Scene India: seriously ill Covid patients share a bed for two. Many are not treated at all. Relatives desperate to find oxygen. Corpses are cremated in parking lots in front of the overcrowded crematoria. Pictures like this were mainly in April and May around the world, on the subcontinent, the corona pandemic showed its most terrible side. The situation in India is also due to the highly contagious delta variant of the corona virus that appeared there. In the meantime, this has not only arrived in the neighboring countries, but is also penetrating Europe.

The longer the pandemic lasts, the more mutations take place, and the more the virus changes, the more likely it becomes that the protection provided by the current vaccines will decrease. "The only way to prevent this is the fair distribution of vaccines to all countries," says Tedros Adhanom Ghebreyesus, head of the World Health Organization WHO.

Serum for the world

And here again the focus is on India, because the country is currently not only the epicenter of the problem, but also an important part of the solution. With the Serum Institute of India it is home to the largest vaccine manufacturer in the world. Almost two thirds of all children worldwide are vaccinated (for example against polio, measles or diphtheria) at least once in their life with a vaccine from the western Indian economic metropolis of Pune. And while manufacturers have reached their limits in many places in recent months, the global market leader in India has managed its current main task of producing large quantities of Covid vaccine in the shortest possible time, quite well - more than two million doses of AstraZeneca per day.  

The vaccines produced in Pune were originally intended to be shipped all over the world. But in view of the dire situation in the country, the Indian government stopped vaccine exports in March until further notice. For the global vaccine initiative Covax, in particular, to which the Indian manufacturer had supplied almost single-handedly, the export stop meant a major setback. By the beginning of summer, Covax was missing around 190 million vaccine doses as a result. And Serum Institute CEO Adar Poonawalla estimates shipments won't resume until later this year.


Unequal task

While in North America, relatively speaking, most people are vaccinated at least once, the most populous continent Asia leads in absolute numbers. Basically, the poorer countries lag far behind the industrialized countries.

Covax graphic

Giant project Covax

Covax - an abbreviation for Covid-19 Vaccines Global Access - was launched in April 2020 by the WHO, the Gavi vaccine alliance and the Coalition for Epidemic Preparedness Innovations CEPI. The ambitious goal: to provide around a quarter of the world's population, especially health workers and the oldest and most vulnerable, with a Covid vaccination by the end of 2021.

192 countries joined the initiative, with richer countries, who mostly cover their vaccine needs through bilateral agreements, supporting the initiative for the benefit of developing countries. With a pledged four billion dollars, the USA is the largest financial donor, followed by Germany, which has promised around two billion euros, and Great Britain. The EU is the fourth largest donor. Donations also come from private organizations such as the Gates Foundation. The poorer countries should receive vaccines at reduced rates or free of charge - 92 developing countries are considered eligible.

Covax supported the pharmaceutical companies in the unprecedentedly fast development and production process of the vaccines through incentives and purchase guarantees and was able to negotiate significantly better conditions than would have ever been possible in individual financially weak developing countries. The United Nations Children's Fund Unicef, which vaccinates millions of children worldwide against measles or polio every year, was commissioned to carry out the largest vaccination campaign in history.

Covid vaccination in Bhutan
Belief in vaccination: In Bhutan, the campaign lasted only a few days.

Vaccination sprint in the mountains

In the small Himalayan kingdom of Bhutan, record-breaking was achieved: at the end of March and beginning of April, more than two thirds of the population were vaccinated against Covid-19 with a dose of Astra Zeneca within a few days. To this end, 1.200 vaccination stations have been set up across the country in the impassable 750.000-inhabitant state. The fast vaccination was mainly made possible by its large neighbor India, which had already provided Bhutan with the vaccines in January. The Indian export ban is now also affecting Bhutan, whose residents are waiting for the second dose. However, there are signals that Switzerland could donate the doses it needs. 

Millions of supplies for Covax

What other wheels can be turned so that developing countries can move forward as quickly as possible in meeting their vaccination needs? On the one hand, the pharmaceutical companies have announced that they will give Covax en masse vaccines at cost price. BioNTech and Pfizer, for example, have promised to make one billion doses available by the end of the year. On the other hand, there is a willingness on the part of the industrialized countries to donate excess vaccination doses. Many of them have ordered significantly more vaccine than they need to immunize the population (Canada has ordered six times more doses than its population, while in Austria vaccine coverage is around XNUMX percent). In addition, the German Chancellor Angela Merkel announced on the sidelines of the GXNUMX summit in Cornwall, England, that the seven major industrialized countries will donate XNUMX billion vaccine doses to poorer countries by the end of XNUMX.

The G7 will also strengthen the Covax umbrella program, the ACT accelerator, financially. In addition to vaccinations, it also provides diagnostics and therapeutics to poorer countries. Currently, around 13 billion euros are missing to carry out the projects planned for this year. According to a recent Study by the International Chamber of Commerce the required funds are disproportionate to the costs that the global economy would have to bear if the infections continued to spread in emerging and developing countries. The full capitalization of the ACT Accelerator is therefore "a clear investment case".  

Covax has sand in the gear

The first dose of Covax vaccine was given to Nana Akufo-Addo on February 24th. Akufo-Addo is not a health worker, but the President of Ghana. With his vaccination, he wanted to set a good example for his compatriots, he said. 600.000 doses produced by the Serum Institute by the manufacturer AstraZeneca were on board the plane to Accra, and 100.000 people in Ghana were vaccinated on the first day.

Because of the lack of doses from India, many of the first vaccinated people are still waiting for their second dose. "We were able to send a few cans to Ghana through donations and redistributions, but that is not enough," reports Covax coordinator Benjamin Schreiber. In mid-June, Covax had delivered a total of around XNUMX million vaccine doses to XNUMX countries. Christoph Strupat, health expert at the German Development Institute DIE, draws an interim balance: "So far, Covax has lagged significantly behind expectations and goals."

Interview with Benjamin Schreiber, Covax coordinator

The first Covax delivery arrives in Malawi.

Assembly plan for vaccination Ikeas

While there is currently a debate about a lack of vaccine supplies, Covax coordinator Benjamin Schreiber is already one step further in his thoughts.

Expansion of production

Ultimately, it is necessary to significantly expand production. In recent years, global vaccine demand has reached a volume of three to five billion doses, this year the need is an additional twelve billion Covid vaccine doses - an increase that is hardly solvable for the private sector only.

African pioneer

Morocco vaccinated faster than most European countries in the spring and vaccinated by far the most people in other African countries. By mid-June, around 25 percent of the almost 40 million inhabitants had received at least one dose. The WHO celebrated the kingdom as a “prime example” for a successful vaccination campaign, for example because the country relied on several providers at an early stage and a functioning digital platform allows appointments to be made quickly. Because of the Indian export ban, however, the Moroccan vaccination campaign has recently lost much of its pace.

The revocation of patent protection for Covid-19 vaccines, which is sometimes heavily demanded in this context, does not turn out to be a promising means of countering the current vaccine shortage on closer inspection. The debate was triggered by the application submitted by South Africa and India to the World Trade Organization (WTO) to repeal the TRIPS agreement on intellectual property rights for Covid vaccines. More than a hundred WTO member states supported the push to ensure that all manufacturers are allowed to produce approved Covid vaccines. The argument: This is the only way to provide the production capacities required for a rapid vaccination of the world's population at short notice.

Most industrialized countries immediately waved them off, and pharmaceutical companies argue that the high investments in vaccine research could only be refinanced thanks to the 20-year patents. In a nutshell: no progress without patents. Most recently, however, the USA has also spoken out in favor of suspending patent protection - only after its own population could be supplied with vaccines extremely quickly also due to a strict export ban, which has led to bottlenecks in India, for example, and domestic demand has now almost ceased. France also joined the American demands, and the EU Commission also indicated its willingness to talk. 

Proponents of a revocation of patent protection repeatedly make the analogy to the fight against HIV / AIDS in the 1990s. The new types of HIV drugs saved the lives of many people in the industrialized countries. But above all in Africa, where the disease raged the worst and continues to do so to this day, these drugs were unaffordable. Millions of people died. The South African government under Nelson Mandela defied the patent protection regulations and had Indian pharmaceutical companies produce generics. This was followed by a lawsuit by the pharmaceutical companies, which they ultimately withdrew due to the huge damage to their image that this entailed. Generics for HIV drugs were accepted in principle and prices dropped from about $ 10.000 to just $ 150 for treating a sick person. 

Covax vaccination in the Congo
Problem child: In the Congo there is a lack of the necessary vaccination infrastructure, so that thousands of Covax doses had to be flown out again.

Are we now experiencing a new version of the conflict at that time? The situation is only really comparable at first glance. Vaccines not only require significantly more and more cost-intensive research than drugs, their production is also much more complicated than that of HIV tablets, for example. So it is not because of the licenses that the Covid vaccine is scarce, said the operational manager of BioNTech Sierk Poetting recently to the weekly newspaper "Die Zeit". Given the complicated production process and the lack of raw materials alone, it is not possible for a company in Africa to ramp up production of the vaccine within a few months. Furthermore, in view of the need to adapt the vaccines to new virus mutations, a revocation of patent protection only seems to be of limited use. Economist Gabriel Felbermayr, who will take over the management of the Austrian Institute for Economic Research WIFO in autumn, spoke to the magazine "Der Spiegel" from a "very problematic signal" that comes from the demands for a revocation of patent protection: " Hundreds of companies have invested billions of euros in research; only a few were successful. For the industry it is necessary that on average it can be expected that research is worthwhile, ”says Felbermayr. 

Christoph Strupat from DIE considers the entire polarization to be ineffective and pleads for a differentiated view of the situation - and the available vaccines: “A patent protection revocation would not really do much with the new mRNA vaccine. But in addition to the Serum Institute, there are a few other companies in India that can manufacture vector-based vaccines, i.e. those from Johnson & Johnson and Astra Zeneca. " 

In the medium term, a middle ground is needed between the status quo and the abolition of patent protection. According to Strupat, many scientists welcome the Costa Rican idea called C-tap (Covid-19 Technology Access Pool): a patent and knowledge pool that is intended to encourage more cooperation between manufacturers. It is by no means the case that the current crisis has not already led to more cooperation. According to the International Trade Association of Pharmaceutical Companies, pharmaceutical companies have concluded a total of 280 partnership agreements for the production of Covid-19 vaccines - around three quarters of these agreements involve a technology transfer. 

Caribbean vaccines

Covid vaccines from Cuba
Cuban candidates: The island state is researching its own Covid vaccines.

Cuba is one of the few developing countries that is making a name for itself with vaccines and medical technology from its own production. The country is currently researching five potential Covid-19 vaccines. Soberana-2, Cuba's most advanced vaccine candidate, is already in phase three of clinical trials. The Cuban government hopes to produce 100 million doses of this by the end of the year. Vaccines that are not needed in the home market are to be sold to allies such as Venezuela. The socialist island nation can look back on a long history of developing and exporting vaccines.

Post-Covax: Vaccines Made in Africa

In the future, Africa might also have its own pharmaceutical industry. At a specially organized conference, numerous African heads of government recently emphasized that vaccine production in Africa should be set up on its own. In view of such announcements, Strupat is cautiously optimistic: “Around the AIDS or Ebola crisis, it was also signaled that they wanted to set up an African production facility. Nothing happened. One can only hope that a pandemic of this magnitude will result in such a process now and in the long term."

The EU is happy to support such a request. It recently announced that it would contribute one billion euros to set up vaccine production facilities in Africa. This means that by XNUMX more than half of the vaccines used in Africa will be manufactured in several production sites on the continent. These efforts are also linked to the hope that the search for a highly effective malaria vaccine will finally reach its goal through the novel mRNA technology.

In addition to South Africa, Kenya, Senegal, Ghana and Rwanda are particularly interested in establishing vaccine production in their own country. According to Strupat, this is no coincidence, as these countries in particular are no longer supplied by the non-profit vaccination alliance Gavi due to their increased prosperity. With which he shows the limits of a free vaccine supply: “Unfortunately, it has to be said that Gavi and ultimately also the Covax initiative are opposed to efforts to set up local production. For industry, the vaccine market in Africa is a 'Gavi market', that is, donation-driven. ”As long as this does not change, it is not worthwhile for companies to invest in building production facilities or researching vaccines.

Happy a little too early

In Chile, more than 60 percent of the population had already received the first dose of vaccine against Covid-19 in mid-June. The early and, since then, continuous availability of vaccines was decisive for the efficient vaccination campaign. "Above all, there is also a well-functioning infrastructure with a close-knit network of vaccination centers, where vaccination takes place unbureaucratically and according to risk and age group allocation," reports the economic delegate in Santiago de Chile, Drazen Maloca. Despite the rapid progress in vaccination, there was a second wave of Covid in April, which was even more serious than the first. This could also be related to the success of the vaccination itself and a premature looseness in social behavior.

Covax isn't the only sign of hope

The pandemic is a tremendous test and the fight against the virus is a logistical challenge for every single country in the world. A number of emerging and developing countries from Morocco to Bhutan have achieved remarkable things. And in India, too, things are slowly improving: While the number of infections is falling, more than 200 million Indians are vaccinated at least once.

Photos: UNICEF / Edward Kabuye, Olivia Acland, Mixael Porto Chiong, UNICEF Bhutan / 2021 / SPelden