David Adler
On July 20, the World Trade Organization holds another Trade-Related Aspects of Intellectual Property Rights (TRIPS) Council meeting to consider waiving intellectual property protections for COVID-19 vaccines. But vaccinating the world will take more than just increasing supply. Vaccines need to be distributed and administered so they end up in people’s arms. Yet there is still limited global focus on this critical last mile problem.
The United States is a perfect case study of the importance of rollout planning and what can go wrong. It led the world in COVID-19 vaccine development and manufacturing, accomplished by Operation Warp Speed, in record time. But vaccine rollout was another story: The United States lagged behind both Israel and the United Kingdom in getting shots into people’s arms. Now, as the United States and the world consider ways to vaccinate every country, there is every reason to believe this rollout problem will reappear on a global scale. Even if the world manufactures an adequate vaccine supply—a very big if—this doesn’t mean afflicted countries will be able to effectively administer vaccines. Given ongoing deaths from COVID-19 in countries experiencing outbreaks as well as the flourishing of new variants that could breach existing vaccines, the consequences will be deadly.
The origins of this rollout problem are predominantly institutional: The U.S. government and multilateral institutions working on supplying vaccines to the world have less of a focus on getting shots into people’s arms. This is often left up to individual countries ill-equipped for this task. But there is also a domestic U.S. political problem. The U.S. government’s efforts to vaccinate the world are often driven by the agendas of activism-focused nonprofits. Activists are united in a righteous solution of “vaccine equity,” which focuses on ensuring vaccine supply is fairly distributed among all countries in the world. However, activists have not yet, at least en masse, turned their attention to the technical challenges surrounding global rollout, including the long-term planning required for distribution and actually getting shots into people’s arms. This lack of political pressure means these issues aren’t getting the attention required to effectively vaccinate the world.
Some of these institutional and political fissures marked the original rollout of COVID-19 vaccines in the United States—and explain some of its initial shortcomings. Although it isn’t widely known, the rollout had two components: “distribution,” meaning getting the vaccine to a specific location, and “administration,” meaning shots in the arm. The federal government’s Operation Warp Speed oversaw the distribution of vaccines and the complex logistics involved, including the ultra-cold storage requirements for mRNA vaccines. The distribution aspect of the rollout was highly successful, with 99 percent of vaccines arriving on time and at the right temperature.
Administering shots in the arm was another story. This was primarily left up to the states. Initially, Operation Warp Speed planned to have the U.S. Defense Department administer shots in the arms, but state and local authorities complained of the militarization of vaccine administration and took over this function. For whatever the reason—lack of resources, lack of planning, poor communication from the federal government—the states had trouble administering the vaccines on time. As of Jan. 15, more than 31 million doses had been “distributed” but only around 12 million doses had been “administered.” Over time, and with bolstered support from the incoming Biden administration, rollout rapidly improved. Nonetheless, vaccine hesitancy remains a major point of resistance to more widespread immunization in the United States.
These rollout problems found in the United States are amplified many times when it comes to global rollout. The Biden administration discovered this first hand when it attempted to donate 80 million doses from domestic U.S. supply to the rest of the world in June but fell well short of this target. White House press secretary Jen Psaki said, “what we found to be the biggest challenge is not actually the supply—we have plenty of doses to share with the world—but this is a herculean logistical challenge. And we’ve seen that as we’ve begun to implement.” She pointed to the distributional challenges associated with storing vaccines at the proper temperature as well as the need for needles and syringes.
The TRIPS waiver can be seen as essentially a political or even theatrical gesture.
As Psaki’s comments show, there is more to vaccinating the world than just increasing supply. Even if there are vaccine shortages at this moment, limited vaccine supply may not be a binding constraint by year end. Serum Institute of India, the world’s largest vaccine manufacturer, has announced it will begin exporting later this year, implying India should have adequate vaccine supply by then. Pfizer/BioNTech has pledged to deliver 2 billion doses to low- and middle-income countries. AstraZeneca is continuing to scale up production.
Nonetheless, the Biden administration’s signature international COVID-19 policy, the TRIPS waiver, is a supply side move—but one unlikely to lead to any actual increase in supply. This waves intellectual property protections for COVID-19 vaccines to further foreign production. The U.K. and German governments have viewed it skeptically and can block it. Also, as has been widely noted, manufacturing involves trade secrets and supply chain issues that go well beyond intellectual property (IP) rights. Less widely noted is the fact that the Johnson & Johnson, AstraZeneca, and Novavax vaccines have already been licensed to Indian manufacturers, so it is not clear to what degree IP rights are really hindering additional foreign production.
Therefore, the TRIPS waiver can be seen as essentially a political or even theatrical gesture, well removed from the messy world of vaccine distribution and administration. It appealed to a domestic audience hostile to Big Pharma and an international audience of countries like India and South Africa whose industrial policies have long called for limitations on IP rights.
The Biden administration’s policies keep evolving, and newer proposals are likely to show more immediate results. The United States has pledged to buy 500 million U.S. produced doses of the Pfizer/BioNTech vaccine over the next year and donate them to low-income countries. Many financing initiatives have been announced. But U.S. plans of how to tackle the critical last mile and get the vaccines into people’s arms have not been as clearly fleshed out, with the United States mostly taking a hands-off approach.
Administering vaccines requires a global rollout plan. After all, as the truism goes, a global pandemic demands a global response. However, this phrase is open to interpretation, with vaccine nationalism typically cloaked in globalist rhetoric. Many in the United States are deeply uncomfortable with a U.S.-led pandemic effort and hear the statement to mean that globalist institutions should take the lead. In other countries, the phrase can mean something very different. For instance, when European Commission President Ursula von der Leyen floated the idea of a “vaccine export transparency mechanism” to block vaccine exports from the EU to the U.K., she said it was for the “global common good.” These various meanings are somehow aligned in discouraging any U.S. unilateralism and pose challenges to a more active U.S. involvement in a global rollout.
The primary global initiative to ensure all countries have access to COVID-19 vaccines is COVAX, co-convened by the Coalition for Epidemic Preparedness Innovations, the vaccine alliance Gavi, and the World Health Organization. Gavi oversees procurement but does not have an on-the-ground presence for administering vaccines. This is left up to the health ministries of developing countries and other partners. The coalition’s key partner responsible for delivering vaccines is UNICEF. UNICEF is a children’s agency whose mission is helping every child thrive all over the world. However, it is the elderly who are most at risk for COVID-19. Ultimately, COVAX has rollout capabilities but limited bandwidth and resources when it comes to vaccine administration.
The United States has these resources, including deep expertise in both vaccine distribution and administration. Operation Warp Speed showed the Defense Department can manage the complex ultra-cold logistics required for mRNA vaccine distribution. The Centers for Disease Control and Prevention (CDC) and the U.S. Agency for International Development (USAID) have knowledge of vaccine administration—although addressing a global pandemic would be a “stretch goal.” The United States could use its personnel and expertise to help solve the global rollout problem, either on its own or in a partnership with multilateral institutions, such as COVAX.
This is not to imply the United States, with its declining life expectancy, necessarily has a better health system than other afflicted countries—only that it has rollout knowledge it learned the hard way. The key lesson is the last mile is the hardest part to roll out. Rather than having vaccine supplies arrive and only then start training, it is better to have mass vaccination sites up and running and already fully staffed. The United States could offer technical guidance and materials necessary for rollouts, including refrigeration, ancillary kits, and having enough needles on hand. USAID could offer advice on how a country could improve its vaccine readiness plan.
Addressing vaccine hesitancy is also critical to a successful rollout. The reasons behind vaccine hesitancy are complex and vary by country and population. Hence, responses need to be country specific but will typically require a massive communications effort. Where is the global effort? Where is the global planning for this effort?
Tackling these global, last-mile challenges faces huge domestic roadblocks in the United States. It would require making global rollout a top U.S. foreign-policy priority, necessitating the planning, financing, and personnel of something akin to the Marshall Plan. It would be expensive. It involves industrial planning, which still has negative overtones in the United States. Which agency in the U.S. government should coordinate such a plan? The State Department? The Defense Department? The National Institute of Health? The CDC? The White House COVID-19 Response Team? Perhaps the most divisive question is if the United States should lead such an effort or follow the WHO’s directives.
But none of this is relevant because there is no domestic political pressure for pursuing such an approach, unlike the TRIPS waiver. This is because nonprofit activism is still primarily focused on supply and eliminating vaccine hoarding by rich countries. True global vaccine equity requires a broader definition and effort beyond just manufacturing more supply, namely creating a global rollout plan and deploying the health resources necessary to get shots into people’s arms.
The end result is the United States is hesitant to find more concrete ways to get involved with a global rollout beyond just pledging more vaccine supplies or money. It is hesitant to directly intervene to help the worst afflicted poor countries distribute and administer vaccines. And vaccine hesitancy, in whichever form it takes, can be deadly.
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