Gleeson - 2023

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Health & Place 83 (2023) 103051
Contents lists available at ScienceDirect
Health and Place

journal homepage: www.elsevier.com/locate/healthplace
Global inequities in access to COVID-19 health products and technologies:

A political economy analysis
Deborah Gleeson a, *, Belinda Townsend b, Brigitte F. Tenni a, c, Tarryn Phillips d
a
School of Psychology and Public Health, La Trobe University, VIC, 3086, Australia
b
Menzies Centre for Health Governance, School of Regulation and Global Governance, Australian National University, 8 Fellows Road Acton, Canberra, ACT, 2000,
Australia
c
Nossal Institute for Global Health, University of Melbourne, 5th Floor, 333 Exhibition Street, Melbourne, Victoria, 3189, Australia
d
Department of Social Inquiry, La Trobe University, VIC, 3086, Australia
A R T I C L E I N F O A B S T R A C T
Keywords: This paper presents a political economy analysis of global inequities in access to COVID-19 vaccines, treatments,
COVID-19 and diagnostic tests. We adapt a conceptual model used for analysing the political economy of global extraction
Inequity and health to examine the politico-economic factors affecting access to COVID-19 health products and tech
Access to medicines
nologies in four interconnected layers: the social, political, and historical context; politics, institutions, and
Global vaccine equity
policies; pathways to ill-health; and health consequences. Our analysis finds that battles over access to COVID-19
Political economy
Structural violence products occur in a profoundly unequal playing field, and that efforts to improve access that do not shift the
Pharmaceutical industry fundamental power imbalances are bound to fail. Inequitable access has both direct effects on health (pre
TRIPS waiver ventable illness and death) and indirect effects through exacerbation of poverty and inequality. We highlight how
COVAX the case of COVID-19 products reflects broader patterns of structural violence, in which the political economy is
COVID-19 technology access pool structured to improve and lengthen the lives of those in the Global North while neglecting and shortening the
lives of those in the Global South. We conclude that achieving equitable access to pandemic response products
requires shifting longstanding power imbalances and the institutions and processes that entrench and enable
them.
1. Introduction globally by March 2022 were administered in LICs (Balakrishnan,

2022). Inequities in access to COVID-19 therapeutics have been even
COVID-19 vaccines were developed at amazing speed and have been more marked, with more than 70% of treatment courses reserved by
critical in reducing mortality from the pandemic. In January 2021, high income countries (People’s Vaccine Alliance, cited in Iacobucci,
however, the Director-General of the World Health Organization (WHO) 2022) and only eight LICs having received deliveries of oral antiviral
Dr Tedros Ghebreyesus warned that “… the world is on the brink of a treatments by November 2022 (UNICEF, n.d.).
catastrophic moral failure – and the price of this failure will be paid with These inequities reflect failures in the global response to COVID-19.
lives and livelihoods in the world’s poorest countries” (WHO, 2021a). At Early in the pandemic, the Access to COVID-19 Tools Accelerator (ACT-
that stage, more than 39 million COVID-19 vaccine doses had been A) was set up as a global collaboration to “… speed up an end to the
administered in at least 49 higher-income countries, in comparison with pandemic by supporting the development and equitable distribution of
just 25 doses in a single lowest-income country. These inequities have the tests, treatments and vaccines the world needs to reduce mortality
persisted throughout the pandemic. By November 2022, almost 13 and severe disease …” (WHO, n.d.-a). The vaccines pillar of ACT-A,
billion doses of COVD-19 vaccines had been administered around the COVAX, began with the modest aim to deliver 2 billion doses by the
world, but less than 25% of people in low-income countries (LICs) had end of 2021, enough to vaccinate 20% of the population in every
received a dose (Global Change Data Lab, 2022). country (WHO, 2020). But COVAX is widely acknowledged to have
Access to diagnostic tests and treatments for COVID-19 has also been failed (de Bengy Puyvallée and Storeng, 2022). By the end of 2021, more
highly inequitable. Only 0.4 percent of the 3 billion diagnostic tests used than 76% of people in high and upper-middle-income countries had
* Corresponding author.
E-mail address: [email protected] (D. Gleeson).
https://doi.org/10.1016/j.healthplace.2023.103051
Received 5 April 2023; Received in revised form 30 May 2023; Accepted 31 May 2023
Available online 8 June 2023
1353-8292/© 2023 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).
D. Gleeson et al. Health and Place 83 (2023) 103051
received a vaccine dose, in contrast to only 8.5% of those in low-income based on structural reforms that tackle these power imbalances,
countries (LICs) (de Bengy Puyvallée and Storeng, 2022). Instead of including through reforming the ways in which pharmaceutical R&D are
COVAX, donations became the main mechanism through which funded, preventing exclusive monopolies on health products and tech
COVID-19 vaccines were provided to LICs. However, by June 2022, less nologies, and empowering LMICs in global governance structures.
than 50% of the 2.1 billion vaccine donations pledged by G7 countries to The purpose of this paper is to apply a political economy of health
poorer countries had been delivered (Oxfam International, 2022, June approach to analysing the development of global inequities in access to
25). COVID-19 health products and technologies, the failures to correct them
The other three ACT-A pillars were even less successful. The thera and the prospects for change. We adapt a conceptual framework applied
peutics pillar received less than 20% of the US$ 9.1 billion sought to the political economy of extraction and health, and in doing so pre
(WHO, 2022a). The diagnostics pillar, which planned to provide 500 sent a novel framework for examining the causes of global inequities in
million diagnostic tests to low and middle-income countries (LMICs) by the distribution of COVID-19 products and their impacts on health.
mid-2021, had only delivered 97 million by the end of 2021 (WHO,
2022a). The health systems strengthening pillar was widely perceived to 2. Materials & methods
be dysfunctional (WHO, 2022a).
In addition to problems with the global distribution of vaccines, the In order to systematically interrogate the global political and eco
development and manufacturing of COVID-19 vaccines and other nomic dynamics underpinning the inequitable distribution of COVID-19
products was concentrated in Western countries, with little sharing of vaccines, diagnostics and therapeutics, we applied a ‘political economy
intellectual property (IP) or technology transfer to enable of global health’ framework first developed by Birn et al. (2017), and
manufacturing in the Global South. Efforts to encourage voluntary then adapted by Schrecker et al. (2018) in the context of analysing the
sharing, such as the COVID-19 Technology Access Pool (C-TAP) set up political economy of global resource extraction (i.e. mining) and its
by the WHO, failed to correct the imbalance, and negotiations at the health effects (see Fig. 1). This conceptual framework provides a
World Trade Organization (WTO) over a temporary waiver of its IP rules structured and theory-informed tool for unpacking the layers of political
for COVID-19 health products and technologies ultimately failed to economy from global forces to the health consequences for communities
secure a meaningful outcome (Amin and Kesselheim, 2022). and individuals. To our knowledge, the conceptual framework has not
In the wake of these failures, attention has now begun to shift to previously been applied in the context of access to medicines, and its
planning for future pandemics and the Pandemic Prevention, Pre application for examining the global distribution of COVID-19 medical
paredness and Response Accord (hereafter, Pandemic Accord) currently products and technologies represents a novel development in applying a
being negotiated at the WHO presents an opportunity to take a different structured political economy approach to this topic.
approach. However, as we will show in this paper, the inequities of the Central to a political economy approach is the notion that to un
COVID-19 pandemic are deeply rooted in power asymmetries in the derstand inequities in health outcomes, we need to examine how po
global political and economic order which have shaped the unfair litical, economic and social factors operate and interact at multiple
development and distribution of COVID-19 health products and tech levels. Birn and Schrecker’s frameworks enable these factors to be
nologies. We illustrate the pathways to ill health extending from these mapped out at multiple levels: from the broad social, political, economic
global dynamics by tracing the politics and policies that have led to a and historical context at the global level, to the international and na
high burden of disease and avoidable deaths due to inadequate vacci tional politics, institutions and policies which structure health and ill
nation rates, low testing levels and lack of access to treatments. We health, to the pathways to ill health at the national and local level (such
argue that future efforts to equitably share health products must be as exposures and living conditions), and ultimately to the embodiment
Fig. 1. Schematic of the political economy of global extraction and health (Schrecker et al., 2018).
2
of these structural factors in the health consequences for communities forms of harm caused by systemic poverty, power asymmetries and
and individuals (Birn et al., 2017; Schrecker et al., 2018). neglect, which ultimately lead to reduced life chances for many of the
We adapted these frameworks specifically for examining inequities world’s poor (Hamed et al., 2020, p. 1663). Given the colonial and
in access to COVID-19 health products and technologies, using the four racialised lines along which this structural violence plays out, this in
categories of factors at different levels set out by Schrecker et al. (2018): turn reveals a form of necropolitics, in which elites of the Global North
tend to hold the power to determine who lives and who dies (Mbembe,
⋅ The social, political, economic, and historical context (international) 2019; Sumba, 2021). Made explicit through the framework, these un
⋅ Politics, institutions and policies (international and national) derlying theories lay bare how health inequities – whether in relation to
⋅ Pathways to (ill) health (national and local) global extraction or COVID-19 health products and technologies – tend
⋅ Human health consequences (local and individual). to be well-trodden grooves within the political economy. To identify the
factors impacting access to COVID-19 health products and technologies
The first level (the social, political, economic, and historical context) at each level, we drew on our extensive knowledge of the literature on
focuses on the international context and enables a deep examination of access to medicines from over a decade of research in this field, along
the historical evolution of the global order in which the problem – with a comprehensive review of scholarly and grey literature on the
resource extraction in the context of the work of Schrecker et al. (2018), political and economic factors affecting access to medicines in the
and inequities in access to COVID-19 products in the current study – has context of the COVID-19 pandemic.
arisen. The second level (politics, institutions, and policies) enables an
examination of the way this global order interacts with contemporary 3. Results
international and national politics, institutions, and policies. The third
level (pathways to ill health) illuminates the ways in which the global Fig. 2 presents the framework adapted for the political economy of
political economy and the politics, institutions and policies are linked access to COVID-19 health products and technologies.
with health outcomes and their distribution (the fourth and final level).
This multi-layered framework acts as a blueprint for understanding
health inequities as a form of structural violence. A term coined by 3.1. The social, political, economic, and historical context
Johan Galtung (1969) and developed further by Paul Farmer (2004),
structural violence refers to systematic forms of oppression “built into The dynamics which have shaped inequitable access to COVID-19
structures, institutions, ideologies and histories” (Dilts et al., 2012, p. health products and technologies – and which have given rise to the
91). Violence, here, refers to the more “invisible, indirect and insidious” politics, institutions and policies adopted to procure and distribute these
products during the COVID-19 pandemic – are deeply embedded in
Fig. 2. Schematic of the political economy of access to COVID-19 health products and technologies.
3
various aspects of the social, political, economic, and historical context. Intellectual Property Rights (TRIPS) in 1995 was a watershed moment in
These include capitalism, neoliberalism and globalisation, the estab the evolution of the global IP regime, resulting in the internationalisa
lishment of the global IP regime in the context of trade liberalisation, the tion of enforceable IP standards that had mainly been adopted by
corporate power of the pharmaceutical industry, entrenched power wealthy countries until that time (’t Hoen, 2016). TRIPS mandated
asymmetries in global health governance, and failures to ensure equi patent terms of at least 20 years for both products and processes, in all
table access to pharmaceuticals during previous pandemics. In this fields of technology, along with a suite of other IPRs.
section, we trace the history of these factors and how they created the IP was successfully linked with trade through the intense lobbying of
conditions in which efforts to equitably distribute COVID-19 vaccines, the pharmaceutical industry along with other IP-intensive industries
treatments and tests were bound to fail. such as the software and entertainment industries (Shadlen, 2007).
These industries worked together with developed states, particularly the
3.1.1. Capitalism, neoliberalism, and globalisation United States and European Union, to incorporate IPRs within a wider
Many of the root causes of the failure to achieve an equitable dis package of agreements and trade-offs (Drahos, 2002b, ’t Hoen, 2009).
tribution of COVID-19 medical products and technologies can be traced Drahos (2002a) describes how US pharmaceutical company, Pfizer,
to twenty-first century capitalism and neoliberal political regimes. played a key role in the lobbying campaign, selling the importance of
Neoliberalism, while a term used in many different ways, broadly refers IPRs to the US economy through industry associations, business net
to the “doctrine of the free market and related political and individual works and trade advisory committees, and making financial contribu
freedoms” (Ahlberg and Bradby, 2022) or the “extension of competitive tions to think tanks with political influence. Having secured US
markets into all areas of life, including the economy, politics and soci government support, US corporations then focused on building an in
ety” (Springer et al., 2016, p. 2). Sell (2020, p. 150) explains that while ternational business coalition to pressure other governments to support
neoliberalism in the 1970s and 1980s was characterised by “deregula their IPR agenda, particularly in Europe and Japan (Drahos, 2002a).
tion, privatization, and the transformation of social protection regimes – Developing countries initially opposed the inclusion of patents in the
all underpinned by a faith in free markets”, twenty-first century capi WTO agreements but ultimately agreed to TRIPS, at least partly in the
talism has shifted towards a focus on the role of intangible assets (such as hope that a multilateral agreement would reduce unilateral pressure
IP), financialisation, profits and competitiveness in global markets. from the USA and other wealthy countries (’t Hoen, 2009). However,
Financialisation, a key feature of 21st century capitalism, refers to the this was not to be – the USA in particular continued to pressure other
dominance of financial markets, instruments and institutions over eco states to increase IP protection using its Special 301 law, which iden
nomic outcomes and policies. This incentivises the pharmaceutical in tifies countries that are perceived to provide inadequate IP protection
dustry, for example, to reorder its priorities from creating products that and market access for US IP owners, and subjects them to trade sanctions
meet health needs to delivering value to shareholders (Sell, 2020). Such (’t Hoen, 2009). Various scholars have also documented the undemo
shifts have been accompanied by globalisation, described by Jenkins cratic process for the negotiations, where ‘Green Room’ consultations
(2004, p. 1) as “a process of greater integration within the world were held between key countries to discuss technical details, often
economy through movements of goods and services, capital, technology excluding developing countries, which also lacked the expertise in their
and (to a lesser extent) labour, which lead increasingly to economic negotiating teams to fully understand the implications of what was
decisions being influenced by global conditions”. being proposed (Drahos, 2002a).
The historical shifts towards 21st century capitalism, neoliberalism Sell (2007, p. 42) argues that:
and globalisation help to explain many of the intractable problems
Overall, TRIPS reflects and promotes the interests of global corpo
associated with the maldistribution of COVID-19 products explored
rations that seek to extend their control over their intellectual
further below, including the over-reliance on market solutions, the
property. These firms, acting through the United States government
monopoly power of the pharmaceutical industry – underpinned by the
(and with the support of Europe and Japan), largely captured the
recognition of intellectual property rights (IPRs) – and the tolerance for
WTO process and succeeded in making public international law to
massive pharmaceutical industry profits from products which are
suit their particular needs.
extremely inequitably distributed.
Battles over IP protection continued after TRIPS. In the context of
3.1.2. The establishment of the global intellectual property regime lack of access to HIV drugs, developing countries successfully negotiated
It was in the context of this broader shift towards neoliberal glob the Declaration on the TRIPS Agreement and Public Health (Doha
alisation in the 1980s and 1990s that the global IP regime originated Declaration) which affirmed the right of WTO members to take measures
(Townsend, 2016). After the Second World War, companies in countries to protect public health through the use of ‘TRIPS flexibilities’. These
like the USA, Germany, and the UK, facing intense domestic competi included compulsory licensing (licensing a patented invention without
tion, sought to expand into new markets where national pharmaceutical the consent of the patent holder), parallel importation (importing a
industries were not yet established (Drahos, 2002a). As countries like patented product without the permission of the patent holder) and
India began to develop the technology and capacity to manufacture transition periods for least developed countries (LDCs) (’t Hoen, 2009).
generic drugs, the absence of IP protections in many developing coun A subsequent WTO decision in 2003 on the implementation of the Doha
tries began to threaten the market share and profitability of the phar Declaration sought to address the inability of countries lacking domestic
maceutical giants, such as Pfizer (Drahos, 2002a). By the 1980s, the US pharmaceutical manufacturing capacity to effectively utilise compul
pharmaceutical and other industries had begun to focus on the General sory licensing (Abbott, 2005). While the Doha Declaration was a very
Agreement on Tariffs and Trade and the subsequent establishment of the significant development that facilitated compulsory licensing, the
WTO as a forum where they could make gains that were not possible complex process for exporting to countries without domestic production
through unilateral pressure on individual countries (Drahos, 2002a). capacity remained so cumbersome and impractical that it has only been
Prior to the establishment of the WTO in 1995, few developing used once (’t Hoen, 2009).
countries provided pharmaceutical patents, which were seen to advan The USA and EU also sought to further expand IPRs and reduce the
tage pharmaceutical companies in developed countries, rather than scope for using TRIPS flexibilities through ‘TRIPS-plus’ rules in bilateral
benefiting the Global South (Townsend, 2016). Those developing and regional free trade agreements, including provisions requiring, for
countries that did introduce IP standards similar to those of developed example, extensions to patent terms, exclusivity for test data submitted
countries during the 1900s did so largely as the result of colonialism to regulators, and restrictions on compulsory licenses (Sell, 2007). The
(Drahos, 2002b). widespread adoption of these rules has resulted in further delays to the
The establishment of the Agreement on Trade-Related Aspects of market entry of generic drugs, increasing medicine costs for consumers
4
and governments (Tenni et al., 2022). dominated by actors committed to neoliberal ideologies and private
market solutions (Stein, 2021). Large private philanthropic organisa
3.1.3. Corporate power of the pharmaceutical industry tions such as the Bill and Melinda Gates Foundation arise from the global
A key aspect of the global historical context for inequitable access to concentration of wealth and resources and are invested in maintaining
COVID-19 health products and technologies is the corporate power of existing power structures (Kim, 2021). The Gates Foundation, while
the pharmaceutical industry. Kapczynski (2022) describes four mutually contributing enormously to global health spending and undoubtedly
reinforcing sources of the pharmaceutical industry’s power: property saving lives (McCoy and McGoey, 2011), has played a particularly
power, vertical power over politics, ideational power, and material pivotal role in the financialisation of the global health sector and the
power. While Kapzynski’s analysis focuses on the USA, these forms of creation of new financial markets in global health (Stein, 2021). This is
power can also be seen on a global scale. The pharmaceutical industry’s in the context of an increasingly weak and under-resourced WHO (Stein
property power derives from overlapping IPR over patents, regulatory and Sridhar, 2018). The neoliberal framing that infuses global health
data, and trade secrets, which allow them to keep competitors out of the governance “obfuscates the relations of power that undergird global
market and charge high prices for their products (Kapczynski, 2022). health inequities” (Kim, 2021), enabling, as McCoy and McGoey (2011,
Vertical power, Kapczynski (2022, p. 4) argues, involves “forms of p. 161) argue, “palliative” rather than “long-term structural solutions”.
power over the political process itself that help industry entrench the Crucially, many aspects of global health governance reflect legacies
status quo”. This vertical power is exerted primarily through intense of colonialism. Tropical medicine, the antecedent of modern global
lobbying (particularly in the USA), underpinned by the huge profits health, originated in the late nineteenth century, when colonial powers
generated from property power, and the enshrinement of these property sought to treat diseases like malaria that afflicted colonised people as
rights in international law. Ideational power arises from invoking part of a wider process of ‘civilising’ them, in the context of protecting
neoliberal narratives about the crucial role of the private sector in their own commercial interests (Fofana, 2021; Kim, 2021). The era of
pharmaceutical innovation (and scepticism about the role of govern ‘international health’ that followed in the twentieth century was a
ment) (Kapczynski, 2022) along with the narrative that IP drives inno continuation of this ‘civilising’ mission: philanthropic organisations
vation and economic growth. The industry also holds material power in armed with technological solutions engaged in paternalistic disease
the form of technical expertise, experience and control over personnel eradication programs that paid little regard to the recipients (Fofana,
and facilities, which governments cannot quickly and easily replicate 2021). The ‘global health’ era that followed from the 1990s in response
(Kapczynski, 2022). While the industry’s power is not absolute, chal to new disease threats such as HIV, while acknowledging the intercon
lenges to it tend to have limited success (Kapczynski, 2022). nectedness of the world, remained dominated by institutions and experts
At the global level, the research-based pharmaceutical industry acts from high income countries (HICs) who continue to set the global
as a transnational industry to consolidate and expand its power and agenda, in a continuation of colonial practices (Fofana, 2021). These
pursue a global agenda around entrenching and expanding its monopoly practices perpetuate a view of the recipients of global health support as
rights (Gleeson et al., 2017). Financialisation of the industry has been inferior, support the imposition of donor control, and foster dependency
driven by mergers and acquisitions, giving rise to “pharmaceutical be (Kwete et al., 2022).
hemoths” focused on maximising profits and shareholder value (Keenan
et al., 2022, p. 2). Large pharmaceutical companies establish many 3.1.5. Failures of previous pandemics
subsidiary companies incorporated in various countries, with opaque Inequitable access to pharmaceuticals in the context of public health
relationships between them, enabling taxable income to be moved to emergencies and pandemics is a longstanding problem. In the 1990s, the
countries with lower tax rates (Gleeson et al., 2017). These subsidiaries emergence of antiretroviral therapies for HIV turned it from a uniformly
tend to become members of industry associations in the countries in fatal disease into a treatable chronic illness; however, until political
which they are incorporated, exerting political influence at the national mobilisation enabled widespread generic production in the early 2000s,
level which reflects the global agenda of the parent company (and the millions of people in developing countries lacked access to these drugs
wider agenda of the research-based pharmaceutical sector) (Gleeson (’t Hoen, 2009). When an avian influenza (H5N1) outbreak emerged in
et al., 2017). As we discussed in the previous section, a key part of the Asia in 2004, the Indonesian Government refused to share virus samples
industry’s global agenda is to drive the expansion of strong monopoly with the WHO, for fear they would be used to develop commercial
rights through international trade agreements. These power dynamics vaccines which Indonesia and other developing countries would not be
help to explain how entrenched and diffuse the industry’s power is, and able to access (Fidler, 2010). Developments during the 2009-H1N1
how difficult it is for governments and other stakeholders to shift the pandemic saw these LMIC concerns come to fruition. HICs made large
status quo. advance purchase agreements, reserving almost all of the vaccine doses
that could be manufactured in the first year (Fidler, 2010). While WHO
3.1.4. Power asymmetries in global health governance negotiated with pharmaceutical companies and HICs to secure some
The global health governance context in which efforts to procure and donations, pledges were made only after HICs had enough vaccine for
distribute COVID-19 products for LMICs were generated is also riddled their own populations, and even then were pledged without nominating
with power asymmetries. These dynamics are not unique to COVID-19. delivery dates (Fidler, 2010). Fortunately, the 2009-H1N1 pandemic did
As Otterson et al. (2014) point out, power asymmetries that compromise not turn out to be as severe as expected, but the inequities in access to
efforts to address health inequities in all policy areas are entrenched and vaccines that occurred in 2009 were not successfully resolved – and set
reinforced by dysfunctions in global governance structures and systems. the scene for what was to play out in the COVID-19 pandemic more than
Krikorian and Torreele (2021) describe the emergence of a donor-driven a decade later.
global health architecture from the early 2000s, with a central role for
the private sector and a more marginal role for governments in cor 3.2. Politics, institutions, and policies
recting market failure. Donor funds were used to support vertical
disease-focused programs relying on market mechanisms, including We now turn our attention to the politics, institutions, and policies in
public-private partnerships, to secure pharmaceuticals in bulk at place during the COVID-19 pandemic – born out of power asymmetries
reduced prices for the poor (Krikorian and Torreele, 2021). These ar in the global order described in the previous section – and how they have
rangements left the global world order, prevailing ideologies, and the shaped access to COVID-19 medical products and technologies. We
pharmaceutical industry’s business models intact, supporting the status begin by scrutinising the way in which the development of these prod
quo (Krikorian and Torreele, 2021). ucts and technologies has been underpinned by massive injections of
In this donor-driven architecture, global health has become public funding, generating equally massive profits for private companies
5
with few (or no) strings attached. We then analyse how the governance more, with some prices exceeding the highest prices previously set for
and design of ACT-A reproduces existing power asymmetries and colo vaccines (Wouters et al., 2021). While price information is generally
nial practices in global health governance, and the reliance of COVAX on kept confidential, various revelations (some accidental) have exposed
neoliberal ideologies and market arrangements. We next examine the large anomalies in pricing between countries. For example, South Africa
vaccine nationalism of HICs, and the vaccine charity and diplomacy paid more than double per dose for the Oxford-AstraZeneca vaccine than
approaches which developed in the absence of equitable sharing, and the European Union (Dyer, 2021).
which exacerbated and further entrenched power imbalances. Finally, Pfizer, which priced its COVID-19 vaccine at US$30 per dose in the
we unpack the pharmaceutical industry’s stranglehold on the produc USA – a price estimated as nearly 30 times the cost of manufacturing –
tion of COVID-19 products and technologies, and the failure of efforts to announced in late 2022 that it would increase the cost per dose to
correct inequities, including the COVID-19 Technology Access Pool (C- around $110–130 in 2023 (Cullinan, 2022, October 24).
TAP), the mRNA vaccine technology transfer hub and negotiations to
waive IP rights for COVID-19 products. 3.2.2. Top-down governance and design of the Access to COVID-19 Tools
Accelerator (ACT-A)
3.2.1. Public funding of private monopolies ACT-A was quickly assembled in April 2020 as a loose collaboration
Enormous amounts of public funding were poured into the research between established global health actors including private sector
and development of COVID-19 vaccines. Early in the pandemic, at least stakeholders, public-private partnerships, and donors, reflecting the
US$5.6 billion was provided by governments in up-front funding to existing global health landscape rather than new governance arrange
support vaccine R&D, along with more than US$45 billion committed in ments (Moon et al., 2022). Initial participants included the Gates
advance to purchase the resulting products (Moon et al., 2021). Wouters Foundation, CEPI, Gavi, the Vaccine Alliance, The Global Fund to Fight
et al. (2021) estimated that US$10 billion was invested in 26 vaccine AIDS, Tuberculosis and Malaria (The Global Fund), Unitaid, Wellcome,
candidates that had been approved in at least one country, were in phase the WHO, the Developing Countries Vaccine Manufacturers Network,
3 clinical trials, or were under contract to CEPI or COVAX. International Federation of Pharmaceutical Manufacturers and Associ
These injections of funding meant that governments, rather than the ations, and the International Generic and Biosimilar Medicines Associ
private sector, took on the risks and costs associated with vaccine ation (Moon et al., 2022). The governance structures of ACT-A were
development (Moon et al., 2021). But despite this heavy subsidisation, plagued by a lack of transparency and accountability, with the roles of
governments chose not to attach conditions to this funding to require various parties, including donors, HICs and industry groups, unclear and
companies to price their products affordably, or to share their data, shifting over time (WHO, 2022a; Moon et al., 2022).
technology, and know-how. The Trump Administration’s initiative for From its inception, ACT-A’s reliance on the existing global health
funding vaccine R&D, Operation Warp Speed, for example, gave close to architecture meant it was invested in perpetuating market-based ar
US$1 billion to Moderna for the development of its COVID-19 vaccine, rangements and adopting a charitable model which distinguished be
but Moderna – despite relying on previous research undertaken by the tween donors and recipients (Krikorian and Torreele, 2021). It was
National Institutes of Health – retained ownership of its technology and heavily criticised by civil society for its limited focused only on stop-gap
know-how and full control over price (Cancryn et al., 2021, May 11). measures during the acute phase of the pandemic and the assumption
Moreover, Moderna stipulated that doses purchased by the USA could that LMICs would be able to obtain COVID-19 products and technologies
not be shared with other countries – a condition that severely con through normal market operations after this time (ACT-A Civil Society
strained the US Government’s capacity to donate excess doses later on and Community Representatives, 2021).
(Cancryn et al., 2021, May 11). Both the design and the initial governance structure of ACT-A
When a team of scientists at the University of Oxford developed a excluded LMICs (Moon et al., 2022). In contrast, nine HICs were
front-runner COVID-19 vaccine, for which they planned to offer non- initially included (Moon et al., 2022). Civil society organisations were
exclusive, royalty free licenses to enable the product to be provided also largely excluded from the governance structure in ACT-A in 2020,
free or at cost during the pandemic, Bill Gates reportedly pushed the although this had improved by 2021 (WHO, 2022b). An independent
team to sign an exclusive license deal with pharmaceutical giant external evaluation of ACT-A (WHO, 2022a) found that the top-down
AstraZeneca (Baker, 2020, July 15). This was despite an estimated governance structure meant the countries ACT-A was primarily inten
97–99% of the funding for the research behind the vaccine coming from ded to benefit were not meaningfully engaged and did not have a sense
public and charitable sources (Cross et al., 2021). Governments of ownership of the initiative (WHO, 2022a). The exclusion of LMICs
contributed 45.9% (£31.8 million) and charitable trusts 31% (£21.5 also resulted in an overwhelming focus on the procurement of products,
million) while only 2.8% (£1.9million) was contributed by industry with insufficient attention to delivery and the logistical and health
sources (Cross et al., 2021). This called into question the prevailing system supports needed by LMICs to roll out vaccines (WHO, 2022a).
view, famously espoused by Boris Johnson, that the successful devel
opment of COVID-19 vaccines was a product of capitalism and greed 3.2.3. COVAX: a private-public partnership based on power asymmetries
(Safi, 2021). While AstraZeneca pledged to sell the vaccine at and private markets
not-for-profit prices during the pandemic, it included a clause enabling it The governance and operating model of COVAX, the vaccines pillar
to declare the pandemic over (Scheibner et al., 2022), and began to sign of ACT-A, was equally deeply embedded in existing power asymmetries,
for-profit contracts in November 2021 for the following year (Espiner, neoliberal ideologies, and market arrangements. Its governance was
2021, November 12). based on global public-private partnerships; a governance mechanism
Leading COVID-19 vaccine manufacturers have profited handsomely that is afflicted with power asymmetries and where wealthy govern
from the pandemic, bringing in billions of dollars in revenue and many ments and corporate partners hold the most power (de Bengy Puyvallée
hundreds of millions in profit (Hassan et al., 2021). Pfizer, for example, and Storeng, 2022).
brought in almost $37 billion in revenue from its COVID-19 vaccine in In many ways, COVAX represented a new type of ‘super public pri
2021, and expected vaccine sales of $32 billion and sales of its antiviral vate partnership’ (Storeng et al., 2021). Not only does it have the fea
drug Paxlovid of $22 billion in 2022 (Kollewe, 2022, February 9). Its net tures of established PPPs, such as a vertical, single-disease focus and
profit for 2021 was almost $22 billion, more than double its profit in the focus on technological solutions; it also has distinctive features due to its
previous year (Kollewe, 2022, February 9). scale and complexity. These include its attempt to coordinate a frag
Prices set by vaccine manufacturers have varied wildly. While mented global governance field in a complex and convoluted structure –
AstraZeneca and Johnson & Johnson pledged to sell their vaccines at in which WHO becomes a partner rather than a coordinator – its vast
low prices during the pandemic, other companies have charged far scale; and its blurring of the boundaries between public and private
6
actors (Storeng et al., 2021). to halt the administration of boosters until LIC had completed vacci
The operating model of COVAX was based on advanced purchase nation of high-risk groups (Cullinan, 2021) were ignored.
agreements with manufacturers. Self-financing countries would pay for The pharmaceutical industry was also complicit. The monopolisation
their own vaccines, while the Advanced Market Commitment (AMC) of vaccines by HICs was facilitated by the vaccine manufacturers, who
arm of COVAX would provide donor-funded doses free of charge to 92 ultimately held greater power over the distribution of vaccines and
mainly LICs. could have forced HICs to go through COVAX to obtain vaccines rather
COVAX not only continued the existing trend of financialisation in than negotiating bilateral agreements (Scholz et al., 2022).
the global health sector, but also expanded the use of financial in The callousness of HICs in the face of the “fatal implications of global
struments in global health governance (Stein 2021). Initially set up as a inequality” – the tacit acceptance of preventable death on a large scale –
‘global buyers’ and distribution club’, the idea was that countries would has been described by Sumba (2021, p. 48) as “necropolitics at large”,
share the financial risks of vaccine production, while equitably distrib while these dynamics have also been understood in terms of “vaccine
uting the resulting products. However, early in the process, concessions apartheid” and “structural violence” for privileging the lives of those in
were made to HICs to enable them to negotiate bilateral deals directly the global North over the global South (Sparke and Levy, 2022; Harman
with vaccine manufacturers, which undermined the premise on which et al., 2021; Hassan et al., 2021).
COVAX was based and transformed COVAX from a buyer’s club to an
‘insurance policy’ for rich countries whose focus turned to more direct 3.2.5. Vaccine charity and diplomacy
ways to secure vaccines (Stein, 2021). The separation of COVAX into Unable to purchase vaccines in a market where supply had been
two arms, with the AMC funded through donations, also meant monopolised by rich countries’ bilateral deals, COVAX had to rely on
self-financing countries could benefit from the insurance policy COVAX donations. However, it lacked enforcement mechanisms to require
provided without being obliged to contribute to the AMC. As a result, by countries that had purchased more than their fair share of vaccines to
December 2020, “COVAX had changed from a buyer’s club based on share their excess doses. Donations of doses to COVAX were pledged
global solidarity and sacrifice to a charity-based aid project” (Stein, early but generally arrived late; with few eventuating before the second
2021, p. 8). half of 2021 after donor countries had already met their domestic de
COVAX accommodated the interests of commercial actors, chan mand and most failing to materialise before the end of 2021 (de Bengy
nelling public funds towards vaccine development and manufacturing Puyvallée and Storeng, 2022). Some were earmarked for specific
and requiring little of the industry in return (Storeng et al., 2021). As countries, and many excess doses were donated bilaterally rather than
Eccleston-Turner and Upton (2021, p. 433) argue, “This arrangement is through COVAX (de Bengy Puyvallée and Storeng, 2022).
therefore a win-win for pharmaceutical companies, because the COVAX Many vaccine donations were too ill-timed or too close to expiry to
pillar bears a significant share of the financial risks associated with be able to be absorbed by recipient countries. In December 2021, the
failure, leaving the pharmaceutical companies free to profit on the back WHO Director-General noted that more than two thirds of donated doses
of any success. In essence, this arrangement privatizes profit and so had an expiry date of less than 3 months (WHO, 2021b). The ad hoc
cializes risk”. Vaccine manufacturers were able to prioritise selling doses timing and lack of predictability made it difficult for developing coun
at high prices to wealthy countries, without having to provide any at tries to prepare, for example by putting cold chain arrangements in
cost to COVAX (de Bengy Puyvallée and Storeng, 2022). No vaccine place, and often meant that countries’ preferences for vaccine type were
manufacturers donated doses to COVAX in 2020-21 (de Bengy Puyvallée not able to be accommodated (WHO, 2022a).
and Storeng, 2022), and vaccine procurement contracts often prohibited Many countries sidestepped COVAX altogether, opting for a ‘vaccine
countries from exporting, donating and even re-selling vaccines without diplomacy’ approach, making bilateral donations to countries in line
the manufacturer’s permission (Apuzzo and Gebrekidan, 2021, January with their national interests, to “reap diplomatic and geopolitical
28). The COVAX model also “obscures the power the industry holds over benefit” (Storeng et al., 2021, p. 9). These dynamics have further
the global allocation of vaccines, placing primary responsibility for entrenched power asymmetries, disempowering recipient countries and
redistribution (or failure to do so) on wealthy country governments.” (de increasing their dependency on the charity of the rich countries that seek
Bengy Puyvallée and Storeng, 2022). to wield influence through their donations (Holzer et al., 2022). Sparke
and Levy (2022) argue that both “vaccine charity” (humanitarian do
3.2.4. Vaccine nationalism - hoarding of COVID-19 vaccines by rich nations through COVAX) and “vaccine diplomacy” (bilateral donations
countries made for strategic and geopolitical motives) have not only failed to
The absence of a global governance framework that effectively deliver the vaccines needed in LIC in a timely way, they have also
enabled equitable sharing of vaccine doses meant that, faced with protected the existing global vaccine market from more radical alter
intense political pressure to cater for their own populations, states ten native approaches to equitable manufacturing and distribution, which
ded to adopt a stance of moral nationalism (privileging domestic access) might have achieved “vaccine liberty” for LMICs.
rather than moral cosmopolitanism (prioritising other countries’ pop Non-Western powers including China and Russia also engaged in
ulations along with their own) (Scheibner et al., 2022). Predictably, rich significant vaccine diplomacy, distributing millions of nationally
countries quickly began to undermine COVAX by negotiating directly developed doses to other countries through bilateral sales and dona
with pharmaceutical companies to pre-purchase large quantities of tions, but largely bypassing COVAX (de Bengy Puyvallée and Storeng,
vaccines for their domestic populations even before COVAX had started 2022). These donations were driven by a somewhat different set of
to negotiate with industry, essentially starving COVAX of supplies. By motivations to those of the West, including economic and reputational
November 2020, more than half of the first 7.5 billion doses had been factors in addition to strategic geopolitical considerations (Suzuki and
pre-purchased by HICs representing less than 14 percent of the world’s Yang, 2022). While these doses played a significant role in lifting global
population (So and Woo, 2020). By December 2020, when the first vaccination rates, for politico-economic reasons as well as their limited
vaccine doses were being rolled out, Canada had entered pre-purchase effectiveness in comparison with mRNA vaccines developed in the West,
agreements for 9.5 doses per head of population (So and Woo, 2020); they did not provide an effective solution to global inequities.
by August 2021 Australia had exceeded this, with more than 10 doses
per person ordered (Gleeson et al, 2022). 3.2.6. The pharmaceutical industry’s stranglehold on production of COVID-
In 2022, HICs proceeded to third and fourth doses, placing continued 19 products and technologies
pressure on supply. By December 2021, the rate of administration of Pharmaceutical companies have protected their exclusive rights to
booster doses in HIC had exceeded the total doses administered in LICs manufacture COVID-19 products and exclude others from the market by
(Mancini and Stabe, 2021, December 19). Moreover, pleas by the WHO filing large numbers of patents in multiple countries. Gaviria and Kilic
7
traced the complex webs of patents and license agreements on various Institutes of Health (signed in May 2022) (WHO, n.d.-b). No private
aspects of the technology underpinning the mRNA COVID-19 vaccines, sector pharmaceutical companies have contributed to the pool, and
which involves a very large number of entities (Gaviria and Kilic, 2021). some pharmaceutical industry executives have dismissed and ridiculed
Scheibner et al. (2022) searched patent databases for patents filed in just the initiative (Silverman, 2020).
two countries for six key COVID-19 vaccines and found over 100 active The WHO also established an mRNA vaccine technology transfer hub
and pending patent applications for the USA and more than 40 for in South Africa, which has used information in the public domain to
Australia. develop a vaccine similar to the Moderna vaccine (World Health Orga
Facing criticism over the inequitable distribution of its COVID-19 nization, n.d.-b). However, despite appeals from WHO, the mRNA vac
vaccine in 2020, Moderna made a pledge not to enforce its COVID-19 cine manufacturers (Moderna, Pfizer and BioNTech) have all refused to
patents during the pandemic (Moderna, 2020, October 8). However, cooperate and share their technology and know-how with the mRNA
by March 2022, Moderna announced that while it would never enforce hub (Wise, 2022). BioNTech hired a consultancy firm that reportedly
its COVID-19 patents in the 92 LMICs included in the COVAX AMC, it sought to undermine the hub, lobbying for its termination (Davies,
expected its IP to be respected beyond these 92 (Moderna, 2022). 2022). Moderna has filed patents in South Africa and has been granted at
The pharmaceutical industry, with few exceptions, kept a tight grip least three, according to Médecins Sans Frontières (2022), and is suing
on the exclusive rights to manufacture COVID-19 vaccines, engaging in Pfizer and BioNTech for patent infringement, claiming that it copied
very little voluntary sharing of IP or know-how to enable more wide mRNA technology that Moderna developed before the pandemic (Reed,
spread manufacturing. There have been few voluntary licenses negoti 2022, 26 August). Moderna also announced that it would set up an
ated with companies in LMICs, with the notable exception of the Oxford- mRNA manufacturing facility in Kenya, possibly an effort to undermine
AstraZeneca vaccine (Chaudhuri, 2022). AstraZeneca licensed the the mRNA hub. At this stage, it is not clear what the mRNA hub’s
Serum Institute of India to provide a billion doses for LMICs, along with prospects are for successfully navigating what could be a minefield of
several companies in various other countries. However, these voluntary continuing obstruction and potential litigation over IP rights.
licenses come with conditions. For example, the terms of its contract In October 2020, India and South Africa put a proposal to the WTO to
prevented the Serum Institute of India from supplying upper-middle temporarily relax IP rules in the TRIPS Agreement for COVID-19 medical
income and HICs (Chaudhuri, 2022). products during the pandemic (WTO, 2020). The proposed TRIPS waiver
The two companies making mRNA vaccines – Pfizer/BioNTech and would have enabled companies around the world to freely produce
Moderna – have not entered any licensing agreements involving tech COVID-19 products and technologies including vaccines, treatments,
nology transfer with companies in LMICs. While Pfizer entered an tests, and equipment (e.g., face masks and ventilators) without fear of
agreement with the Biovac Institute in South Africa to manufacture the litigation over possible infringements of IPR. The TRIPS waiver proposal
Pfizer-BioNTech vaccine for African Union countries, Biovac’s role was eventually gained the support of more than 100 of the WTO’s 164
limited to the fill and finish stage of manufacturing, with the vaccine member countries and was sponsored by more than 60, but faced strong
substance provided ready-made from Europe (Pfizer, 2021, July 21). opposition from wealthy countries, including the EU, the UK,
BioNTech announced in February 2022 that it would establish a Switzerland, Canada, Japan, and Australia (Wijesinghe et al., 2022).
‘modular’ mRNA manufacturing facility to manufacture mRNA vaccines Ultimately, the TRIPS waiver negotiations failed to secure a mean
for African countries, but this involves shipping fully equipped pro ingful outcome. The USA, which had originally opposed the waiver,
duction lines along with BioNTech staff to operate them, at least initially announced its support for a waiver limited to vaccines in May 2021
(Davies, 2022). (Office Of The United States Trade Representative, 2021), a move which
Companies have been more prepared to engage in voluntary dramatically improved the prospect of agreement on a waiver. However,
licensing agreements for the small-molecule antiviral COVID-19 treat the EU (particularly Germany), the UK and Switzerland – where many
ments, presumably because these are more likely than vaccines to be companies making COVID-19 products are headquartered – remained
subject to compulsory licensing if the industry does not enter voluntary staunch opponents (Third World Network, 2021). The research-based
arrangements. But these agreements tend to exclude large parts of the pharmaceutical industry was vocal in its opposition, claiming that a
world. Both Merck Sharpe & Dohme and Pfizer have established waiver would decimate further innovation on COVID-19 vaccines
agreements with the Medicines Patent Pool for Lagevrio and Paxlovid (Wijesinghe et al., 2022).
respectively, resulting in license agreements for their antiviral treat The EU issued a counterproposal that sought to merely clarify and
ments with generic manufacturers (Medicines Patent Pool, 2021a, make minor adjustments to the existing compulsory licensing provisions
November 16, Medicines Patent Pool, 2021b, October 27). But the in the TRIPS Agreement (Yu, 2022). However, the compulsory licensing
countries that can benefit from these are limited to mainly low and provisions in TRIPS have limitations that make them difficult to use,
lower-middle income countries (106 and 95 respectively), with particularly for vaccines. A separate compulsory license would need to
upper-middle income countries such as Thailand, China and Mexico be issued in each country for each patent, and the complex patent
unable to be supplied under these licenses. Pfizer has also agreed to landscape for vaccines, where multiple patents can be held by multiple
deals with UNICEF and the Global Fund, for a total of 10 million treat entities on various aspects of the underlying technologies, components,
ment courses of Paxlovid to be provided at not-for-profit and/or tiered and processes, makes it difficult to even discover all the relevant patent
prices (Pfizer, 2022, September 22). However, this represents a very claims. Much of the knowledge and technology essential to making
small proportion of the treatment courses being manufactured, pro vaccines is not included in patent applications and is instead covered by
jected by Pfizer (2022) to amount to 120 million by the end of 2022. trade secrets protection – but compulsory licensing covers only patents
and not trade secrets (Amin and Kesselheim, 2022). It is also so proce
3.2.7. Failure of efforts to correct inequities durally difficult for countries without manufacturing capacity to import
Efforts to encourage the pharmaceutical industry to voluntarily share pharmaceuticals under the TRIPS compulsory licensing provisions that
its IP and know-how largely failed. Following a request by Costa Rica, they do not represent a feasible solution for health emergencies (Wije
the WHO set up the COVID-19 Technology Access Pool (C-TAP) in May singhe et al., 2022). Due to these and other barriers, to date, there has
2020 to provide a platform for such voluntary sharing (WHO, n.d.-b). not yet been any successful use of compulsory licensing to manufacture
However, although 45 countries (mainly LMICs) endorsed this platform, COVID-19 vaccines.
it remained unused for eighteen months. At the time of writing, the only It was not until June 2022, 20 months after India and South Africa
licensing agreements included under auspices of C-TAP have been first tabled their proposal, that agreement on a Ministerial Decision on
negotiated with public research agencies, the Spanish National Research the TRIPS Agreement (WTO, 2022) was finally reached. More than five
Council (finalised in November 2021) and the United States National million people died because of the pandemic during those 20 months
8
(Yu, 2022). But the Ministerial Decision was only a shadow of the lower-middle income countries with three doses of an mRNA vaccine
original TRIPS waiver proposal (Amin and Kesselheim, 2022). In would avert approximately 1.5 million deaths at a cost of $US61 billion.
contrast to the comprehensive original proposal, it was limited to one Moore et al. (2022) used 2021 data from 152 countries to quantify the
type of COVID-19 product (vaccines), at least in the first instance, and effects of different vaccine sharing strategies, finding that a more equi
one type of IPR (patents). While the original proposal aimed to waive 40 table distribution of vaccines would result in substantial decreased
articles of the TRIPS Agreement, the final outcome waived only one mortality in LICs without producing correspondingly large increases in
paragraph of one article (TRIPS Article 31(f)), making it easier for HICs, as long as vulnerable groups are vaccinated. Additionally, more
vaccines made using its provisions to be exported from the country of equitably sharing vaccines would reduce the total number of infections,
manufacture to a second developing country. Perversely, developing reducing the opportunities for more severe variants to emerge. The
countries with vaccine manufacturing capacity were encouraged to authors estimated that the equitable vaccine distribution scenario would
make binding commitments to opt out of utilising the Decision (WTO, have averted at least 1.3 million deaths attributable to COVID-19 by the
2022; Footnote 1). end of 2021.
The Ministerial Decision included a clause committing WTO mem While it is difficult to estimate the impact of COVID-19 on life ex
bers to decide on its expansion to cover the production and supply of pectancy in LMICs at this stage due to limited data, emerging evidence
COVID-19 diagnostics and therapeutics within 6 months (WTO, 2022). from India and Latin America suggests that the impact is likely to be
However, this deadline passed with no agreement, and at the time of larger than for HICs (Schöley et al., 2022). It is also too early to measure
writing, it appears unlikely that members will ever agree to include the burden of post COVID-19 condition (also known as ‘long COVID’) in
diagnostics and therapeutics within its scope. LMICs. Post COVID-19 condition is defined by the WHO as “… the illness
that occurs in people who have a history of probable or confirmed
3.3. Pathways to ill health and human health consequences SARS-CoV-2 infection; usually within three months from the onset of
COVID-19, with symptoms and effects that last for at least two months”,
We now trace the pathways to ill health and the human health where “… symptoms and effects of post COVID-19 condition cannot be
consequences of inequitable access to COVID-19 vaccines, treatments, explained by an alternative diagnosis” (WHO, 2021c). However, a (not
and tests, drawing on published evidence to date. Since the pathways are yet peer-reviewed) systematic review of the incidence and prevalence of
relatively straightforward, we discuss these two levels of the framework long COVID estimates that globally, 144.7 million people experienced
together (following Schrecker et al., 2018), in relation to direct health long COVID three months after infection in 2020 and 2021, and 15.1%
effects (mortality and morbidity arising directly from COVID-19 infec of these cases had not recovered by 12 months post-infection (Wulf
tion) and indirect health effects (excess mortality, exacerbation of global Hanson et al., 2022). The risk of long COVID is likely to be higher in
inequality and poverty, exacerbation of other health inequalities, and unvaccinated people (Notarte et al., 2022), which suggests that the
perpetuation of the pandemic). burden of long COVID resulting from the lag in vaccinating people in
LMICs may be significant.
3.3.1. Direct health effects
The most obvious immediate health consequence of the inequitable 3.3.2. Indirect health effects
distribution of COVID-19 health products and technologies is a high Excess mortality rates (the difference in the number of deaths from
burden of disease and avoidable deaths due to inadequate vaccination the number expected based on data from previous years) measure both
rates, low testing levels and lack of access to treatments. Vaccination deaths that are directly attributable to COVID-19 and those indirectly
protects individuals against severe illness and death and also helps to associated with the pandemic, due to its broader impact on health sys
slow transmission of COVID-19. Access to diagnostic tests is necessary tems and other aspects of society (WHO, 2022b). Excess mortality rates
not just for surveillance and guiding policy, but also for preventing show even greater differences between HICs and LMICs than deaths
asymptomatic and pre-symptomatic transmission, and identifying those directly attributable to COVID-19 (Gill and Schellekens, 2021). Globally,
high-risk individuals who have contracted the disease and need treat excess mortality due to COVID-19 has been estimated at 14.9 million in
ment (Batista et al., 2022). the two years from 1 January 2020 (WHO, 2022b). Eighty-one percent
It is important to note that LMICs suffered disproportionately from of these excess deaths are concentrated in middle-income countries
the pandemic even before COVID-19 vaccines were available in any (53% in lower-middle income countries and 28% in upper-middle in
country. A systematic review and meta-analysis of COVID-19 serology come countries respectively), with 4% of excess deaths occurring in
studies found that the infection fatality rate was at least twice as high for LICs. HICs accounted for only 15% of excess deaths during 2020–2021
LMICs as for HICs in the first year of the pandemic (Levin et al., 2022). (WHO, 2022b).
Moreover, eight of the twelve nations with the highest number of deaths COVID-19 has also seen a diversion of resources from other health
from COVID-19 are developing countries (Levin et al., 2022). Mortality programs and the suspension of effective health programs due to lock
data for LMICs is also likely to underestimate the impact of COVID-19 downs and other COVID measures. This will likely cause an increase in
due to reporting limitations (Levin et al., 2022). morbidity and mortality from other causes in years to come. For
Reflecting the necropolitics outlined above, there was a stark impact example, the number of people receiving tuberculosis (TB) treatment
of vaccine inequity on COVID-19 mortality and morbidity. Retrospective globally in 2020 dropped by more than one million, setting progress
mathematical modelling quantifying the impact of the first year of against TB back by a decade or more. WHO estimates 500,000 more
COVID-19 vaccination estimated that vaccinations prevented 19.8 deaths from TB in 2020 than would otherwise be expected (Roberts,
million excess deaths from COVID-19 from December 2020 to December 2021). WHO and UNICEF have reported the largest decline in childhood
2021, however the deaths per capita averted were highest in HICs due to vaccinations in 30 years (WHO, 2022c) and reduced funding for
their earlier and faster vaccine rollouts (Watson et al., 2022). While maternal child health services and family planning has disrupted supply
vaccination saved an estimated 7.4 million lives in LICs over this period, and demand of maternal child health interventions and decreased con
if COVAX had met its target of vaccinating 20% of each country by the traceptive access and use (Rodo et al., 2022; Catterson, 2021). While
end of 2021, an additional 156,900 deaths would have been avoided in these impacts are not directly attributable to inequitable access to
the COVAX AMC countries (Watson et al., 2022). If the WHO’s goal of products to address the pandemic, delays in COVID-19 vaccination in
40% vaccine coverage had been reached, almost 600,000 more lives LMICs may have exacerbated the effects of the pandemic on other health
would have been saved in the 96 countries that did not reach this target programs.
(Watson et al., 2022). Another modelling study by Savinkina et al. The COVID-19 pandemic has had devastating economic conse
(2022) found that vaccinating the whole population in low and quences for LMICs and has exacerbated global inequality and poverty.
9
Inequality and poverty are both key drivers of inequitable health out monopolies on COVID-19 products while the pharmaceutical industry
comes (Commission On Social Determinants Of Health, 2008). A World was permitted to maintain exclusive rights, that ACT-A and COVAX
Bank study (Mahler et al., 2022) found that the first year of the failed to equitably distribute products in a timely way, that wealthy
pandemic, 2020, saw the largest increase in global inequality and countries engaged in hoarding and drip-feeding excess vaccines to the
poverty in a single year since 1990, reversing three years of progress. poor through charitable donations, and that efforts to correct the in
The increases in inequality and poverty were driven by increases in equities, such as the C-TAP and the TRIPS waiver proposal, received
inequality between countries and bigger reductions in average incomes insufficient support.
in poorer countries, rather than in changes within countries (Mahler Several scholars have written about access to COVID-19 vaccines
et al., 2022). These changes – which occurred before vaccines were using political economy perspectives, for example, Ahlberg and Bradby
widely available in any country – were postulated to result from illness (2022) and Sparke and Levy (2022). However, this paper makes a novel
and death as a result of the virus, the partial shutdowns of economies contribution by adapting a structured approach to examine the factors at
and flow on effects to employment and income generation, less re different levels that shape health outcomes. It is telling that a framework
sources available to mitigate the economic effects of the pandemic in related to global extraction can map so easily onto the health impacts of
poorer countries, and lower economic growth due to lower demand for inequitable access to COVID-19 products and technologies. The com
export goods (Mahler et al., 2022). parison emphasises that the necropolitics of the political economy play
A later World Bank report published in September 2021 found that out in predictable ways, tending to improve and lengthen the lives of
while globally, progress in reducing extreme poverty had been wound higher-income communities while reinforcing and tacitly accepting the
back by 3–4 years during 2020-21, LIC lost 8–9 years of progress (Hill untimely deaths of the poor. Moreover, the stark realities of this violence
et al., 2021). Due to the pandemic, an additional 97 million people were are rendered invisible because it occurs in insidious, indirect, and
estimated to be living on less than $US1.90 per day in 2021 (Hill et al., everyday ways: couched in the banal lexicon of “business”, “diplomacy”,
2021). The incomes of the poorest 40% of the global population fell and “charity”. Solutions, therefore, need to tackle these systemic prob
twice as much as for the richest 20% (World Bank Group, 2022). lems, rather than applying a bandaid to the specific issues that arise.
The COVID-19 pandemic also exacerbated inequality within coun What then, are the prospects for change? To enable equitable access
tries. For example, in the first few months of the pandemic, a study of 17 to health products and technologies in future public health emergencies,
LMICs in Latin America and the Caribbean found that households with it will be necessary to disrupt the current neoliberal paradigm and power
lower income levels were more likely to experience job losses and asymmetries, through reforming the ways in which pharmaceutical R&D
business closures (Bottan et al., 2020). Impacts have been more severe are funded, preventing exclusive monopolies on health products and
on vulnerable groups such as women, low-skilled workers and workers technologies, righting the power imbalances between public and private
in the informal sector, indigenous peoples and asylum seekers (Burki, actors and between rich and poor countries — and the ways these are
2020; Hill et al., 2021; Nanda, 2020). reflected and reproduced in global governance structures. As Krikorian
While it is difficult, if not impossible, to disentangle the effects of and Torreele (2021) argue cogently in the title of their paper, “We
inequitable access to COVID-19 medical products and technologies from cannot win the access to medicines struggle using the same thinking that
other factors contributing to increasing poverty and inequality, it is clear causes the chronic access crisis”. These are large and long-term projects,
that poorer countries have borne the brunt of the economic impacts and but our analysis points to the need for fundamental reforms to the global
have been slower to recover than wealthier countries. As Hill et al. order rather than building on the status quo or tinkering at the margins.
(2021) argue, an adequate supply of COVID-19 vaccines (along with The most promising current global initiative to create the conditions
other medical tools) is critical to accelerate economic recovery in LMICs for equitable access to health products and technologies for future
and to avoid further exacerbation of global economic inequality. pandemics is represented by the negotiations for a WHO Pandemic
COVID-19 has also exacerbated other health inequalities and social Accord. While the exact legal basis for the Pandemic Accord has not yet
determinants of health. As Bambra et al. (2020, p. 965) point out: “The been determined, the International Negotiating Body established to
COVID-19 pandemic is occurring against a backdrop of social and eco negotiate it has agreed that “the instrument should be legally binding
nomic inequalities in existing non-communicable diseases (NCDs) as and contain both legally binding as well as non-legally binding ele
well as inequalities in the social determinants of health”, a situation ments” (WHO, 2023, p. 1).
which they term a “syndemic”, where COVID-19 interacts with and A ‘zero draft’ of the Pandemic Accord released in February 2023 as
exacerbates NCDs and social disadvantage. the starting point for negotiations (WHO, 2023) revealed promising
Finally, inequitable access to COVID-19 vaccines and other tools to proposals for provisions that, if couched in enforceable language, could
manage the pandemic is likely to perpetuate the pandemic due to the go a long way towards promoting equitable access to products in future
continued emergence of new variants in areas of uncontrolled trans pandemics. It includes, among others, measures to increase trans
mission. A modelling study by Ye et al. (2022) demonstrated that greater parency in the funding of pharmaceutical R&D and to encourage con
inequity in vaccine allocation drives earlier and larger outbreaks, ditions to be placed on R&D funding to drive equitable access, along
whereas more equitable sharing suppresses the emergence of new with rules requiring companies to disclose terms and prices of public
variants. procurement contracts. It also emphasises the importance of strength
ening local production in LMICs through technology transfer, commit
4. Conclusion ting the parties to providing mechanisms and incentives for the transfer
of technology to developing countries, along with “measures to support
The analysis we have presented above illustrates how the inequities time-bound waivers of intellectual property rights” (Art. 7 para 4(a)))
in access to COVID-19 health products and technologies, and the failure during pandemics. The draft also suggests that 20% of pandemic-related
to date of various attempts to correct these inequities, are deeply products should be provided to WHO to enable equitable distribution
embedded within and born of a historical legacy of capitalism, neolib (Art. 10, para 3 (h)). However, many of the specific commitments are
eral globalisation and structural violence. It is within this context that couched in non-binding language.
wealthy nations and the powerful pharmaceutical industry have created The same forces that have prevented equitable access to COVID-19
a global IP regime which enables the industry to maintain monopoly health products and technologies threaten to derail or dilute these
power even in the face of vast inequities in access to its products. Given promising proposals, with the pharmaceutical industry already claiming
these aspects of the global social, political, economic and historical the Pandemic Accord draft risks undermine its efforts to rapidly develop
context that permeated the response to COVID-19, it is unsurprising that pandemic products (Cueni, 2023, February 14), and civil society
billions of dollars in public funding was used to support private participation limited to date (Hodgson et al., 2022). For the Pandemic
10
Accord to drive equitable access to pandemic response products in Davies, M., 2022. Covid-19: WHO efforts to bring vaccine manufacturing to Africa are
undermined by the drug industry, documents show. BMJ 376, o304. https://doi.org/
future, it will be critical for LMICs and civil society to be empowered to
10.1136/bmj.o304.
participate meaningfully, with a corresponding reduction in the power de Bengy Puyvallée, A., Storeng, K.T., 2022. COVAX, vaccine donations and the politics
wielded by rich countries, donors, and industry stakeholders. of global vaccine inequity. Glob. Health 18, 26. https://doi.org/10.1186/s12992-
022-00801-z.
Dilts, A., Winter, Y., Biebricher, T., Johnson, E.V., Vazquez-Arroyo, A.Y., Cocks, J., 2012.
Declaration of competing interest Revisiting Johan Galtung’s concept of structural violence. New Polit. Sci. 34 (2),
e191–e227. https://doi.org/10.1080/07393148.2012.676396.
None. Drahos, P., 2002a. Information Feudalism: Who Owns the Knowledge Economy? The
New Press, New York.
Drahos, P., 2002b. Developing countries and international intellectual property
References standard-setting. J. World Intellect. Property 5, 765–789.
Dyer, O., 2021. Covid-19: countries are learning what others paid for vaccines. BMJ 372,
Abbott, F., 2005. The WTO medicines decision: world pharmaceutical trade and the n281. https://doi.org/10.1136/bmj.n281.
protection of public health. Am. J. Int. Law 99, 317–358. Eccleston-Turner, M., Upton, H., 2021. International collaboration to ensure equitable
ACT-A Civil Society And Community Representatives, 2021. Macro changes to the ACT- access to vaccines for COVID-19: the ACT-accelerator and the COVAX facility.
A: a briefing by the ACT-A civil society and community Representatives. https://c Milbank Q. 99, 426–449. https://doi.org/10.1111/1468-0009.12503.
ovid19advocacy.org/more-transparency-accountability-and-inclusion-needed-in-ac Espiner, T., 2021. November 12. AstraZeneca to Take Profits from Covid Vaccine. BBC
t-a-letter-to-act-a-leadership-and-brief-from-cs-and-community-representatives/. News. Retrieved from. https://www.bbc.com/news/business-59256223. (Accessed 8
(Accessed 25 October 2022). November 2022).
Ahlberg, B.M., Bradby, H., 2022. Ethnic, racial and regional inequalities in access to Farmer, P., 2004. An anthropology of structural violence. Curr. Anthropol. 45 (3),
COVID-19 vaccine, testing and hospitalization: implications for eradication of the 305–325. https://doi.org/10.1086/382250.
pandemic. Frontiers in Sociology 7. https://doi.org/10.3389/fsoc.2022.809090. Fidler, D.P., 2010. Negotiating equitable access to influenza vaccines: global health
Amin, T., Kesselheim, A.S., 2022. A global intellectual property waiver is still needed to diplomacy and the controversies surrounding avian influenza H5N1 and pandemic
address the inequities of COVID-19 and future pandemic preparedness. Inquiry: The influenza H1N1. PLoS Med. 7, e1000247 https://doi.org/10.1371/journal.
Journal of Health Care Organization, Provision, and Financing 59, pmed.1000247.
00469580221124821. https://doi.org/10.1177/00469580221124821. Fofana, M.O., 2021. Decolonising global health in the time of COVID-19. Global Publ.
Apuzzo, M., Gebrekidan, S., 2021. January 28. Governments sign secret vaccine deals. Health 16, 1155–1166. https://doi.org/10.1080/17441692.2020.1864754.
Here’s what they hide. New York Times. https://www.nytimes.com/2021/01/28/ Galtung, J., 1969. Violence, peace, and peace research. J. Peace Res. 6 (3), 167–191.
world/europe/vaccine-secret-contracts-prices.html. (Accessed 22 November 2022). https://doi.org/10.1177/002234336900600301.
Baker, S., 2020. July 15. Covid Vaccine Front-Runner Is Months Ahead of Her Gaviria, M., Kilic, B., 2021. A network analysis of COVID-19 mRNA vaccine patents. Nat.
Competition. Bloomberg. https://www.bloomberg.com/news/features/2020-07-1 Biotechnol. 39, 546–548. https://doi.org/10.1038/s41587-021-00912-9.
5/oxford-s-covid-19-vaccine-is-the-coronavirus-front-runner. (Accessed 8 November Gill, I., Schellekens, P., 2021. COVID-19 is a developing country pandemic. Future
2022). Development [Online]. Available from: https://www.brookings.edu/blog/future-d
Balakrishnan, V.S., 2022. 2 years of the access to COVID-19 tools-accelerator. Lancet evelopment/2021/05/27/covid-19-is-a-developing-country-pandemic/.
Infect. Dis. 22, 948. https://doi.org/10.1016/S1473-3099(22)00378-4. Gleeson, D., Neuwelt, P., Monasterio, E., Lopert, R., 2017. How the transnational
Bambra, C., Riordan, R., Ford, J., Matthews, F., 2020. The Covid-19 pandemic and health pharmaceutical industry pursues its interests through international trade and
inequalities. J. Epidemiol. Community Health 74, 964. https://doi.org/10.1136/ investment agreements: a case study of the Trans Pacific Partnership Agreement. In:
jech-2020-214401. De Jonge, A., Tomasic, R. (Eds.), Research Handbook on Transnational Corporations.
Batista, C., Hotez, P., Amor, Y.B., Kim, J.H., Kaslow, D., Lall, B., Ergonul, O., Figueroa, J. Edward Elgar, Cheltenham, UK, pp. 223–254.
P., Gursel, M., Hassanain, M., Kang, G., Larson, H., Naniche, D., Sheahan, T., Wilder- Gleeson, D., Tenni, B, Townsend, B., 2022. Four actions Australia should take to advance
Smith, A., Shoham, S., Sow, S.O., Yadav, P., Strub-Wourgaft, N., Loveday, S.-J., equitable global access to COVID-19 vaccines. Australian and New Zealand Journal
Hannay, E., Bottazzi, M.E., 2022. The silent and dangerous inequity around access to of Public Health 46, 423–425. https://doi.org/10.1111/1753-6405.13268.
COVID-19 testing: a call to action. eClinicalMedicine 43. https://doi.org/10.1016/j. Global Change Data Lab, 2022. Our world in data: coronavirus (COVID-19) vaccinations
eclinm.2021.101230. [Online]. Available: https://ourworldindata.org/covid-vaccinations. (Accessed 20
Birn, A.-E., Pillay, Y., Holtz, T.H., 2017. Textbook of Global Health. Oxford University November 2022).
Press, New York. Hamed, S., Thapar-Bjorket, S., Bradby, H., Ahlberg, B.M., 2020. Racism in European
Bottan, N., Hoffmann, B., Vera-Cossio, D., 2020. The unequal impact of the coronavirus health care: structural violence and beyond. Qual. Health Res. 30 (11), 1662–1673.
pandemic: evidence from seventeen developing countries. PLoS One 15, e0239797. https://doi.org/10.1177/1049732320931430.
https://doi.org/10.1371/journal.pone.0239797. Harman, S., Erfani, P., Goronga, T., Hickel, J., Morse, M., Richardson, E.T., 2021. Global
Burki, T., 2020. The indirect impact of COVID-19 on women. Lancet Infect. Dis. 20, Vaccine equity demands reparative justice — not charity. BMJ Glob. Health 6,
904–905. https://doi.org/10.1016/S1473-3099(20)30568-5. e006504. https://doi.org/10.1136/bmjgh-2021-006504.
Cancryn, A., Owermohle, S., Banco, E., 2021. May 11. How Trump’s deal with Moderna Hassan, F., Yamey, G., Abbasi, K., 2021. Profiteering from vaccine inequity: a crime
hampers the global vaccine effort Politico. Retrieved from. https://www.politico.co against humanity? BMJ 374, n2027. https://doi.org/10.1136/bmj.n2027.
m/news/2021/11/05/trump-deal-moderna-global-vaccine-effort-519771. (Accessed Hill, R., Lakner, C., Mahler, D., Narayan, A., Yonzan, N., 2021. Poverty, Median Incomes
8 November 2022). and Inequality in 2021: a Diverging Recovery. World Bank Group, Washington, D.C.
Catterson, K., 2021. The effects of covid-19 on sexual and reproductive health: a case Hodgson, T.F., Carmona, M.S., Podmore, M., 2022. States cannot negotiate a pandemic
study of six countries. Retrieved from. https://reliefweb.int/report/world/effects-co treaty alone. BMJ 377, o1281. https://doi.org/10.1136/bmj.o1281.
vid-19-sexual-and-reproductive-health-case-study-six-countries. (Accessed 18 Holzer, F., Roa, T.M., Germani, F., Biller-Andorno, N., Luna, F., 2022. Charity or
November 2022). empowerment? The role of COVAX for low and middle-income countries. Develop.
Chaudhuri, S., 2022. Patent protection and access to covid-19 medical products in World Bioeth. https://doi.org/10.1111/dewb.12349.
developing countries. In: Dutta, M., Husain, Z., Sinha, A.K. (Eds.), The Impact of Iacobucci, G., 2022. COVID-19: “Grotesque inequity” that only a quarter of paxlovid
COVID-19 on India and the Global Order: A Multidisciplinary Approach. Springer courses go to poorer countries. BMJ 379, o2795. https://doi.org/10.1136/bmj.
Nature, Singapore. https://doi.org/10.1007/978-981-16-8472-2_12. o2795.
Commission On Social Determinants Of Health, 2008. Closing the Gap in a Generation: Jenkins, R., 2004. Globalization, production, employment and poverty: debates and
Health Equity through Action on the Social Determinants of Health. Final Report of evidence. J. Int. Dev. 16, 1–12. https://doi.org/10.1002/jid.1059.
the Commission on Social Determinants of Health. World Health Organization, Kapczynski, A., 2022. The political economy of market power in pharmaceuticals.
Geneva. J. Health Polit. Pol. Law. https://doi.org/10.1215/03616878-10234184.
Cross, S., Rho, Y., Reddy, H., Pepperrell, T., Rodgers, F., Osborne, R., Eni-Olotu, A., Keenan, L., Monteath, T., Wójcik, D., 2022. Patents over patients? Exploring the
Banerjee, R., Wimmer, S., Keestra, S., 2021. Who funded the research behind the variegated financialization of the pharmaceuticals industry through mergers and
Oxford-AstraZeneca COVID-19 vaccine? BMJ Glob. Health 6, e007321. https://doi. acquisitions. Compet. Change 10245294221107851. https://doi.org/10.1177/
org/10.1136/bmjgh-2021-007321. 10245294221107851.
Cueni, T.B., 2023. Five priorities for global pandemic preparedness. Health Policy Watch Kim, H., 2021. The implicit ideological function of the global health field and its role in
[Online]. Available: https://healthpolicy-watch.news/five-priorities-to-global-pan maintaining relations of power. BMJ Glob. Health 6, e005620. https://doi.org/
demic-preparedness/. 10.1136/bmjgh-2021-005620.
Cullinan, K., 2021. WHO appeals to postpone COVID-19 vaccine boosters until 2022; Kollewe, J., 2022. February 9. Pfizer Accused of Pandemic Profiteering as Profits Double.
Tedros lashes out at pharma association. Health Policy Watch [Online]. Available: The Guardian. https://www.theguardian.com/business/2022/feb/08/pfizer-covid-v
https://healthpolicy-watch.news/who-appeals-for-no-covid-19-vaccine-boosters-un accine-pill-profits-sales.
til-2022/. Krikorian, G., Torreele, E.L.S., 2021. We cannot win the access to medicines struggle
Cullinan, K., 2022. More industry support for pharma’s pandemic vaccine equity plan – using the same thinking that causes the chronic access crisis. Health and Human
‘not enough’ says civil society, Health Policy Watch. Retrieved from. https://health Rights 23, 119–128. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8233016/.
policy-watch.news/more-industry-support-for-pharmas-pandemic-vaccine-equity-pl Kwete, X., Tang, K., Chen, L., Ren, R., Chen, Q., Wu, Z., Cai, Y., Li, H., 2022. Decolonizing
an-not-enough-says-civil-society/. (Accessed 8 November 2022). global health: what should be the target of this movement and where does it lead us?
Global Health Research and Policy 7, 3. https://doi.org/10.1186/s41256-022-
00237-3.
11
Levin, A.T., Owusu-Boaitey, N., Pugh, S., Fosdick, B.K., Zwi, A.B., Malani, A., Soman, S., Roberts, L., 2021. How COVID hurt the fight against other dangerous diseases. Nature
Besançon, L., Kashnitsky, I., Ganesh, S., Mclaughlin, A., Song, G., Uhm, R., Herrera- 592, 502–504. https://doi.org/10.1038/d41586-021-01022-x.
Esposito, D., De Los Campos, G., Peçanha Antonio, A.C.P., Tadese, E.B., Meyerowitz- Rodo, M., Singh, L., Russell, N., et al., 2022. A mixed methods study to assess the impact
Katz, G., 2022. Assessing the Burden of Covid-19 in developing countries: systematic of COVID-19 on maternal, newborn, child health and nutrition in fragile and
review, meta-analysis and public policy implications. BMJ Glob. Health 7, e008477. conflict-affected settings. Conflict Health 16, 30. https://doi.org/10.1186/s13031-
https://doi.org/10.1136/bmjgh-2022-008477. 022-00465-x.
Mahler, D.G., Yonzan, N., Lakner, C., 2022. The impact of COVID-19 on global inequality Safi, M., 2021. April 15. Oxford/AstraZeneca Covid vaccine research ‘was 97% publicly
and poverty. Retrieved from. https://openknowledge.worldbank.org/handle/10 funded’. Guardian. Retrieved from. https://www.theguardian.com/science/2021/a
986/38114. (Accessed 3 November 2022). pr/15/oxfordastrazeneca-covid-vaccine-research-was-97-publicly-funded. (Accessed
Mancini, D.P., Stabe, M., 2021. December 19. Covid boosters in rich countries outnumber 29 May 2023).
all jabs among poor nations. Financial Times [Online]. Available: https://www.ft. Savinkina, A., Bilinski, A., Fitzpatrick, M., Paltiel, A.D., Rizvi, Z., Salomon, J.,
com/content/5144cd19-2c67-46d0-a37d-a869006bfbdb. (Accessed 24 March Thornhill, T., Gonsalves, G., 2022. Estimating deaths averted and cost per life saved
2022). by scaling up mRNA COVID-19 vaccination in low-income and lower-middle-income
Mbembe, A., 2019. Necropolitics. Duke University Press, Durham. countries in the COVID-19 Omicron variant era: a modelling study. BMJ Open 12,
McCoy, D., McGoey, L., 2011. Global health and the Gates foundation – in perspective. e061752. https://doi.org/10.1136/bmjopen-2022-061752.
In: Rushton, S., Williams, O.D. (Eds.), Partnerships and Foundations in Global Health Scheibner, J., Nielsen, J., Nicol, D., 2022. An ethico-legal assessment of intellectual
Governance. International Political Economy Series. Palgrave Macmillan, London, property rights and their effect on COVID-19 vaccine distribution: an Australian case
pp. 143–163. https://doi.org/10.1057/9780230299474_7. study. Journal of Law and the Biosciences 9. https://doi.org/10.1093/jlb/lsac020
Médecins Sans Frontières, 2022. Removing intellectual-property barriers from COVID-19 lsac020.
vaccines and treatments for people in South Africa. Retrieved from. https://ms Schöley, J., Aburto, J.M., Kashnitsky, I., Kniffka, M.S., Zhang, L., Jaadla, H., Dowd, J.B.,
faccess.org/removing-intellectual-property-barriers-covid-19-vaccines-and-treatme Kashyap, R., 2022. Life expectancy changes since COVID-19. Nat. Human Behav.
nts-people-south-africa. (Accessed 8 November 2022). https://doi.org/10.1038/s41562-022-01450-3.
Medicines Patent Pool, 2021a. November 16. Pfizer and The Medicines Patent Pool Scholz, M., Smith, C.N., Reigler, M., Burton, A., 2022. Public health and political
(MPP) Sign Licensing Agreement for COVID-19 Oral Antiviral Treatment Candidate corporate social responsibility: pharmaceutical company engagement in COVAX.
to Expand Access in Low- and Middle-Income Countries [Press release]. Retrieved INSEAD Working Paper No. 2022/42/ATL.
from. https://medicinespatentpool.org/news-publications-post/pfizer-and-the-med Schrecker, T., Birn, A.-E., Aguilera, M., 2018. How extractive industries affect health:
icines-patent-pool-mpp-sign-licensing-agreement-for-covid-19-oral-antiviral-tre political economy underpinnings and pathways. Health Place 52, 135–147. https://
atment-candidate-to-expand-access-in-low-and-middle-income-countries. (Accessed doi.org/10.1016/j.healthplace.2018.05.005.
8 November 2022). Sell, S.K., 2007. TRIPS-Plus free trade agreements and access to medicines. Liverp. Law
Medicines Patent Pool, 2021b. The Medicines Patent Pool (MPP) and MSD enter into Rev. 28, 41–75. https://doi.org/10.1007/s10991-007-9011-8.
licence agreement for molnupiravir, an investigational oral antiviral COVID-19 Sell, S.K., 2020. What COVID-19 reveals about twenty-first century capitalism: adversity
medicine, to increase broad access in low- and middle- income countries [Press and opportunity. Development 63, 150–156. https://doi.org/10.1057/s41301-020-
release]. Retrieved from. https://medicinespatentpool.org/news-publications-pos 00263-z.
t/mpp-msd-new-licence-announcement-molnupiravir. (Accessed 8 November 2022). Shadlen, K.C., 2007. Intellectual property, trade, and development: can foes Be friends?
Moderna, 2020. Statement by Moderna on intellectual property matters during the Global Governance 13, 171–177.
COVID-19 pandemic [Online]. Available: https://investors.modernatx.com/news- Silverman, E., 2020. Pharma leaders shoot down WHO voluntary pool for patent rights
releases/news-release-details/statement-moderna-intellectual-property-matters-d on Covid-19 products. Stat [Online]. Available from: https://www.statnews.
uring-covid-19. (Accessed 14 February 2021). com/pharmalot/2020/05/28/who-voluntary-pool-patents-pfizer/. (Accessed 28
Moderna, 2022. Moderna announces its global public health strategy [Press release]. May 2020).
Retrieved from. https://investors.modernatx.com/news/news-details/2022/Modern So, A.D., Woo, J., 2020. Reserving coronavirus disease 2019 vaccines for global access:
a-Announces-Its-Global-Public-Health-Strategy/default.aspx. (Accessed 8 November cross sectional analysis. BMJ 371, m4750. https://doi.org/10.1136/bmj.m4750.
2022). Sparke, M., Levy, O., 2022. Competing responses to global inequalities in access to
Moon, S., Alonso Ruiz, A., Vieira, M., 2021. Averting future vaccine injustice. N. Engl. J. COVID vaccines: vaccine diplomacy and vaccine charity versus vaccine liberty. Clin.
Med. 385, 193–196. Infect. Dis. 75, S86–S92. https://doi.org/10.1093/cid/ciac361.
Moon, S., Armstrong, J., Hutler, B., Upshur, R., Katz, R., Atuire, C., Bhan, A., Springer, S., Birch, K., Macleavy, J., 2016. The Handbook of Neoliberalism. Routledge,
Emanuel, E., Faden, R., Ghimire, P., Greco, D., Ho, C.W.L., Kochhar, S., Schaefer, G. Oxford.
O., Shamsi-Gooshki, E., Singh, J.A., Smith, M.J., Wolff, J., 2022. Governing the Stein, F., 2021. Risky business: COVAX and the financialization of global vaccine equity.
Access to COVID-19 Tools Accelerator: towards greater participation, transparency, Glob. Health 17, 112. https://doi.org/10.1186/s12992-021-00763-8.
and accountability. Lancet 399, 487–494. https://doi.org/10.1016/S0140-6736(21) Stein, F., Sridhar, D., 2018. The financialisation of global health. Wellcome Open Res 3,
02344-8. 17. https://doi.org/10.12688/wellcomeopenres.13885.1.
Moore, S., Hill, E.M., Dyson, L., Tildesley, M.J., Keeling, M.J., 2022. Retrospectively Storeng, K.T., de Bengy Puyvallée, A., Stein, F., 2021. Covax and the rise of the ‘super
modeling the effects of increased global vaccine sharing on the COVID-19 pandemic. public private partnership’ for global health. Global Publ. Health 1–17. https://doi.
Nat. Med. https://doi.org/10.1038/s41591-022-02064-y. org/10.1080/17441692.2021.1987502.
Nanda, S., 2020. Inequalities and COVID-19. In: RYAN, M.J. (Ed.), COVID-19: Volume I: Sumba, E.O., 2021. Necropolitics at large: pandemic politics and the coloniality of the
Global Pandemic, Societal Responses, Ideological Solutions. Taylor & Francis Group, global access gap. Critical Studies on Security 9, 48–52. https://doi.org/10.1080/
London. 21624887.2021.1904354.
Notarte, K.I., Catahay, J.A., Velasco, J.V., Pastrana, A., Ver, A.T., Pangilinan, F.C., Suzuki, M., Yang, S., 2022. Political economy of vaccine diplomacy: explaining varying
Peligro, P.J., Casimiro, M., Guerrero, J.J., Gellaco, M.M.L., Lippi, G., Henry, B.M., strategies of China, India, and Russia’s COVID-19 vaccine diplomacy. Rev. Int. Polit.
Fernández-De-Las-Peñas, C., 2022. Impact of Covid-19 vaccination on the risk of Econ. https://doi.org/10.1080/09692290.2022.2074514.
developing long-COVID and on existing long-COVID symptoms: a systematic review. ’t Hoen, E., 2016. Private Patents and Public Health: Changing Intellectual Property
eClinicalMedicine 53. https://doi.org/10.1016/j.eclinm.2022.101624. Rules for Access to Medicines. Health Action International, Amsterdam.
Office Of The United States Trade Representative, 2021. Statement from ambassador ’t Hoen, E., 2009. The Global Politics of Pharmaceutical Monopoly Power: Drug Patents,
katherine tai on the covid-19 trips waiver [Online]. Available: https://ustr.gov/abo Access, Innovation and the Application of the WTO Doha Declaration on TRIPS and
ut-us/policy-offices/press-office/press-releases/2021/may/statement-ambassador Public Health. AMB Publishers, The Netherlands. https://www.opensocietyfound
-katherine-tai-covid-19-trips-waiver. (Accessed 16 May 2021). ations.org/publications/global-politics-pharmaceutical-monopoly-power.
Otterson, O.P., Dasgupta, J., Blouin, C., et al., 2014. The political origins of health Third World Network, 2021. EU, Switzerland, UK continue opposition, amid support for
inequity: prospects for change. Lancet 383, 630–667. https://doi.org/10.1016/ TRIPS waiver [Online]. Available: https://www.twn.my/title2/health.info/2021/h
S0140-6736(13)62407-1. i210906.htm. (Accessed 15 October 2021).
Oxfam International, 2022. June 25. G7 vaccines failures contribute to 600,000 Townsend, B., 2016. International medicines governance 1940s to 1970s: lessons for
preventable deaths [Online]. Available: https://www.oxfam.org/en/press-releases/ public health. Critical Public Health 26, 466–476. https://doi.org/10.1080/
g7-vaccines-failures-contribute-600000-preventable-deaths. (Accessed 27 October 09581596.2015.1103837.
2022). Tenni, B., Moir, H.V.J., Townsend, B., Farrell, A.-M., Keegel, T., Gleeson, D., 2022. What
Pfizer, 2021. July 21. Pfizer and BioNTech announce collaboration with biovac to is the impact of intellectual property rules on access to medicines? A systematic
manufacture and distribute COVID-19 vaccine doses within Africa [Press release]. review. Globalization and Health 18, 40. https://doi.org/10.1186/s12992-022-
Retrieved from. https://www.pfizer.com/news/press-release/press-release-detail/p 00826-4.
fizer-and-biontech-announce-collaboration-biovac. (Accessed 6 November 2022). Unicef (N.D.). Covid-19 market dashboard. Retrieved from. https://www.unicef.
Pfizer, 2022. Paxlovid manufacturing fact sheet. Pfizer. Retrieved from. https://cdn.pf org/supply/covid-19-market-dashboard. (Accessed 23 November 2022).
izer.com/pfizercom/Pfizer_PGS_PAXLOVID_FactSheet_061322.pdf. (Accessed 23 Watson, O.J., Barnsley, G., Toor, J., Hogan, A.B., Winskill, P., Ghani, A.C., 2022. Global
November 2022). Impact of the first year of COVID-19 vaccination: a mathematical modelling study.
Pfizer, 2022a. Pfizer to supply global fund up to 6 million PAXLOVID™ treatment Lancet Infect. Dis. https://doi.org/10.1016/S1473-3099(22)00320-6.
courses for low-and-middle-income countries [Press release]. Retrieved from. https Wijesinghe, S., Adikari, C., Ariyaratna, R., 2022. The Proposal for Waiver of Wto’s Trips
://www.pfizer.com/news/press-release/press-release-detail/pfizer-supply-global- Agreement to prevent, contain and treat COVID-19: investigating the benefits and
fund-6-million-paxlovidtm-treatment. (Accessed 8 November 2022). challenges for low- and middle-income countries. J. Intellect. Property Law Pract.
Reed, J., 2022. Moderna Suing Pfizer over Covid Vaccine Technology. BBC News. https://doi.org/10.1093/jiplp/jpab182 jpab182.
Retrieved from. https://www.bbc.com/news/health-62691102. (Accessed 8 Wise, J., 2022. Covid-19: drug companies urged to share vaccine technology to boost
November 2022). equity and access. Br. Med. J. 377, o1086. https://doi.org/10.1136/bmj.o1086.
12
World Bank Group, 2022. Poverty and Shared Prosperity 2022: Correcting Course. World World Trade Organization, 2020. Waiver from Certain Provisions of the TRIPS
Bank. Agreement for the Prevention, Containment and Treatment of COVID-19:
World Health Organization, 2020. ACT Accelerator Investment Case. WHO. https Communication from India and South Africa. Council for Trade-Related Aspects of
://www.who.int/publications/m/item/act-a-investment-case. Intellectual Property Rights, Geneva: WTO. IC/C/W/669, 2 October 2020.
World Health Organization, 2021a. WHO Director-General’s opening remarks at 148th World Trade Organization, 2022. Ministerial decision on the TRIPS agreement. WT/MIN
session of the Executive Board [Online]. Available: https://www.who.int/director- (22)/30 WT/L/1141. Retrieved from. https://docs.wto.org/dol2fe/Pages/SS/d
general/speeches/detail/who-director-general-s-opening-remarks-at-148th-session- irectdoc.aspx?filename=q:/WT/MIN22/30.pdf&Open=True. (Accessed 9 November
of-the-executive-board. (Accessed 28 January 2021). 2022).
World Health Organization, 2021b. WHO Director-General’s opening remarks at the Wouters, O.J., Shadlen, K.C., Salcher-Konrad, M., Pollard, A.J., Larson, H.J.,
USAID Development Ministerial on COVID-19 [Online]. Available: https://www. Teerawattananon, Y., Jit, M., 2021. Challenges in ensuring global access to COVID-
who.int/director-general/speeches/detail/who-director-general-s-opening-remarks 19 vaccines: production, affordability, allocation, and deployment. Lancet. https://
-at-the-usaid-development-ministerial-on-covid-19. (Accessed 23 November 2022). doi.org/10.1016/S0140-6736(21)00306-8.
World Health Organization, 2021c. Coronavirus disease (COVID-19): post COVID-19 Wulf Hanson, S., Abbafati, C., Aerts, J.G., Al-Aly, Z., Ashbaugh, C., Ballouz, T., Blyuss, O.,
condition [Online]. Available: https://www.who.int/news-room/questions-and- Bobkova, P., Bonsel, G., Borzakova, S., Buonsenso, D., Butnaru, D., Carter, A.,
answers/item/coronavirus-disease-(covid-19)-post-covid-19-condition. (Accessed 3 Chu, H., De Rose, C., Diab, M.M., Ekbom, E., El Tantawi, M., Fomin, V., Frithiof, R.,
November 2022). Gamirova, A., Glybochko, P.V., Haagsma, J.A., Javanmard, S.H., Hamilton, E.B.,
World Health Organization, 2022a. External evaluation of the access to COVID-19 tools Harris, G., Heijenbrok-Kal, M.H., Helbok, R., Hellemons, M.E., Hillus, D., Huijts, S.
accelerator (ACT-A). Retrieved from. https://www.who. M., Hultström, M., Jassat, W., Kurth, F., Larsson, I.-M., Lipcsey, M., Liu, C., Loflin, C.
int/publications/m/item/external-evaluation-of-th D., Malinovschi, A., Mao, W., Mazankova, L., Mcculloch, D., Menges, D.,
e-access-to-covid-19-tools-accelerator-(act-a). (Accessed 23 October 2022). Mohammadifard, N., Munblit, D., Nekliudov, N.A., Ogbuoji, O., Osmanov, I.M.,
World Health Organization, 2022b. 14.9 million excess deaths associated with the Peñalvo, J.L., Petersen, M.S., Puhan, M.A., Rahman, M., Rass, V., Reinig, N.,
COVID-19 pandemic in 2020 and 2021 [Press release]. Retrieved from. https:// Ribbers, G.M., Ricchiuto, A., Rubertsson, S., Samitova, E., Sarrafzadegan, N.,
www.who.int/news/item/05-05-2022-14.9-million-excess-deaths-were-associated- Shikhaleva, A., Simpson, K.E., Sinatti, D., Soriano, J.B., Spiridonova, E., Steinbeis, F.,
with-the-covid-19-pandemic-in-2020-and-2021. (Accessed 23 November 2022). Svistunov, A.A., Valentini, P., Van De Water, B.J., Van Den Berg-Emons, R.,
World Health Organization, 2022c. COVID-19 pandemic fuels largest continued Wallin, E., Witzenrath, M., Wu, Y., Xu, H., Zoller, T., Adolph, C., Albright, J.,
backslide in vaccinations in three decades. Retrieved from. https://www.who.int/ne Amlag, J.O., Aravkin, A.Y., Bang-Jensen, B.L., Bisignano, C., Castellano, R.,
ws/item/15-07-2022-covid-19-pandemic-fuels-largest-continued-backslide-in- Castro, E., Chakrabarti, S., Collins, J.K., Dai, X., Daoud, F., Dapper, C., Deen, A.,
vaccinations-in-three-decades. (Accessed 21 November 2022). Duncan, B.B., Erickson, M., Ewald, S.B., Ferrari, A.J., Flaxman, A.D., Fullman, N.,
World Health Organization, 2023. Zero draft of the WHO CA+ for the consideration of Gamkrelidze, A., Giles, J.R., Guo, G., Hay, S.I., He, J., Helak, M., et al., 2022.
the intergovernmental negotiating Body at its fourth meeting. A/INB/4/3. Retrieved A Global Systematic Analysis of the Occurrence, Severity, and Recovery Pattern of
from: https://apps.who.int/gb/inb/pdf_files/inb4/A_INB4_3-en.pdf. (Accessed 5 Long COVID in 2020 and 2021. medRxiv. https://doi.org/10.1101/
April 2023). 2022.05.26.22275532, 2022.05.26.22275532.
World Health OrganizatioN. n.d.-a. What is the ACT-Accelerator [Online]. Available: Ye, Y., Zhang, Q., Wei, X., Cao, Z., Yuan, H.-Y., Zeng, D.D., 2022. Equitable access to
https://www.who.int/initiatives/act-accelerator/about. (Accessed 19 October COVID-19 vaccines makes a life-saving difference to all countries. Nat. Human
2022). Behav. 6, 207–216. https://doi.org/10.1038/s41562-022-01289-8.
World Health Organization. N.d.-a. COVID-19 Technology Access Pool [Online]. Yu, P.K., 2022. The COVID-19 TRIPS Waiver and the WTO Ministerial Decision. Texas
Available: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/glo A&M University School of Law Legal Studies Research. Paper No. 22-48. Retrieved
bal-research-on-novel-coronavirus-2019-ncov/covid-19-technology-access-pool. from. https://papers.ssrn.com/sol3/papers.cfm?abstract_id=4150090. (Accessed 9
(Accessed 28 December 2018). November 2022).
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