CAPE TOWN – The two men at the centre of Africa’s COVID-19 response – John Nkengasong and Strive Masiwiya – vowed that the pandemic would not follow the same pattern as for HIV, where millions of Africans died because they could not get access to the life-saving antiretroviral (ARV) medicine available in wealthy Western countries.

For over a year, Nkengasong, director of Africa Centres for Disease Control and Prevention (CDC), and Masiwiya, the African Union’s (AU) Special Envoy on COVID-19, have been meeting virtually every night between 9pm and 11pm to plan how to get vaccines for the continent.

“Before I joined this position, I spent 29 years in the area of HIV/ AIDS. I saw firsthand the suffering, the trauma of our continent between 1996 and 2006, where about 12 million Africans died because ARV drugs to treat HIV patients were available, but they were not accessible to the continent,” Nkengasong told a recent briefing on vaccine access. 

“We say to ourselves when we meet every evening to discuss [COVID-19]: never again, never should history repeat itself on our watch.”

But as the Delta variant tears through African countries and promises of COVID-19 vaccines have repeatedly failed to materialise, that familiar divide between wealthy nations with access to medicine and poorer countries without has re-emerged.

The global vaccine access facility, COVAX, has only been able to deliver 25 million of the 700 million vaccines the AU had expected this year. Deliveries ground to a halt in March when its main supplier, the Serum Institute of India (SII), halted all deliveries outside India – due to the huge spike seen in domestic cases. Although Aurélia Nguyen, Managing Director of the COVAX Facility recently promised that the pace will pick up again in the fall with the dispatch of hundreds of millions more doses around the world  – clearly senior African officials are also wary. Too many unmet promises have littered the way, while lives also are being lost every day. 

COVAX – undermined and outmanoeuvred

Effectively, COVAX has largely been undermined and outmanoeuvred by wealthy countries that have struck bilateral deals with pharmaceutical companies – the “vaccine nationalism” that has made many wealthy nations’ platitudes about global solidarity sound like cynical spin-doctoring.

But COVAX is also accused of being opaque about its operations, unable to be honest about its supply problems, and unable to escape the paradigm of a charity-based approach to Africa. 

Critics on all sides also point to one singular tactical failing of the initiative. Despite pledges from major donors, COVAX’s lack of adequate cash in hand in late 2020, left it at the back of the line when rich countries were placing their major pre-orders. For an initiative that was anchored in the status quo, this inability to compete in the open marketplace was a fatal design flaw. 

"COVAX had the backing of the World Health Organization, CEPI, vaccines alliance Gavi and the powerful Gates Foundation. What it did not have was cash, and without cash it could secure no contracts."

— Balasubramaniam (@ThiruGeneva) July 20, 2021

COVAX Left AU in the dark about financial shortfalls 

Zimbabwean-born billionaire Masiwiya, who also heads the AU’s African Vaccine Acquisition Task Team (AVATT), has become increasingly vocal about COVAX’s lack of transparency at critical moments.  

He recently charged that the vaccine facility withheld “material information” about its supply problems early in 2021. And once vaccine supply problems surfaced more visibly,  it was too late for the AU to plug the holes.

One key moment was in January 2021, when COVAX provided AVATT with a written schedule of vaccines that would be delivered from February.  But according to Masiwiya, COVAX  “failed to disclose that they were still trying to get money, that pledges [of $8.2 billion] which had been made by certain donors had not been met.

“That’s pretty material information,” added Masiwiya, who took leave from his telecom firm, Econet Global, to support the AU response to the pandemic. “Had we known that actually this was hope and not reality, we may have acted very differently. 

“We found ourselves in March, scrambling. Now we are told that is India’s problem. And we think the problems are much deeper than that.”

Masiwiya also questioned COVAX’s reliance on vaccines from the Serum Institute of India (SII), saying that it had been evident to AVATT after meeting the SII late last year that the company would be unable to meet all its orders.

Slow performance and secrecy

Kate Elder, Senior Vaccines Policy Advisor at Médecins Sans Frontières (MSF) Access Campaign, agrees with his critique of COVAX.  Along with opaque decision-making, she criticised the secrecy around the terms of advanced purchase agreements signed between COVAX and the pharmaceutical industry, as well as “deals made with “self- financing countries”, for which key details such as monies paid and vaccines procured, have not been disclosed publicly. 

“The global rollout of COVID-19 vaccines has been grossly inequitable, largely due to wealthy governments hoarding vaccines, but also due to the very slow performance of the COVAX facility”, which has failed to deliver on “big promises’,” Elder told Health Policy Watch.

“We heard from many developing countries that they were under a lot of pressure to join COVAX, but that they had difficulty getting information on what they could expect to receive from COVAX, what volumes of vaccines and in what timeframe,” Elder said.

“But it was presented as the global solution so many governments, rightly so, signed up to it and put their reliance in COVAX to deliver vaccines. Fast forward to July 2021 and we see all the challenges that COVAX has experienced, most importantly what that’s meant for developing countries in terms of accessing COVID-19 vaccines, which is absolutely devastating as Africa now enters a third wave of the pandemic with such low vaccination coverage rates.”

In South Africa, the African country worst affected by COVID-19, Cyril Ramaphosa’s government has come under intense pressure from opposition parties, medical professionals and civil society for failing to procure vaccines. However, Ramaphosa had been the chairperson of the AU for most of 2020, and pursued a continental approach to vaccine procurement – but continental negotiations struggled to secure vaccine deliveries as a January deal for 270 million doses failed to materialise.

After South Africa’s brutal second COVID-19 wave in December and January, the country pursued bilateral deals with pharmaceutical companies, including an order for AstraZeneca vaccines from SII for which it was charged double that paid by the European Union. Since June, the country – now in a deadly third wave – has been receiving the BioNtech-Pfizer vaccine – but at “prohibitive cost”, according to government officials. It is also using the Johnson and Johnson vaccine and had covered 13,6% of its population with at least one dose by Wednesday.

The only other African countries that have managed to vaccinate more than 10% of their populations – Seychelles, Mauritius, Comores, Morocco, Djibouti, Zimbabwe and Botswana – have done so primarily with vaccines supplied by China, according to Africa CDC.

Paternalistic and donor-driven? 

Ugandan epidemiologist Catherine_Kyobutungi, head of the African Population and Health Research Center in Nairobi head, has described COVAX as being “paternalistic, donor-driven” and based on a “rich-countries-helping-poor-countries mentality”.

“COVAX is unravelling,” and there is a need to go back and fundamentally re-think the approach, Kyobutungi told Development Today.

“A small group of ‘experts’ sat down and defined the problem and defined the solution for a continent of 1.3 billion people. They packaged it in an attractive way, marketed it, and drove the narrative. Until the rubber hits the road, and you run into headwinds, and you see that this solution is not working. Africa is getting one percent of the global [vaccine] total. So, you have to ask yourself, who thought this up? What was on their minds?”

Gavi, the Global Vaccine Alliance, which manages COVAX, declined requests by Health Policy Watch for comment on this article, and on the criticisms that have been levelled at COVAX by Masiyiwa, MSF and others.  

After initially promising a response from Gavi CEO Seth Berkley, a Gavi spokesperson later deferred. She said only that a response from Berkley was not possible as COVAX is “anticipating some announcements on upcoming partnerships with the AU”.

However, COVAX’s managing director, Aurelia Nguyen, addressed a WHO Africa media briefing shortly after Masiwiya’s criticisms, reporting that the facility expects to deliver some 520 million COVID-19 vaccine doses to Africa this year, but mostly from September onward – and stressed that she was unhappy with the lack of progress.

By Wednesday, COVAX had delivered 134,6 million doses to 134 countries globally – but planned to deliver two billion doses by the end of 2021.

Europeans return to football stadiums – Africans remain trapped in lockdowns

The anxiety of Africans about vaccine access comes as the continent is seeing its biggest peak yet in daily COVID cases, along with the biggest wave of COVID-related mortality due to the lack of vaccinations combined with woefully inadequate hospital infrastructure. 

“Just talked to the Manager of Heal Africa,” related one appeal for aid from Goma, DR Congo on a private chat group Monday. “Three died tonight of Covid, one of them because they ran out of oxygen. He can produce 15 bottles per day but would need 20. He said they also ran out of protective material [PPE for health care workers].” 

In some developed countries, like the UK and Israel, new COVID-19 infections, driven by the Delta variant, also are rising sharply again. But there, hospitalizations and deaths have risen much more slowly – due to high rates of vaccination coverage of 60% or more. Similarly, in Europe, as well as the United States, where 57% of the population over the age of 12 is fully vaccinated, deaths continue to decline, or plateau at levels not seen since the beginning of the pandemic – despite gradually rising numbers of Delta-driven infections. 

Even countries like India, where nearly 30% of the population is now vaccinated, are finally seeing lower hospitalization and death rates as a result of mass vaccination, permitting a slow return to normalcy. 

In contrast, with only 1.3% of Africans are fully vaccinated, African countries have been forced to impose new lockdowns as their public health weapon of last resort – resulting in  hunger, unemployment and political instability. 

“Europe has vaccinated a large chunk of its population and so has the United States,” lamented Nkengasong at a recent Africa CDC special vaccine briefing. 

He pointed to the recent Euro Cup seen the world over, with televised images of “stadiums full with young people shouting and hugging and doing what we cannot in Africa”.

“If we have a predictable supply of vaccines, we can break the backbone of this pandemic by the end of next year,” says Nkengasong. “But if vaccines are not available to enable us to vaccinate at speed and at scale then, past next year we’ll be moving towards the endemicity of this virus on our continent and the consequences will be catastrophic.

“Our economy will continue to be damaged, the death rate will continue to increase. We will see the fourth, fifth, sixth waves, and it will be extremely difficult for us to survive as a people.”

Changing the narrative – African Union makes its own plan

 Masiwiya is determined to ensure that the narrative is different this time around. 

“We are not going to allow this pandemic to become like HIV, and go on and on and on and on killing our people,” he said recently.  

“We’re not going to allow the fourth, the fifth and the sixth wave of this pandemic. That’s what I wake up every day to do. I spend 10 hours a day on it. I don’t go to my business office because I believe that we can defeat it, and we must.”

As a result, AVATT is moving ahead with its own procurement programme, including securing a commitment for the supply of some 400 million vaccines from Johnson & Johnson.  AVATT is also holding talks with Chinese vaccine manufacturers, and others. 

Interestingly, the US is channeling the African portion of its newly-pledged 80-million vaccine donations via both the AU and COVAX.  A similar split is expected for the recently announced US donation of 500 million doses of Pfizer vaccines, to be distributed over end 2021 and 2022.

For Masiwiya, reliance on donations is a non-starter: “We will not solve our problem because of donations. We will solve our problem because we’ve gone out and we have bought our vaccines,” he added, disclosing that all but two African countries had secured loans to pay for the AVATT-acquired vaccines.

Ultimately, AIDS on the continent was brought under control when ARV prices were slashed once they were made by generic producers and African countries, assisted by donors, negotiated directly with these producers. 

Local Production is Key Long-term Goal 

Most African leaders now agree that for COVID-19 vaccines to start flowing more freely, they also need to be produced in Africa, for Africans. 

Wednesday’s announcement by Pfizer/BioNtech that it had signed a letter of intent with South African company, Biovac, to  manufacture its COVID-19 vaccine for distribution within the African Union, has been widely hailed as an important step in the right direction for the continent – even if the 100 million plus doses to be produced in 2022, still  remain relatively small in comparison to the needs today. 

South African President Cyril Ramaphosa described it as  “a breakthrough in our effort to overcome global vaccine inequity”. 

Masiyiwa added his support, saying: “The only way to guarantee Africa’s access to vaccines now and in the future is through this type of strategic manufacturing partnerships, which we welcome greatly.”

But global health experts also were quick to note that the deal will not solve the immediate shortfalls faced – which can be addressed only through more dose-sharing by rich countries.

BREAKING: Pfizer will manufacture ~100 million #Covid19 vaccines a year in Cape Town.

It's great to see that doses will be made closer to where they're needed the most.

But they won't be ready until next year.

💉Until then, rich countries need to share doses ASAP. pic.twitter.com/rFw0hb1FUG

— Wellcome (@wellcometrust) July 21, 2021

At the same time, medicines access critics have already slammed the deal.

Although this is the first African company to pay a part in the production of an mRNA vaccine, it will relegate Biovac to the task of vaccine “fill and finish” – as compared to production of active vaccine ingredient.  Production of active ingredient, access advocates say, would involve a higher level of technology and capacity-building for African companies.

The arrangement also effectively maintains the exclusivity of Pfizer/BioNTech mRNA manufacturing knowledge with the pharma firms, the critics charge.

That is in comparison to earlier WHO efforts to engage Biovac in an open-license vaccine technology transfer hub arrangement  – which nonetheless failed to gain the required support from a pharma partner.

“The world so badly needs actual tech transfer and expanded mRNA production in the global South that it’s deeply disappointing to see so much good PR for what I’d call a deeply colonial arrangement,” Matthew Kavanagh, professor of global health at Georgetown University, told Health Policy Watch.

“Pfizer keeps control of the entire production process and distribution; does not share the know-how to make mRNA vaccines; and Biovac gets the privilege of putting vaccine made in the global North into vials in 2022.”

The IP waiver alternative 

Meanwhile, voices like UNAIDS Executive Director Winnie Biyanyima and WHO Director-General Tedros Adhanom Ghebreyesus have sharply challenged the pharmaceutical  industry for failing to more dramatically expand voluntary sharing of vaccine technology – or else agree to a waiver on COVID vaccine-related intellectual property – as proposed by India and South Africa. 

Speaking at one recent Geneva event featuring the German Health Minister, Jens Spahn, Byanyima warned that history was repeating itself – and challenged the European minister’s contention that voluntary industry collaborations are the best route for expanding vaccine access. 

She questioned why pharmaceutical companies should have the power to determine “when and with whom to share [vaccine know-how] with, at the time they want.” 

“Here is my challenge, my dilemma,” she told Spahn.  “When antiretrovirals were first found in the west, in Europe and America, people in the south continued to die. It was only when a global movement came to demand access to ARVs.  And it took six more years before the prices came down. 

“Nine million people died who could be alive today…. Now their survivors are now at risk of severe disease and deaths from COVID,” said Biyanyima. “How many years will they have to fight to have a vaccine that would protect them?”

Rich countries and dose-sharing

At the same time, pharma industry leaders have pointed out that no manufacturing arrangement can change the status quo immediately – and in fact global health leaders should be putting more pressure on rich countries, as compared to industry, to share doses right away.

Either way, while HIV/AIDS has not yet seen a vaccine for the disease that killed millions in low- and middle-income countries before the turn of the millennium, the tools to end the COVID-19 pandemic are ‘in our hands”,  Tedros declared Wednesday. 

“Our common goal must be to vaccinate 70% of the population of every country by the middle of next year. The reason why we’re not ending it is the lack of real political commitment,” he told the International Olympic Committee on the eve of the start of the summer Olympics. 

“If they choose to, the world’s leading economies could bring the pandemic under control globally in a matter of months by sharing doses through COVAX, funding the ACT Accelerator, and incentivizing manufacturers to do whatever it takes to scale up production.”

 

Image Credits: UNICEF, WHO, Billy Miaron/ Wikipedia, Africa CDC, Health Policy Watch.