In my country, it is the only way to safely emerge from quarantine.
I just surpassed the eleventh week of our lockdown here in Manila with barely a scratch, and I celebrate it. I am fed, healthy, and still in high spirits despite losing so much, like many others. I am able to look after my aging parents and do the household errands on their behalf. I am not a burden to our creaky public health system. I am happily complying with the lockdown orders.
That may seem like a heavy cross to bear, but in a developing nation, my situation would stand out as the height of good fortune. Just outside of our gated sanctuary are clusters of shanty homes built with scraps of old plywood and corrugated steel. The residents of these urban poor communities live on daily earnings of around $10–20 from selling fish, meat, and produce at the wet market, driving a tricycle, or serving as household help. These services have enabled modest wage earners like me to enjoy a high standard of living in a country where $100 can go very far. When Metro Manila was ordered to shut down on March 15, some of these low wage earners lost their source of income instantly. Some of them pleaded to their government for help, saying that hunger, not COVID-19, will kill them. Their government, however, is incapable of providing an immediate and helpful response, so the more enterprising lot went about their business anyway and rejected social distancing measures.
The whole world knows by now, from the Wuhan example alone, that forced isolation and social distancing work. If most of us did not comply, our situation would have been dire and much worse than the current total of 17,000+ cases (3,909 recoveries, 957 deaths) out of 100+ million people. But even in a theoretical Wuhan-like quarantine, a leakage of desperate quarantine violators would be inevitable. The majority of our citizens need to work every day to survive, and they will, the prospect of prison time notwithstanding. They can get away too because they live in a free country so lacking in advanced law enforcement capabilities and with little-to-no provision for mass testing. Those who are sheltered in place will have to co-exist with those who wander about with or without a mask.
This renders public health safety, at least from where I live, dangerously inferior.
The only way I can leave my house without fear of infection is for a vaccine to be invented, approved for safety, and eventually injected into my bloodstream. Unfortunately, once that vaccine for COVID-19 ships, almost EVERYONE in the world would want it. Countries, where the laboratories working on a vaccine are located, will get first dibs. Countries with the resources that the Philippines does not have will be first in line, as always. The US, the current epicenter of the pandemic, will likely buy in the truckloads because they have more deaths, with COVID-19 cases there now approaching 2M out of the total 6M confirmed cases globally. Their president has already alerted the US Defense Department to manage manufacturing logistics.
This is the grim scenario I foresee as a citizen of a country entrenched in the lower end of the global economic spectrum. I know from my years of working in government what it is like to be the bullied child in international affairs — useful sometimes (i.e. strategic geopolitical assets), useless most of the time (i.e. no money, no influence). But at the height of a global health crisis, the Philippines and other developing nations should not be left to fend for themselves, despite our seeming irrelevance on the world stage. We have done what we could in sheltering our people and lowering the death toll. We need the COVID-19 vaccine just as much as every country does.
The question is, will we have equal access to the vaccine once it is ready to hit the market?
How A Vaccine Works
I am not a medical doctor (and if you are, feel free to skip this part until herd immunity), so as far as vaccines are concerned, all I know is that they protect me from acquiring preventable diseases. I know because I have not had chickenpox, which is common among young children. I know from personal experience that my first varicella vaccine in 1983 and the Varilrix shot that I got thirty years later were effective.
How the varicella vaccine protects my body from getting chickenpox is a fascinating discovery. The Varilrix vaccine, in particular, contains a weakened varicella-zoster, the virus that causes the chickenpox, but not enough to make me ill. It only has the amount that can trigger my body’s adaptive immune system to watch out for the virus in the future. In short, vaccines contain intel that is teaching the body to prepare to respond (The science of how immune cells detect and control pathogens which is beyond me is explained well here). So the weakened virus in the vaccine is like a spy — it knows how to make you sick but it won’t because it is trying to defect and seek refuge in its new host (your body) and protect that host from its former allies.
This kind of espionage is exactly what we need to defend ourselves from COVID-19 given how invisible, widespread, and deadly it is.
Vaccine Development’s Complex Realities
The process of creating a safe vaccine is lengthy, complex, and expensive. It requires at least a billion dollars and around ten years to deliver a final, licensed vaccine. It demands excellence in research, product development, and management, and a massive funding commitment that will see the project through from start to finish. The ballpark figure may include the cost of vaccines that are rejected and abandoned and additional allocations for viruses that are constantly mutating.
Luckily for us, the coronavirus is found to be a stable pathogen unlikely to mutate significantly which helps with fast-tracking the development of a COVID-19 vaccine.
These realities make vaccine development an investment usually reserved for rich states that can finance vaccine research entities such as the World Health Organization’s (WHO) Initiative for Vaccine Research, the United Nations’ Children’s Fund (UNICEF)-United Nations’ Development Programme (UNDP)-World Bank-WHO Special Programme for Research and Training in Tropical Diseases, and the International Vaccine Institute. They can partner with top vaccine-producing pharmaceutical companies such as Pfizer, Merck, Sanofi Pasteur, and GlaxoSmithKline.
Despite their lack of resources, developing countries benefit from this global network. These stakeholders work with countries where diseases are endemic and share information on their research efforts and the challenges in disease prevention. This information helps with minimizing the spread of disease, lowering health expenditure, and ultimately, reducing global poverty.
The manufacture of a safe and effective vaccine is for the greater good, but it still has to make a lot of business sense in order for a vaccine manufacturer to embark on the project. It could be a lucrative investment where the disease is prevalent and governments are cooperative, but the true long-term financial rewards are in ensuring public health and safety. Everyone will want a vaccine that can prevent a virus from entering the body (well, except maybe anti-vaxxers who seem to prioritize their beliefs more than science).
I want a vaccine because I do not want to get sick. It is painful, expensive, and stressful to get sick. I have been good to myself for a very long time — eating right, working out regularly, getting enough sleep — and would gladly pay good money for a vaccine rather than risk getting sick, especially when it had been reported that COVID-19 causes long-term lung damage. Fortunately, I have been vaccinated for most preventable diseases, and except for measles, I have not had the sad experience of enduring the other illnesses.
With the rest of the world likely fearing the costs of illness as I do, the race to find a safe and effective COVID-19 vaccine is on. As Harvard Kennedy School Professor on International Finance (now Chief Economist of The World Bank) Carmen Reinhart has said, “If it’s not over on the disease, it’s not over on the balance sheet.” We have to win the war against COVID-19 to get our lives and livelihoods back, and the most effective way to do that is through a vaccine.
Ultimately, the goal of a vaccination program, once a vaccine is ready to ship, is herd immunity. This refers to vaccinating a significant number of people, making it difficult for the virus to be transmitted from one person to another. Herd immunity is essential for protecting people who cannot be vaccinated like very young children, older people, and people with weak immune systems. Another way of achieving herd immunity is for a large portion of the population to be infected by COVID-19, but that could mean a high death toll. This then makes the development of a COVID-19 vaccine the most important goal of the world today.
Assuming a COVID-19 vaccine is finally here and approved for global distribution, can the world produce enough?
Not right away. Almost everyone is vulnerable to COVID-19. Each person may need at least 2 doses to achieve immunity. That is approximately 16 billion doses.
Additional factories will have to be built, ideally once a vaccine has been approved because the requirements of an inactivated vaccine, for example, is different from an RNA vaccine. There are no extant factories that have manufactured millions of doses of vaccines with the advanced technology being used by either Inovio or Moderna for the RNA vaccine. The RNA vaccine is revolutionary and has not been mass-produced, unlike inactivated vaccines that seem easiest to produce in large quantities but take much longer to produce than the RNA.
Vaccines have to be refrigerated at a storage temperature of at least 5 degrees C, which makes the global shipment of 16 billion doses requiring refrigeration no mean feat.
A single pharmaceutical company will not be able to handle global demand, so the European Union (EU)’s proposal to put pressure on companies to give up their monopolies on the vaccines they have developed could lead to cooperation and help expedite mass production.
Production for other vaccines must continue, so experienced vaccine manufacturers will have to revisit their supply chain and see how a new high-demand vaccine can disrupt operations. Infectious diseases still cause almost 30% of all deaths worldwide. The demand for their vaccines remains high. How do you manufacture a COVID-19 vaccine while still producing existing vaccines? How do you prevent a shortage in production?
Will the vaccine be equitably distributed?
Not likely, but as with the call to make the vaccine affordable, there is also an effort to help make the vaccine accessible to everyone. The US Biomedical Advanced Research and Development Authority (BARDA)’s acting director Gary Disbrow already said that their focus is on the “whole-of-America approach required to expedite the availability of vaccines.” BARDA has channeled substantial resources for large pharmaceutical companies such as Johnson & Johnson, French drug company Sanofi and Moderna based in Massachusetts.
This does not bode well for developing countries, but the World Health Organization (WHO), having learned its lesson from the inequitable distribution of vaccines for HIV and H1N1, has made information on the development and the deployment of the actual vaccine equally available to all.
Vaccines require syringes, wipes, and medical adhesives to be administered. Can countries hoard these materials in the same way that PPEs were embargoed? Yes, especially countries where these products are manufactured. We saw that in the mad scramble for PPEs.
Will the COVID-19 vaccine reach developing nations in time?
It could, through the help of organizations such as the Global Alliance for Vaccines and Immunisation (GAVI), which, according to its website, aims to encourage vaccine manufacturers to lower vaccine prices for the poorest countries in return for long-term, high-volume and predictable demand from those countries. As of 2019, there are 58 developing countries that are eligible for vaccine support. GAVI is a public-private partnership that counts the Bill and Melinda Gates Foundation, Unicef, WHO and The World Bank as founding partners.
There is also a global call for a “people’s vaccine.” Oxfam, an international non-profit organization, has published an open letter from 140 world leaders and experts “calling on Health Ministers at the World Health Assembly to rally behind a people’s vaccine against this disease urgently. Governments and international partners must unite around a global guarantee which ensures that, when a safe and effective vaccine is developed, it is produced rapidly at scale and made available for all people, in all countries, free of charge. The same applies for all treatments, diagnostics, and other technologies for COVID-19.”
What Developing Countries Can Do
The odds are not all stacked against developing countries, especially if there is a designated committee that can already lay the groundwork now for this massive vaccination program in cooperation with other governments.
There is a scene in the movie Contagion about inoculation lotteries, which looked rather organized, but chaos still ensued. The COVID-19 vaccine committee should have the right people in their team that can quell possible anarchy.
Governments should coordinate with the WHO regarding licensing requirements for the local manufacture of vaccines. They can closely track the developments in foreign laboratories that are already at phases 1 and 2 of their clinical trials. Finding a local firm that meets the global standards of an RNA vaccine manufacturer, say, is a long shot, but it is still a shot worth taking.
Developing countries should start preparing for vaccination kits and their contents to avoid having to compete with other countries for supplies. Since most medical supplies are being used now for COVID-19 cases, local pharmaceutical companies may want to ramp up production for vaccine-specific requirements such as wipes and syringes.
While our public health professionals are hard at work fighting this war for us, our foreign service and trade ambassadors can start forging partnerships with their counterparts and other vital stakeholders in the international health community. They can look into procuring vaccines from the nearest first world neighbor where they have friendly relations, which could be Singapore or even China which has labs developing a vaccine for Southeast Asian countries. They need to sort out tariffs and bottlenecks in the global supply chain for medical materiel and work around those as early as now to reduce unnecessary delays. No one wants another end-run where one country is accused of hijacking a shipment of PPEs already purchased by another country. This can be avoided through peaceful diplomacy.
All government hands in developing countries should be on deck to help make sure that when the vaccine is finally available, we will have access to it. Public officials who work outside of public health can start planning for this now. Living conditions in developing countries are far more desperate than in other countries, and there is a global initiative to help everyone access the vaccine. We just need to make sure we are not overlooked.