Edna Bonhomme | Diseases of Relevance · LRB 27 April 2022

In January 2021, a South African health official said that AstraZeneca was charging them $5.25 per dose for its Covid vaccine. The price for EU countries was $2.16. The alleged reason for the disparity was that European nations had invested in the research. Two thousand South Africans had taken part in clinical trials for the vaccine, but that didn’t entitle the country to a discount. Many low-income countries have had to take out loans to pay for Covid vaccines.

Around 17 per cent of the world’s population lives in Africa, and around 17 per cent of clinical trials are now conducted there, though most of them – 58 per cent – are in Egypt, and a further 20 per cent in South Africa. (The number has recently risen steeply: between 1991 and 2018 only 2.5 per cent of clinical trials took place in Africa.) As the Lancet recently put it, ‘research infrastructure and expertise from decades of HIV and tuberculosis research enabled several Covid-19 vaccine trials to be conducted in South Africa.’

One study, published in the New England Journal of Medicine in March 2021, found that the AstraZeneca vaccine was not effective against infection by the Beta variant. In a subsequent trial, known as the Sisonke study (‘we are together’ in isiXhosa), South African researchers recruited nearly 500,000 healthcare workers, including forty thousand known to have HIV, to test the efficacy of the single-dose Johnson&Johnson vaccine. The ANTICOV trial, running in thirteen countries in sub-Saharan Africa, is looking at possible ways to repurpose existing treatments. This research not only helps Africans, but advances scientific understanding of the effectiveness of Covid vaccines and treatments for everyone.

A 2013 study found that ‘diseases of relevance to high-income countries were investigated in clinical trials seven to eight times more often than were diseases whose burden lies mainly in low-income and middle-income countries.’The NEJM reported in 2009 that pharmaceutical companies were conducting more clinical trials in developing countries, yet ‘among the ongoing phase 3 clinical trials that we examined that were sponsored by US-based companies in developing countries, none were trials of diseases such as tuberculosis that disproportionately affect the populations of these countries.’ Of more than 1500 new drugs produced between 1975 and 2004, only 21 targeted malaria, tuberculosis and other neglected diseases that are most common in low-income countries.

We are far from the colonial period, when there was a sharp stratification of who was thought to deserve medical aid, but the residues of European imperialism are still evident: there are rather more European pharmaceutical companies conducting research in Africa than African pharmaceutical companies conducting research in Europe.

Consent is an issue. Some people, especially in rural areas, may not always understand what they are agreeing to, or know that they can leave a clinical trial. They may not be fully aware that an experimental drug is not an established therapy, or may in some cases be presented with a false choice between taking an experimental drug or having no medication at all.

According to the Africa CDC, approximately 15 per cent of Africans have been vaccinated against Covid (ranging from 63 per cent in Rwanda or Morocco to 6 per cent in Nigeria or Sudan) compared to 75 per cent of Europeans; the global average is 57 per cent. In a continent with 1.4 billion people and hundreds of ethnic groups, there is a wide range of experiences for the way Covid transmission, vaccination and impact play out.

Some countries don’t only struggle with acquiring vaccines – patents are still a barrier to universal access – but also lack the necessary equipment to store mRNA vaccines and enough trained healthcare workers to administer the drugs. Public health programmes are fragmented and underfunded. In South Africa, the government allocates 4.4 per cent of GDP to healthcare, compared to 8 per cent for the UK.

There have been efforts to increase Covid vaccine production in Africa. In February, BioNTech announced that it would establish manufacturing facilities in Rwanda and Senegal. A month later, Moderna followed suit, promising to develop a site in Kenya. Rather than suspend its patents, the company has opted to work with a limited number of internationally based pharmaceutical companies that will produce the drug. This, they argue, will ensure that the mRNA vaccine is of the highest quality. On the other hand, not freely sharing the information limits production and potentially keeps costs high.

The history of HIV shows what can go wrong when drug manufacturers cling to their patents. During the early 2000s, antiretroviral drug treatments were priced at $10,000 per person per year – too expensive for most of the world. At first, pharmaceutical companies fought to uphold their intellectual property and their prices, and thousands of lives were lost. After years of activism and legal battles, however, they finally allowed the generic licensing of antiretroviral drugs. This has made them far more affordable, helping millions of HIV-positive people to live longer, healthier lives.

Living with Covid is not a matter of willing the pandemic to be over; it means distributing the medical technology and resources globally so that everyone can benefit. In simple terms, vaccinating as many people as possible – no matter their country of origin – reduces the overall risk of infection, transmission and death worldwide.

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