For previous articles on this topic by Fatima Hassan, read here and here.

In early 2020, many of us in the access to medicines movement warned that it is neither prudent to rely on the market alone, nor just charity in the face of the Covid-19 pandemic. It would not be sustainable. We argued that this approach of commodifying essential life-saving interventions, vaccines in particular, despite significant public funding and socialised risk supporting accelerated vaccine research (about $100-billion of funding), would result in the public not getting timely and enough access to the fruits of publicly funded and supported research.

In the months to follow, the Vatican, the WHO’s director-general, 170 former heads of states and Nobel Laureates, scientists, researchers, and many others have echoed our growing concerns.

We mourn the 3.5 million people who have already died within the space of just more than a year and the many, many more that are likely to follow. Yet, we have multiple safe and effective vaccines that could be used to save millions of lives. But, according to recent data, only 21.8% of the world population has received at least one dose of a Covid-19 vaccine. This means that 2.7 billion doses have been administered globally, and about 38 million doses are now administered each day across multiple countries. But, just under 1% of people in low-income countries have received at least one dose.

For Africa, the data indicate that less than 3% of people have been vaccinated, one of the worst faring continents for vaccine access and coverage. And if one compares the number of vaccines available, delivered, and administered, versus what has been promised or ordered, they are two massively different sets of numbers.

According to the director-general of the WHO, the world urgently needs 11 billion doses to contain the pandemic. But, in a “grotesque” display of vaccine inequality, only about 20 places in the world have administered enough vaccines to cover 40% of their population, while the tools and technologies exist to speedily change this number.

It is also reported that the wealthiest 27 nations globally have a quarter of the world’s vaccine supplies. Bloomberg’s vaccine tracker estimates that 2.59 billion doses of vaccines have been administered, for about 16.9% of the global population across 180 countries. The UK has reached 46% (fully administered) vaccine coverage, while in the US it is about 45% (this does not reflect state-by-state vaccine access disparities in the US).

We also argued in the early days of the pandemic, that based on past experience of how private pharmaceutical corporations behave in epidemics, that in this pandemic, it is not a good strategy to only rely on a handful of manufacturers to make safe and effective vaccines or even therapeutics. This is because when billions of doses are needed at the same time, limiting manufacturing to just a few companies, with export bans and other restrictions, creates scarcity, requiring rationing and prioritisation based on risk profile.

This means that while everyone, everywhere should be eligible for a vaccine at the same time, certain at-risk groups must be prioritised, first based on public health factors, ethics and equity principles. This is why, for example, the WHO called early on in 2021 for healthcare workers around the world to be prioritised along with elderly people before others. This did not materialise.

We also argued that in addition to supporting the Trips waiver governments themselves should also take compulsory measures against companies that are unable to meet demand, mainly because they limit the number of manufacturing partners in a pandemic. This reduces the ability to scale up supplies to those in need. This is called artificial scarcity. And because CEOs are not elected leaders, they should not be in the driving seat in a pandemic.

In South Africa for a long time, and especially this past year, we have been waiting for Parliament and all political parties to urgently attend to passing the Patent Amendment Bill despite the Covid-19 pandemic showing the havoc that patent monopolies create. The tabling of the bill has stalled and is being blocked by certain political parties, we believe, to protect vested private interests. This could undermine future efforts to ensure that we access life-saving medicines and vaccines in affordable and sustainable ways.

Regrettably, global mechanisms that were touted as the solution to securing “equity” in and for the global South, with a promise of fair prioritisation in the allocation of available global supplies, relied only on volunteerism and cooperation. These mechanisms mainly still refuse to address market failures and intellectual property’s stranglehold on equity. Also, it cannot properly address the pressing need for vaccine supplies around the world right now. This includes Covax — which is now facing a massive shortfall in supplies for 2021. According to its most recent forecast, there is a real possibility that it will not be able to help even more than a quarter of vulnerable populations in low-income countries by the end of 2021. Neither will the WHO’s voluntary pooling mechanism called “C-TAP”, which so far does not have a single brand name vaccine manufacturer joining.

Locally, for several reasons, also to do with the SA government’s vaccine selection choices and timing of those decisions, the impact of the Covid-19 crisis in India coupled with the AstraZeneca/Oxford University/Serum II narrow licensing terms for that supply pipeline, Covax will deliver a first shipment of just Pfizer vaccines for South Africa before end June 2021.

Granted, both these initiatives (C-TAP and Covax) have been hamstrung by the tactics of very powerful and profitable companies alongside certain governments, especially G7 states. They have been unwilling to broadly share vaccine know-how or technology; unwilling to compel that transfer; nor fully support the entire Trips waiver proposal while millions of people are now at risk of dying, needlessly.

But information sharing also means transparency, which sadly there has been very little of. For months the Health Justice Initiative has been asking for all the 2021 MAC Vaccine Advisories to be made public, on the Department of Health’s website, even before the special leave of the minister of health took effect. Despite repeated requests, this has not been forthcoming, leaving everyone to speculate in a pandemic on vaccine selection decisions, supplies, deliveries and other relevant details.

Some donations have been offered for use over the next 12-18 months but fall far short of what is needed: literally billions of doses. So, in the current context, it will take many years before global South countries can reach optimal population coverage and immunity levels. With multiple variants, the consequences of having to wait so long for supplies will be even more devastating on all health systems. MSF has also warned that due to vaccine supply shortages, most people in low- and middle-income countries will not receive adequate supplies of vaccines until at least 2023.

But, while we wait for supplies, deaths are on the rise. Again, locally, the South African Medical Research Council (SAMRC) and UCT joint mortality report indicates that from May 2020 to 5 June 2021 “there has been a cumulative total of nearly 167,000 excess deaths from natural causes of persons 1+ years of age”. At present, South Africa is in a Level 4 lockdown, in the third wave, with increasing rates of infection, and hospital bed capacity at risk of breaking point in several provinces, with both grief and population impatience rising alongside a very stretched and battered health workforce.

So far, the medicines regulator (an independent statutory body) has approved Johnson & Johnson with conditions, Pfizer through a section 21 approval, and the Serum II/AstraZeneca batch through a section 21 approval (in January 2021, the planned AstraZeneca roll-out was paused and the vaccines donated or sold to other African countries).

According to the South African Health Products Regulatory Authority (Sahpra), it is reviewing or obtaining more data from additional candidates where companies locally have submitted dossiers: Coronavac (Sinovac), and Sputnik V. SinoPharm has just submitted an application for section 21 approval.

To date, according to Sahpra, Novavax and Moderna have not submitted regulatory dossiers or section 21 approval requests. Moderna appears to not want to enter the SA market at all, nor other low- and middle-income countries, though it has recently signed agreements with Saudi Arabia and Botswana.

Outside of the Sisonke study trial, in South Africa as at 19 June, 2021 1,661,856 million people have been vaccinated as part of the national roll-out with a first shot of the Pfizer vaccine. This is, mostly in Gauteng and KZN, presumably for people all over 60 years, and perhaps including some health workers that were not in the Sisonke study. Teachers commenced receiving vaccines last week too.

About 480,000 health workers were also vaccinated through the Sisonke study trial, and media reports indicate so too were athletes, sports officials from different sporting bodies and perhaps others too who are not healthcare workers or classified as a “high-risk” group.

While this has been taking place, reports also indicate that certain richer nation’s embassies have been vaccinating their staff and their own citizens in SA, in parallel, through specially authorised imports and special supplies. Global vaccine apartheid has now extended to domestic contexts without any consequences, except moral censure. We believe that several richer nation embassies, including the US embassy, have vaccinated their staff too, which we hope they report on. This suggests that South Africa has several parallel vaccine roll-out programmes, and the true number of people being vaccinated in the country is actually not that clear.

So, how is it that G7 member states have stockpiles or enough doses to even send to their staff and citizens overseas? According to the global People’s Vaccine Campaign so far, one-third of the world’s vaccine supplies have gone to G7 member states, while in Africa, less than 3% of people have been administered with a vaccine. It is deeply ironic that these very countries have also for months blocked the Trips waiver proposal led by SA and India since October 2020.

And while more supplies are being promised by Covax, bilaterals and/or African Union’s Covid-19 Africa Vaccine Acquisition Task Team (AU VATT) (there is definitely money) they are not arriving at all or not fast enough, which explains the shocking disparities in global vaccine coverage. In some parts of Africa, not all healthcare workers have received a vaccine, while the North is preparing to vaccinate adolescents and children — which ordinarily should be a joy.

So, SA is having to prioritise according to age and it seems other factors due to scarcity, at times unevenly.

With limited supplies all around and general confusion, one would expect that there should be a constant stream of information to keep the public abreast of developments and to provide hope. There is a desperate need to over-communicate every aspect of this roll-out — but government, the National Command Council and relevant statutory bodies are not taking this fully on board. Daily briefings are a must — there is a lot of anxiety, grief and mistrust now seeping dangerously into vaccine hesitancy territory and even political interference. We need the simplest vaccine programme design, less reliance on electronic systems for now, and simple messaging across all platforms and languages with non-contradictory information and standardisation across provinces (it cannot be that some provinces accept walks-in without an EVDS registration, while others do not).

But information sharing also means transparency, which sadly there has been very little of. For months the Health Justice Initiative has been asking for all the 2021 MAC Vaccine Advisories to be made public, on the Department of Health’s website, even before the special leave of the minister of health took effect. Despite repeated requests, this has not been forthcoming, leaving everyone to speculate in a pandemic on vaccine selection decisions, supplies, deliveries and other relevant details. Most notably, the expert scientific advice on pausing AstraZeneca and donating/selling it is not included in the batch of advisories recently uploaded. Why? For this reason, we now have no choice but to follow legal routes.

And in our local context, there can no longer be any secrecy about the terms and conditions of vaccine contracts and any associated prioritisation decisions — the reasons for this are best illustrated by the recent Johnson & Johnson supply crisis which has had a severe impact on the pace of SA’s roll-out, trust in it, and worse, distortion.

This also includes all vaccine contracts irrespective of non-disclosure agreements (NDAs) with pharmaceutical companies. Here, the tide is turning, multiple redacted versions are now being released elsewhere through legal processes too and are becoming available. The terms and conditions do not bode well for sovereignty or commercial fairness.

Aside from knowing what we paid for vaccines, for how many, and for when, we need to ensure that there is full transparency on these contracts especially in relation to the local fill-and-finish contract between Johnson & Johnson and Aspen Pharmacare. It cannot be that in a pandemic where research was publicly funded, government does not share critical procurement information just because a handful of companies tell them to.

There is a reason we have a Constitution in place, and our country should not be held hostage to untested claims of confidentiality and needless secrecy when so much is at stake. It is also not in the public interest to hide procurement contracts and other key decisions behind a thick veil of secrecy.

Similarly, decisions taken by government and its officials and the medicine regulator on the selection and approval of vaccines or pausing their use must be free of political, commercial or other vested interests and undue influence. This is why vaccine approval, all associated conditions, selection and the prioritisation or changes in age cohort prioritisation by government require transparency, at the very least. As Spotlight said this past week, “we need to know who is making decisions and why”.

It is unconscionable that private companies that conveniently believe in the rule of law for the protection of their own property claims do not also believe in contractual transparency and openness. Secrecy has no place in this pandemic — after all, we the public are paying for vaccines and we are also paying for a national vaccine injury indemnification and compensation scheme.

In a pandemic, transparency matters. Let’s make it matter. DM