This is a POLITICO case study, a look at what works — and what doesn’t — in the fight against HIV. The article is part of Telescope: The New AIDS Epidemic, a deep-dive investigation into the modern face of a disease that transformed the world.
THE BIG PROBLEM
For years after lifesaving antiretrovirals were widely available in rich countries, poor countries struggled to get them, leading to millions of deaths.
THE BIG IDEA
Take on Big Pharma and enshrine the right to health in international trade law. Under the 2001 Doha Declaration, countries affirmed that patent protections — and resulting high prices — shouldn’t stand in the way of saving lives.
Though written in response to inequalities in HIV treatments, the language was aimed to apply to any health challenge going forward.
WHY IT MATTERS
For activists focused on access to medicines, the COVID-19 pandemic is starting to look a lot like the bad old days of HIV.
Medically, HIV stopped being a death sentence in 1996, when effective antiretroviral medications were first introduced. But while the U.S., Europe and other wealthy countries embraced the pricey drug cocktails, it would be another decade before they were fully rolled out in hard-hit parts of Sub-Saharan Africa.
Many more people died of AIDS after the discovery of these drugs than before — annual deaths in South Africa wouldn’t peak until 2008, roughly a decade after they had plummeted in wealthy countries.
IN THEIR VOICES
Winnie Byanyima, UNAIDS Executive Director, on how many lives were cost before the cost of HIV drugs was reduced:
When it comes to the coronavirus, history seems to be repeating itself. This time it’s vaccines that are in short supply. While the U.S. and EU are on track to vaccinate some 70 percent of adults this summer, and are preparing to vaccinate adolescents at low risk of serious illness, Africa is facing a third wave. Just 1 percent of that continent’s 1.3 billion people had received a first dose as of June 10, according to the World Health Organization.
IN THEIR VOICES
Byanyima on the “nationalistic†response to COVID-19 so far:
HOW THEY DID IT (FOR HIV)
When AIDS was first discovered forty years ago, it was equally horrible for everyone. With no treatment and no cure, an HIV diagnosis meant eventual death. That changed in the mid-1990s, when a three-drug cocktail proved to keep the virus under control. The drugs were hard on the body, but people lived.
In terms of raw costs, the cocktail could be produced cheaply — less than a dollar for a day’s dose — but in countries with patent protections, drugmakers could name the price tag. In South Africa, this amounted to about $800 a month in a country where the average annual income was $2,600.
So in 1997, South Africa introduced a new law that would allow it to buy drugs from the lowest bidder — rather than the patent holder. In response, 39 drug companies sued, saying it defied global patent treaties. It turned out to be a major strategic blunder for Big Pharma.
IN THEIR VOICES
Thomas B. Cueni, director general of the global pharmaceutical lobby IFPMA, on the industry’s regrets:
AIDS activists mobilized to play up the David vs Goliath fight. And when Western governments backed the industry, protesters pounced. For example, when Bill Clinton’s vice president, Al Gore, launched his own bid for the White house, protesters unfurled a banner onstage declaring “GORE’S GREED KILLS: AFRICA NEEDS AIDS DRUGS.†The Clinton administration soon announced it would back more flexible IP rules for poor countries.
By 2001, as the EU (and especially France) and the WHO backed the South African law, the companies withdrew their complaint.
That year also saw the adoption of the Doha Declaration. The clarification to the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) was meant to allow countries to override a patent to make a generic version of a drug — known as compulsory licensing — or import cheaper medicines. The impetus was HIV, but the language made clear that TRIPS “does not and should not prevent members from taking measures to protect public health,†and gave governments wide latitude to decide when those measures are needed.
In retrospect, however, the flashy political victories may have created a false sense of accomplishment, said James Love, an architect of the strategy to push for compulsory licensing.
IN THEIR VOICES
James Love, director of Knowledge Ecology International, on the risks of a “Hollywood Endingâ€:
HOW IT WENT (FOR COVID)
When the pandemic struck, there were some early signs of global solidarity. But then-U.S. President Donald Trump started an inexorable race to fulfill domestic needs first.
As the novel coronavirus spread from China to Europe and the United States, paralyzing the world’s top economies, vaccines were the obvious solution. And there was some early political buy-in to the idea that a future inoculation should be accessible around the world: Both Chinese President Xi Jinping and European Commission President Ursula von der Leyen called vaccines a “global public good.†The EU backed COVAX, a new global initiative to dole out vaccines to all countries rich and poor, with words and financing.
Oxford University teamed up with AstraZeneca to make its adenovirus vaccine, and they promised to provide the shot-at cost during the pandemic. Johnson & Johnson made a similar commitment for their single-dose possibility.
AstraZeneca also took the unusual step of teaching the Serum Institute of India to make the jab, with the idea that the Pune-based company would produce billions for the developing world.Â
Yet rather than lessons from AIDS, it was reactions to Trump that set the trajectory for coronavirus vaccines. In March 2020, German media reported on rumors that Trump wanted to buy exclusive rights to an experimental shot by the German biotech CureVac. The White House and the company both denied the rumors, but they set the course for a hoarding frenzy by the EU.
RESULTS
As with AIDS, the response to the coronavirus has been defined by inequality. Those with more buying power are snapping up the limited supply, regardless of price. As of mid-May, low-income countries received less than one percent of the world’s supply of vaccines.
Me first: The ambition behind COVAX was to pool all buying, for countries rich and poor. So when an effective shot hit the market, jabs would be distributed first to health workers in each country, then the elderly.
That never happened. In rich, vaccine-producing countries, domestic concerns took priority. The U.S eschewed COVAX completely, and the EU opted for its own advance purchase plan. By September, rich countries representing 13 percent of the world’s population had already reserved 51 percent of the expected output. The U.S. banned exports of vaccines and ingredients, and EU doses not reserved for the bloc went primarily to other rich countries.
Though the EU offered COVAX substantial loans early on, it wasn’t able to raise funds fast enough to sign early contracts — especially for the more expensive mRNA vaccines. Dependence on one Indian mega-producer also proved disastrous. When the subcontinent faced its own devastating wave, the government shut down vaccine exports, leaving COVAX high and dry.
Too little, too late: By June, as the U.S. and EU were close to satisfying domestic demands for vaccines, the G7 announced a plan to donate 870 million doses over the next year. Yet 11 billion doses are needed over the next 12 months to end the pandemic, according to the WHO’s chief. There’s no clear path for getting there.
Meanwhile, China and Russia offered doses to strategically important countries, but that vaccine diplomacy pushed those without much geopolitical relevance farther back in line.
Back to the 1990s: Given the trouble with COVAX and other efforts, much of the debate has now returned to old ground: intellectual property.
Activists — not to mention U.S. President Joe Biden and the current chiefs of the WHO and World Trade Organization — endorsed a TRIPS waiver for coronavirus vaccines so other parts of the world can ramp up their own production. Meanwhile, manufacturers around the world are volunteering to help produce shots.
But on sharing trade secrets, industry is pushing back. Medicines in pill form are easy to reproduce. You just need the recipe. Vaccines are much more complicated: patents aside, the developer basically needs to teach a manufacturer how to make them.
Not every plant is up to the task of producing the complex biological products needed for modern jabs. According to Cueni, the lobbyist, Big Pharma is teaming up on its own wherever it can to speed manufacturing, with some 218 partnerships involving this sort of knowledge-sharing, but they need to be picky. The U.S. government ordered a manufacturer to dump 60 million poorly made doses of the Johnson & Johnson jab.
IN THEIR VOICES
Cueni on why companies want to control who makes their vaccines:
The result, for those who watched the response to AIDS unfold, is dispiriting. Life has started to return to normal in the West, with plans in place to secure booster shots and inoculate adolescents at low risk of disease, just as poor countries faced fresh surges.
Lieve Fransen, a Belgian physician who coordinated the European Commission’s global HIV policies in the 1990s before going on to help found the Global Fund to Fight AIDS, Tuberculosis and Malaria, recently returned home from India. She was helping the country deal with a surge that has claimed the lives of thousands of unvaccinated medical professionals — and found it jarring to see life in Belgium returning to normal.
What’s missing now, Fransen said, is the constant pressure of AIDS-era activism.
IN THEIR VOICES
Fransen on how coronavirus fatigue in rich countries could increase inequality:
THE TAKEAWAY
The repeated rich-poor divide shows there’s still no clear way to legislate for public goods: It’s still essentially up to the haves whether to share with the have-nots. AIDS-era IP changes proved irrelevant to COVID-19, and the political momentum for equity was nonexistent.
For activists, frustration is especially acute because of the potential to escape from a profit-driven approach. After all, vaccine development is heavily fueled by public funding. Yet without global leadership, everything devolved into a competition for resources among different international initiatives, as Fransen sees it, and a fallback to old IP arguments that, while valid, may do little to move the ball, Love fears.
IN THEIR VOICES
Fransen on divisions and competition within the global response:
IN THEIR VOICES
Love on the IP “food fightâ€:
To hear Cueni tell it, however, those early AIDS activists did help drive a sea change: Private companies have been more willing to team up with other manufacturers, and price tags for the economy-saving vaccines have been relatively low.
IN THEIR VOICES
Cueni (coarsely) on how Big Pharma knew early on they couldn’t have ‘business as usual’ on vaccine prices:
Yet ultimately, political factors in rich countries may continue to be decisive. Biden, for example, promised to re-engage with multilateral health efforts like the WHO, on the campaign trail. Yet there was no daylight between him and Trump on the idea Americans should be vaccinated before sharing doses and ingredients.
IN THEIR VOICES
Love on the persistent political appeal of inequality for those who have access:
THE BIG QUESTION
Will the lessons of the COVID-19 and HIV pandemics prompt genuine preparations for an equitable rollout of lifesaving innovations — or will history keep on repeating itself?
Audio production by Cristina Gonzalez. Carmen Paun contributed reporting.
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