 percent of Russians refuse vaccination because they don't trust the vaccine. Thus far, around 10,000 people from risk groups – mostly in Moscow – have been vaccinated, including teachers and medical workers.
Ten of the doctors who were vaccinated came down with COVID-19 anyway, which the Russian Health Ministry has said is a result of the fact that nine of them received only one dose, instead of the two necessary to establish immunity. The second big problem is that the vaccine has thus far not managed to make it to some of the places where it is needed. According to media reports, vaccine deliveries to remote regions have been delayed due to a lack of transportation and cooling infrastructure.
And those are just the problems experienced by a country that has developed its own vaccine with no outside help. Global distribution will be vastly more complex, even in developed regions.
The first major problem is refrigeration. The vaccine candidate from BioNTech and Pfizer, which is based on mRNA technology, has to be stored at around minus 70 degrees Celsius, which even many modern hospitals can’t do. To handle the problem, Pfizer has designed an ultra-cold transport box the size of a small suitcase that can hold several thousand doses. The company has set up "freezer farms” at logistics centers in the U.S. state of Michigan and in the Belgian town of Puurs, where row after row of freezers have been set up in warehouses. It also has two further warehouses in Karlsruhe, Germany, and in the state of Wisconsin at its disposal.
Lonza Group, a pharmaceutical company in Switzerland, also believes that Moderna’s mRNA candidate will have to be manufactured at extremely low temperatures. The company hopes to produce 400 million doses of its vaccine next year. If stored in vials, the vaccine could have a shelf-life of one year if kept at minus 20 degrees Celsius.
Other vaccine candidates have fewer challenges related to temperature. Zhang Hongtao of the University of Pennsylvania says the Chinese candidates can be kept at 2 to 8-degrees Celsius. Marco Krieger of the Brazilian research institute Fiocruz has reported similar results for the candidate from AstraZeneca. But even then, the vials can’t be shipped or stored without closed chains that include refrigeration at all points of the journey.
The extremely low temperatures needed for some of the vaccines also pose special challenges for vials made of special medical glass – many billions of which are needed worldwide. In addition to manufacturing them in far greater quantities, producers are also working on making them less vulnerable to breaking.
In order to prevent the theft of the coveted vaccines, pharmaceutical companies are also considering equipping shipments with GPS trackers or sending out empty trucks to deceive possible thieves and make it harder to plan attacks. It’s also unclear how the 15,000 flights will be organized that German logistics company DHL estimates will be needed for global distribution. Beyond that, there is a high demand for vaccination centers and qualified medical staff to administer the injections.
Once again, those countries that have sufficient resources and their own manufacturing capacities will be at an advantage. A study by the Duke Global Health Innovation center found that a few dozen industrialized and emerging economies have already secured around 6 billion doses of potential vaccines, without even knowing whether any of these candidates will ever be approved by medical regulatory authorities. The European Union and the U.S. have each reserved more than 1 billion vaccine doses. China, which is producing its own vaccine, hopes to reach 610 million doses by the end of December.
"There is no country and no company that isn’t acting in a nationalistic way in their handling of the vaccine,” says Stephan Exo-Kreischer of the organization One, which has analyzed the agreements between pharmaceutical companies and the G-20 states. Experts fear that in view of the limited production capacities, many developing countries could have to wait until 2024 in a worst-case scenario.
Preventing such a situation is the mission of COVAX, a global initiative that is aiming to establish at least some fairness between rich and poor countries. The initiative is led by WHO, the Gavi Alliance on Immunization and the Coalition for Epidemic Preparedness Innovations (CEPI), an international research alliance. The idea behind COVAX is that state and private donors pay into a fund which, thanks to its bundled market power, can negotiate better terms with vaccine manufacturers. The vaccines acquired would then be distributed so that each participating country could vaccinate 20 percent of its population.
Some 92 developing countries are considered eligible for support under COVAX and are to receive vaccines at discount prices. COVAX has commissioned UNICEF, the United Nations children’s aid organization, which has experience in vaccination campaigns ranging from measles to polio, to purchase 2 billion vaccine doses and 1 billion syringes by the end of 2021 and deliver them to poor countries. The EU has pledged money for the purpose, as has the Gates Foundation and the governments of almost all industrialized countries, with the exception of the U.S. administration under President Donald Trump. China was initially hesitant, but ultimately joined the initiative.
COVAX recently reached the interim target of $2 billion in binding commitments, and there are also pledges from vaccine producers for 700 million of the goal of 2 billion doses. But Seth Berkley, the head of Gavi, has warned that "we urgently need to raise at least an additional U.S. $5 billion by the end of 2021 to ensure equitable distribution of these vaccines to those who need them.”
Benjamin Schreiber is one of the people who will be responsible for the program. The German national works at UNICEF headquarters in New York, where he is coordinating distribution of vaccines to developing nations.
A coronavirus testing center in India: "Most countries simply can’t afford these vaccines."Foto: Rafiq Maqbool / AP
In the end, it’s likely there will be many individual programs rather than a single global vaccination program – at least as many as there are countries on the planet, if not more, says Schreiber. "Carrying out a vaccination program in an urban slum is something completely different than in a rural village or in a conflict zone.” Schreiber currently spends most of his days in video conferences discussing the details with officials around the world.
On the other end of those calls are people like Richard Mihigo, who is based at WHO’s Africa headquarters in Brazzaville on the banks of the Congo River. Mihigo is one of the leaders of the WHO vaccination effort in Africa and his concerns go far beyond just vaccine availability and the need to refrigerate it. "Even more important is making sure that the vaccine gets to the people who need it,” he says.
In Africa, the planning and execution of vaccination campaigns frequently resembles complex operations, and are frequently confronted with challenges like not even having roads available to transport vaccination teams to remote areas. Often, safety is also an issue. During the outbreak of the Ebola epidemic in the eastern part of the Democratic Republic of Congo starting in 2018, for example, military escorts were sometimes necessary in regions where militias were particularly active or the population was especially opposed to the efforts of WHO and the Health Ministry. WHO officials remember well the burning treatment centers there. Rumors spread that it was actually the foreigners bringing Ebola into the area and that it was in fact the vaccine that made people ill. Violence followed. Violence against vaccination teams that is also seen regularly in other African countries. In response, Mihigo says, they plan to work with local community leaders, religious leaders and politicians to ensure greater acceptance.
Mihigo is relying on two sources for acquiring vaccines. The first is a task team set up by the African Union in November to raise money for the purchase of vaccine doses for up to 60 percent of Africa’s population. The second, Mihigo hopes, is help from COVAX.
The initiative has noble intentions, but it remains to be seen whether it can be implemented quickly. Critics complain that no timetable has been set so far. It still isn’t known which countries will be aided by COVAX in what order or how many vaccine doses they will receive or when. It’s likely, a high-ranking operative with an international NGO says, that the vaccine producers will first process the orders of large customers before even starting to take care of poorer countries.
Indeed, there are already signs that the world is breaking up into vaccination blocs. Indian pharmaceuticals entrepreneur Adar Poonawalla believes that the new mRNA vaccines will primarily benefit wealthy, industrialized countries - not just because of the need for ultra-cold storage, but also due to its price, which is said to be around $20 to $25 per dose. "Right now, these vaccines are quite unaffordable for most countries," he says. Furthermore, there is a lack of the factories needed to manufacture them. Countries like India that have traditionally handled large-scale vaccine production for large parts of the world are not equipped to manufacture the new kind of mRNA vaccines.
Poonawalla’s family owns the Serum Institute of India, the world’s largest vaccine manufacturer, which produces for AstraZeneca and the U.S. pharmaceutical company Norovax, among others. Poonawalla says he will be able to manufacture 1 billion doses of the AstraZeneca vaccine alone by the end of next year at a price of around $3 per dose. Half of those stocks would remain in India, with the other half distributed in Asia, Africa and Latin America.
AstraZeneca is doing strong business in Latin America and will supply six countries in the region with a total of 216 million vaccine doses in 2021. At the same time, leftist governments in countries including Argentina and Mexico are relying on Russia’s Sputnik V vaccine. Belarus and Uzbekistan have also expressed interest.
According to WHO, there are currently no bilateral agreements between African countries and vaccine producers. However, a vaccination expert with an international NGO in South Africa reports that offers have already been made to individual countries on the continent and that more are expected from producers like China, Russia or India. The expert said vaccines will most likely be offered to African countries at lower prices and that concessions will be demanded in return, such as easier market access.
China, meanwhile, is taking every opportunity available to expand its sphere of influence. Beijing has offered loans to virtually all Latin American countries for the purchase of Chinese vaccines and has pledged to give priority for supplies to Africa and the Philippines. As a measure of thanks, Philippine President Rodrigo Duterte recently said: "One good thing about China is you do not have to beg, you do not have to plead. One thing bad about the Western countries, it’s profit, profit, profit.”
The fact that the pandemic is currently contained in China and the risk of infection there is close to zero means that Sinopharm, Sinovac and CanSino, the third major Chinese vaccine developer, are unable to test the efficacy of their vaccines in their own country. As such, they have signed testing and manufacturing contracts with more than a dozen other countries. Brazil, Saudi Arabia and Peru, as some of China’s most important suppliers of raw materials, have been included, as well as countries with governments that are friendly to Beijing, including Serbia and Pakistan.
Canada, on the other hand, has had a very different experience with Beijing. CanSino originally wanted to conduct a Phase III trial for its vaccine candidate there, but the test never happened.
The vaccine got stuck in Chinese customs for six weeks until CanSino called off the trial at the end of August. So far, China’s authorities haven’t explained why they never released the shipment. But there is one possible explanation that is indeed hard to overlook. Relations between Canada and China have rapidly deteriorated since Canada, at the request of the U.S., arrested Huawei Chief Financial Officer Meng Wanzhou in 2018 and China took two Canadian citizens hostage in return.
The good news for Canada, though, is that its own vaccination program won't fail just because the trial never happened. The country has secured more doses per inhabitant than any other country in the world. That episode does provide one insight though: Access to the vaccine can be used not only as a reward for good behavior, but also as a means of repression.