“In an interconnected world, none of us is safe until all of us are safe. ”

–  António Guterres, United Nations Secretary General

Introduction

Since day 1 of the COVID-19 pandemic, global health experts have urged world leaders to prioritize global health equity as a crucial part of their pandemic responses. According to the World Health Organization (WHO), health equity can be defined as “the absence of unfair, avoidable or remediable differences between groups of people” that affect their ability to attain good health and wellbeing.  

Global health equity has emerged as a key issue during past pandemics, and COVID-19 has been no exception. Many high-income countries (HICs) – Canada included – have adopted self-interested policies, engaging in vaccine nationalism and failing to work cooperatively with the global community. This leaves other countries vulnerable to the effects of the virus, particularly low- and middle-income countries (LMICs).

In today’s blog, we will discuss:

• What is vaccine nationalism?
• The ACT Accelerator, COVAX, and the TRIPS waiver: mechanisms for advancing health equity
• Foreign policy: Canada’s response

What is vaccine nationalism?

Vaccine nationalism refers to “the prioritization of the domestic needs of the country in an outlay of others” (Lagman, 2021). It represents a self-interested approach to vaccine procurement, with countries opting to purchase vaccines and/or therapeutics for their own citizens instead of collaborating with the global community to distribute limited supplies in an equitable manner.

Vaccine nationalism is a common national policy response to pandemics. During the H1N1 influenza pandemic of 2009, for instance, several HICs hoarded vaccines to the detriment of LMICs (Gruszczynski & Wu, 2021). This resulted in most citizens of impacted countries not receiving the vaccine until after cases had peaked. At this point, vaccines were far less important to mitigating the spread of the virus. 

A similar phenomenon was observed during the HIV/AIDS crisis. When antiretroviral therapies hit the market in the 1990s, HICs were quick to purchase them (Gruszcynski & Wu, 2021). This left LMICs with limited access to the life-saving therapeutics, and discrepancies in HIV prevalence between HICs and LMICs still persist today. 

For countries with the resources to purchase vaccines and therapeutics, engaging in vaccine nationalism may be considered a logical decision to ensure the safety of its own citizens. However, many experts caution that this behavior may actually prolong global pandemics and make these countries worse off in the long run (Riaz et al., 2021). This is because the more opportunities a virus has to spread (particularly among unvaccinated populations), the more likely it is to mutate, resulting in the emergence of new and more infectious variants. 

The ACT Accelerator, COVAX, and the TRIPS waiver: mechanisms for advancing health equity

In an attempt to foster international cooperation and advance health equity in the face of the COVID-19 pandemic, the international community has proposed a wide range of actions. Three of their most prominent developments are outlined below:

The ACT Accelerator

The COVID-19 Tools (ACT) Accelerator was established by the WHO and partners in April 2020. Bridging expertise from both the public and private sectors, this unique mechanism promises to function as a “groundbreaking global collaboration” to develop and distribute vaccines, treatments, and diagnostic tools to bring the COVID-19 pandemic under control (World Health Organization, n.d.). 

The ACT Accelerator consists of four broad pillars of work: 

• Diagnostics: invests in the development of COVID-19 tests to improve diagnostic speed and accuracy
• Treatment: designed to find the most promising COVID-19 treatments and make them accessible for all
• Vaccines (COVAX): invests in a wide portfolio of vaccine candidates and ensures the equitable distribution of COVID-19 vaccines (see below)
• Health system strengthening: helps countries overcome logistical issues related to the supply and distribution of COVID-19 therapeutics and vaccines (Canadian Partnership for Women and Children’s Health, n.d.).

COVAX

The ACT Accelerator’s most significant component is the vaccine pillar, more commonly referred to as the COVID-19 Vaccines Global Access Facility (COVAX). COVAX is a global procurement mechanism designed to accelerate the creation and equitable distribution of COVID-19 vaccines (Canadian Partnership for Women and Children’s Health, 2021). 

The initiative is arranged into two branches. The first is the COVAX Facility, which draws on funding to invest in a wide portfolio of vaccine candidates (Gavi, The Vaccine Alliance, 2020). This maximizes the chances of participating countries gaining access to a successful vaccine. The second branch is the COVAX Advance Market Commitment (AMC), which funds the participation of 92 LMICs who would otherwise lack the financial resources to purchase COVID-19 vaccines for their populations (Gavi, The Vaccine Alliance, 2020). This promotes the equitable distribution of vaccines, ensuring everyone has access regardless of their ability to pay. Funding for these two branches is completely separate, giving countries the flexibility to participate in one over the other (Gavi, The Vaccine Alliance, 2020). 

Participaction in the COVAX pillar represents a win-win solution for all countries. For high-income countries, it acts as a sort of “insurance policy” by giving them access to a wide variety of vaccine candidates (Canadian Partnership for Women and Children’s Health, 2021). For LMICs, it expedites the development of a successful vaccine and guarantees them access once developed. As such, COVAX represents the most equitable mechanism for vaccine distribution, so long as most countries participate. 

TRIPS waiver

Binding upon members of the World Trade Organization (WTO), the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) represents the world’s most comprehensive agreement surrounding intellectual property rights and the international exchange of knowledge and creativity (World Trade Organization, n.d.). In October 2020, India and South Africa submitted a formal request to temporarily waive certain provisions of the TRIPS agreement to expand global production of COVID-19 vaccines (Labonté et al., 2021). This, they argued, would allow countries to bypass barriers related to intellectual property rights to increase vaccine supply. 

While the TRIPS waiver would be highly beneficial for LMICs by increasing their capacity to produce and distribute vaccines to their populations at low-cost, several HICs have expressed skepticism. They claim that granting the waiver may compromise drug quality and safety, as well as disincentivize further innovation to improve current vaccines (Congressional Research Service, 2021). This indecision has stalled progress on the initiative.

Though each of these global mechanisms have promised to advance health equity, massive disparities between HICs and LMICs still persist. According to Our World in Data, just 15.8% of people in low-income countries have received at least one dose of a COVID-19 vaccine. Many HICs, meanwhile, have been able to administer third and fourth doses to large segments of their populations. As a result, these undervaccinated populations remain vulnerable to serious illness and death from COVID-19. 

Foreign policy: Canada’s response

Canada has made efforts to advance global health equity throughout the pandemic. In a July 2020 opinion piece for The Washington Post, Prime Minister Justin Trudeau, alongside other world leaders, urged politicians to commit to the equitable distribution of COVID-19 vaccines “based on the spirit of a greater freedom for all”. The Canadian government has also pledged about $700 million to COVAX (Rabson, 2022), making it one of the initiative’s largest donors. 

Alongside these actions, however, Canada has also engaged in self-interested behaviours over the course of the pandemic. In addition to participating in the COVAX Facility, the country also negotiated its own bilateral deals with vaccine manufacturers to secure priority doses once they became available. According to Duke University, Canada had purchased enough doses to vaccinate its population five times over by the end of 2020 (Marchildon, 2020). This stockpiling was highly criticized for delaying vaccine access in other countries due to the limited supply available. 

The Canadian government has also hesitated to fully support the TRIPS waiver. According to the Canadian Centre for Policy Alternatives (2022), Canada claims to neither oppose or support the initiative. This indecision has stalled its advancement at the WTO, further delaying vaccine access for millions. 

Canada is certainly not alone in these actions – most high-income nations including the U.S., U.K., Japan, and many others have undertaken a protectionist response to COVID-19 instead of a cooperative one. However, more than two years into the pandemic, these decisions are beginning to have consequences. Undervaccination and unabated spread of the virus has resulted in the emergence of new variants, most recently the highly contagious Omicron variant. This has fueled a new wave of cases around the world, delaying national reopening plans and causing thousands of additional deaths.

Lessons learned: preparing for the next pandemic

As the now popular adage goes: no one is safe until everyone is safe. The COVID-19 pandemic has highlighted the urgent need to protect and uphold global health equity during infectious disease crises, especially in the face of a novel virus. Canada and other HICs can take action on this front by:

• refraining from engaging in vaccine nationalism
• facilitating the global production of vaccines and therapeutics in LMICs
• collaborating with international institutions like the WHO and COVAX to ensure the equitable distribution of vaccines and therapeutics

COVID-19 may be the latest pandemic, but it certainly will not be the last. To prepare for the next global infectious disease outbreak, the international community must remember the lessons it has learned and strive to create a more equitable pandemic response going forward. 

Written by: Claire Borganonkar, BPAPM (c)