“Khatra abhi tala hai, lekin poori tarha se khatam nahin hua [The danger has subsided, but hasn’t fully ended yet],” warned the recorded message Pakistanis would hear when calling their loved ones on the phone. A fourth wave could be around the corner, said Chief of the National Command and Operation Centre (NCOC) Asad Umar, urging people to encourage those over 50 years of age to get vaccinated.
But despite the warnings, the increasing threat of the Delta variant, first detected in India, and international travel restrictions on Pakistanis, blatant violations of SOPs (standard operating procedures) continued. Soon enough, Sindh announced its decision to reimpose restrictions.
But while it is easy to cast blame widely, the truth is that Pakistan faces many challenges in its battle against the coronavirus. As the world races towards some semblance of normalcy, countries such as Pakistan, chasing vaccine supplies in a tight global market and battling high vaccine hesitancy, are bound to lag behind.
Globally, over 3.5 billion Covid-19 vaccine doses have now been administered. Over 30 million people are getting jabbed each day, including children as young as 12 years, with certain vaccines now approved for those as young as three.
Even as the threat from new variants of the coronavirus and a fourth wave of infections looms and Pakistan belatedly ramps up its vaccinations, it must also contend with the political economy of vaccines — where issues of their production, supply and distribution are coming up against global politics and an increasingly unequal world
But this global success story is not without its caveats. Global demand for vaccines continues to outstrip supply and distribution remains highly inequitable — countries with the highest incomes are getting vaccinated more than 30 times faster than those with the lowest. And ,as the richer countries continue to regain some semblance of normal life, poorer countries continue to struggle and find themselves disconnected (often quite literally) from the rest of the world.
A GLOBAL SUCCESS STORY
It’s not all bad news. In fact, there has been quite a lot of good news. Having vaccines is a triumph of science and human endeavour. Consider:
A year ago many medical professionals, World Health Organisation (WHO) specialists and global policymakers were sceptical about the world ever finding an effective vaccine. Even optimists were convinced that the world was on the brink of doom since, historically, the average time for any vaccine to make it to market was seven years. Covid-19 was being compared with the 20th century Spanish flu, when over 50 million people perished. World GDP was also projected to shrink for several years.
But today, we have over 15 authorised vaccines and dozens more in the pipeline. While efficacy rates range from 50-95 percent, depending on the type of vaccine, all have been shown to prevent serious illness and death. This remains true for all known virus variants including the Delta and all other known strains.
Covid-19 rates, hospitalisations and deaths have generally flattened or declined where vaccination rates are highest. While instances of new outbreaks remain even where the majority of the population is inoculated, the evidence is clear. New cases are concentrated amongst the unvaccinated.
Data from the recent outbreak in the Seychelles, for example, shows that over 65 percent of those infected were unvaccinated. In the UK, where over 68 percent of adults have received at least one dose, hospitalisations continue to decline, even as the Delta variant drives an uptick in cases.
Infectious disease experts believe that the virus will not cause the disease we have come to recognise over the past year, because so many will be protected through vaccination or previous infection, and the disease will, eventually, become more like the common flu.
Singapore is moving toward a policy of not reporting daily Covid-19 cases to restore a sense of normalcy, as vaccination protects the majority of its population. Germany has called for a review of how the virus has to be considered from a social and public health perspective. German Health Minister Jens Spahn observed that, “because the at-risk groups are vaccinated, a high incidence doesn’t automatically mean an equally high burden” on the health system.
We also know that the vaccines are safe. Since late 2020, the US has administered over 330 million doses. Over this period, there have been less than 5,000 reports of deaths (0.0015 percent) among those who received a Covid-19 vaccine. The American Centres for Disease Control (CDC) and the Food and Drug Administration (FDA) physicians review each case report of death. A review of available clinical information has not established a causal link to vaccines.
The evidence belies the recent brouhaha about blood clots. The odds of these events occurring are less than one in one million. For perspective, the chances of being struck by lightning are higher (one in 0.75 million).
However, in the midst of this historic success of science and human endeavour, there are now the makings of a historic failure of markets, morality and global collective action.
WHAT ABOUT THE POOR COUNTRIES?
As production ramps up, rich countries are faced with large surpluses of vaccines in the second half of 2021. The Brookings Institute estimates that the US will have a surplus of over a billion doses by the end of the year. This is so even in a scenario where every citizen receives a booster jab. The Duke Global Health Innovation Centre estimates that the European Union (EU) will have over 500 million excess doses, and the UK and Canada, 165 million and 156 million respectively.
However, while more than half of all high and upper-middle income countries have administered enough doses to fully vaccinate at least 20 percent of their populations, only three out of 79 low and lower-middle income countries, as designated by the World Bank, have reached the same level of vaccination. The director of the WHO describes this inequality in vaccine distribution as “a catastrophic moral failure.”
Moralities aside, there are also serious economic and practical considerations. The only path to normalcy is vaccination. Unless the world plans for this and fast, we will have to go through periods of lockdowns, slowdowns and other forms of restricted activity, with adverse impacts on employment and incomes in various countries.
In a globally interconnected and dependent world, and with a virus that mutates in spaces where it is allowed to spread, no one is safe until everyone is safe. The International Chamber of Commerce estimates that vaccine inequality at today’s scale could cost the world around 9.2 trillion dollars in economic losses, in the worst-case scenario, with rich countries suffering half of that blow.
The toll of vaccine inequality in terms of lives and livelihoods is being compounded by the politics that now surrounds vaccine production, distribution and acceptability.
At the start of the pandemic, there was a lot of talk about the world being ‘in this together’. But as vaccines are rolled out, this rhetoric of global ‘togetherness’ is fast disappearing.
China, Russia and the West stand accused of having sought to use vaccines to “project their soft power” and competing for influence and goodwill. For instance, of the 72 countries to which China has pledged doses, all but two are participants in its Belt and Road Initiative, an ambitious global infrastructure project that aims to increase Chinese influence, develop new investment opportunities and strengthen economic and trade cooperation across select countries.
But as Western nations stockpiled supplies for their own populations, China sent vaccines overseas — this month, the Chinese foreign ministry announced the country had delivered over 500 million Covid-19 vaccine doses to more than 80 countries. That mission highlighted inadequate Western efforts at a time when tensions between China and many major democracies were running high.
China is also seeking to counter critical views, following criticism regarding its repression in Hong Kong and Xinjiang, by vaunting its economic success, scientific and medical achievements, culture and language.
Russia is also leveraging its early export of vaccines. It misses no chance to accompany offers of vaccine or joint production to Eastern Europe and the Balkans with soft-power messages, dwelling on European failures and highlighting Russian support for countries covered by the European Union’s (EU) enlargement and neighbourhood policies.
The West is now looking to play catch up in ‘vaccine diplomacy’ with G7 pledging almost a billion doses by the end of 2021 for poorer countries. President Biden has promised to help vaccinate the world with “with no strings attached”. The politics, however, is taking an insidious turn, with Western media campaigns that look to discredit the efficacy of Chinese vaccines. These have been described by China’s foreign ministry as a “bias motivated smear”.
The other side has also been hitting back. European Council President Charles wrote recently: “We should not let ourselves be misled by China and Russia, both regimes with less desirable values than ours, as they organise highly limited but widely publicised operations to supply vaccine to others.”
Russia, on the other hand, accuses the West of not authorising the Sputnik V vaccine for political reasons. And while health experts and the WHO publicly acknowledge the effectiveness of Chinese and Russian vaccines based on real world data, doubts regarding the most widely available vaccines till date have the potential to fuel vaccine hesitancy and undermine efforts to end the pandemic.
The use of vaccine passports and the politics surrounding them, where some countries refuse to accept Chinese vaccines and where China doesn’t accept Western ones, adds to global economic woes.
Recently, the EU has gone so far as to disallow AstraZeneca made in India for travel purposes in the block.
The United Nations Conference on Trade and Development reports that even with more of the world’s population vaccinated, tourism losses this year alone could amount to between 1.7 trillion dollars and 2.4 trillion dollars. This is despite an expected rebound in travel in countries such as France, Germany, the UK and the US.
Yet, while failures of equity and collective action abound in vaccine production and distribution, efforts are also underway to address them.
Stephan Bancel, the CEO of Moderna, has launched the ‘Never Again’ programme to set up effective global surveillance of viruses that could seed the next pandemic and to establish mRNA vaccine factories around the world.
The idea is to avoid the losses in lives and livelihoods that the lack of production capacity continues to inflict on the world today. With mRNA technology, vaccines can now be produced within hours, as opposed to years. The Moderna vaccine, for instance, was engineered within 48 hours of the virus genome being sequenced.
The main constraint to mass roll-out of vaccines has been production capacity. The programme envisages public-private partnerships to ensure that capacity to produce is available for the whole world at any given time. While this is a longer-term solution, it is hopeful nonetheless.
Another hopeful sign for mass global vaccination is that, as production increases, the problems of scarcity and high pricing of vaccines shall begin to abate in the months ahead. The global production of Covid-19 vaccines is estimated to be well in excess of 17 billion doses per annum over the next 12 months. Given that over three billion doses have been administered, and the maximum total global requirement (assuming a two-dose regimen) is around 14 billion doses, a wide surplus of vaccines is projected in the months ahead. This is so even if we account for the requirement of booster shots.
As the unchecked spread of the virus spawns new variants and renders high economic costs and tugs at the consciousness of our collective morality, it is critical that the world works together to ensure wide availability of vaccines and help vaccinate everyone. Global initiatives such as Covax, the Coalition for Epidemic Preparedness Innovations (Cepi) and the WHO need to be strengthened to beat this pandemic and guard against future ones. No one is safe until everyone is safe.
A STRATEGY FOR VACCINATING PAKISTAN
A recent survey by the Duke Global Innovation Centre placed Pakistan amongst the bottom three countries in the world in vaccine procurement. By not ordering early, like many other countries did, Pakistan is now struggling to secure supplies in an exceptionally tight global market.
It is also a regional laggard in vaccinations per capita. Comparators Bangladesh and India have fully vaccinated over three percent and five percent of their populations respectively, versus only two percent in Pakistan.
The reasons behind the slow roll-out of the vaccine include an overly risk-averse approach of government functionaries in placing orders — perhaps partly driven by fear of political victimisation via corruption charges in the future; low Covid-19 morbidity and mortality numbers; and an initial reliance on pledges made by GAVI/WHO, which failed to materialise.
Thankfully, in recent weeks, Pakistan has begun ramping up procurement and inoculation with a further 20 million doses expected in July and the daily vaccination rate has touched 500,000 recently.
ADOPTING A SMART STRATEGY
Given the immediate and foreseeable constraints on supplies, Pakistan will have to adopt a smart strategy that maximises effectiveness of vaccine deployment. The strategy must account for the morbidity characteristics of the virus, where the evidence is clear. Over 45s are the main risk cohorts for hospitalisation and death, with risk rising disproportionately with age.
The US, Brazil and India are the top three countries in Covid-19 deaths. Over 95 percent of deaths in the US, 85 percent in Brazil and 88 percent in India are in these age cohorts. In Pakistan 90 percent of deaths are amongst the over 45s. Cases requiring hospitalisation mirror these grim statistics.
This is not to say that young people do not contract the virus or that some do not fall seriously ill, but statistically the risk of serious illness and death is miniscule in the under 45s.
Furthermore, one of the worst hit sectors, with the largest social costs, is education. Students and teachers therefore, must also be prioritised.
A six-point strategy:
1. Focus on the over 45s, post-primary students, teachers and healthcare professionals in large cities where disease spread is highest.
Out of a total of around 35 million people over the age of 45, less than 25 million reside in urban areas. Less than 20 million students are in secondary school and above. Teachers and healthcare workers total less than five million. This makes for a total of 50 million key target-age cohorts for vaccination.
At a daily vaccination rate of 750,000 per day, within 100 days, these target-age cohorts can be fully inoculated.
For context: India is averaging over four million inoculations per day, and China 20 million.
At a cost of around 15 dollars per inoculation, the financing required for round one will be less than 750 million dollars. Part of this can be raised through multilateral agencies such as the World Bank, and the remaining by domestic reapportioning. We must not rely on GAVI/WHO donations.
2. The acquisition of single-dose vaccine must be maximised and robust diplomatic efforts launched to procure vaccines from around the world. It’s also imperative to ramp up local “fill and finish” capacity, which can boost supplies while lowering costs.
This will require public-private partnerships between the National Institute of Health (NIH), the Drug Regulatory Authority of Pakistan (Drap), the Ministry of Health and local pharmaceutical companies with bottling capacity and expertise.
3. Introduce a mass public awareness and marketing campaign across media platforms. It must address vaccine hesitancy and debunk conspiracy theories, especially on social media. Partnerships with social media platforms must be forged to do this.
4. The Benazir Income Support Programme/Ehsaas programme and Nadra can be leveraged to make direct cash transfers to target-age cohorts to incentivise vaccination. A payment of 500 rupees will set the government back by less than 25 billion rupees, even if every target-age cohort citizen is paid.
Lucky draw schemes for the vaccinated can also be widely launched to incentivise vaccination.
5. Vaccine passports should be made mandatory for local and international travel; utility bills (including cell phones); property and vehicle purchases; examinations; wedding functions, hotels and indoors dining. Heavy fines and blocking of CNICs can be imposed for violations especially on the sellers/organisers of these services.
6. Plan and prepare for a vaccine booster programme, given that efficacy is likely to last for up to 12 months for some vaccines.
Some elements of this strategy, the government has already begun to implement and Pakistan has managed the pandemic well thus far by balancing lives and livelihoods, especially when compared to her neighbours. But, as a potential fourth wave starts to develop, we must not tempt fate, and urgently vaccinate, vaccinate, vaccinate. — SH
Published in Dawn, EOS, July 18th, 2021