Janeen Madan Keller introduces this blog, which forms part of CGD’s work on vaccine manufacturing.
In this blog, William Savedoff argues that in a world where geopolitical “heavyweights” dominate vaccine production, middle and smaller powers must collaborate to overcome the complex economic, political, and institutional challenges that hinder timely and equitable access to vaccines. The blog draws on two related CGD publications by Savedoff: one on the economic and political shifts shaping vaccine production, and another arguing for regional agreements to expand vaccine manufacturing in Latin America and Africa—set against today’s increasingly complex geopolitical landscape.
“International relations” seems like an oxymoron these days, with diplomacy faint and bombs exploding. Countries that once relied on alliances and negotiation only a decade ago are disregarding the benefits of international cooperation and destroying the institutions that brought widespread benefits to society. The implications extend to health, where progress against infectious disease through global health initiatives is at risk. Furthermore, with vaccine production concentrated in a few large countries, strong regional or international collaboration is the only way to ensure that life-saving vaccines are available to everyone.
Cooperation after WWII was unique in human history
The post-WWII era was astonishing, both for its aspirations and for the resources poured into creating a new international order. “Globalizing Vaccines” argues that unique factors combined after WWII to bring about global cooperation on vaccines. Though certainly imperfect, it was remarkably successful. The eradication of smallpox and the massive expansion of childhood vaccines are just two achievements of that international order. In both cases, powerful and wealthy countries played a key role by providing political leadership and, often, the funding to make it happen.
Solidarity was sacrificed in times of scarcity
The fissures in this international order began decades ago, but the COVID crisis laid them bare. The COVAX initiative which sought to assure an equitable global distribution of vaccines, tempered its goals to fit within the limited funding it expected. This meant seeking enough vaccines for 92 of the world’s poorer and smaller countries to cover one-fifth of each one’s population.
Other countries could join COVAX if they agreed to pay for their vaccines. In return, they benefitted from COVAX’s advance market commitment strategy and greater negotiating power through pooled procurement. Most wealthy countries joined the COVAX agreement, but they also scrambled in parallel to ensure supplies, directly negotiating with vaccine producers. This “me first” approach monopolized supplies and undermined COVAX. This was not just a breakdown in north-south commitments. India halted exports of COVID-19 vaccines for a time, and middle-income countries like South Africa and Indonesia also cut bilateral deals, demonstrating a failure of south-south solidarity as well.
Increasing clout through collaboration
As discussed in my paper on the geographical diversification of vaccine production, vaccine production today requires a large market, critical supplies, skilled professionals, and effective regulatory institutions. Only a few countries—the United States, China, and India—come close to meeting these criteria. And this is why they are among the world’s leading vaccine producers. Smaller countries that are active in vaccine production, such as Cuba, the Netherlands, and Switzerland, generally started manufacturing when the demands for scale and technical sophistication were not as great as today. They also rely on exports or international manufacturing agreements to achieve adequate scale for efficient production.
The most obvious lesson of the post-WWII era is for smaller countries to cooperate. Collaborations create larger markets and draw on larger pools of skilled professionals than any one country can do by itself. Brazil has a market of 200 million people, but a Latin American bloc would give it a market of 680 million (about twice the size of the United States). African countries, too, could have a substantial market of 1.5 billion people if they negotiated a common vaccine strategy. Such negotiations are underway in both regions but are falling short on funding and action.
Why does cooperation ever happen?
The last two centuries have demonstrated that mutual interests are not enough to motivate international collaboration. Rather, successful collaborations tend to involve large countries leading the way through persuasion (or coercion) to create agreements that are mutually binding. In the process, large countries sacrifice some of their discretion and interests to gain even more from obtaining cooperation from others. This was as true for military security after WWII as it was for eradicating smallpox and drastically curtailing polio and measles.
Today, the US is ignoring the benefits of international health collaboration and retreating from its leadership role. Other powerful countries, like Russia and China, are not going to fill the void on global vaccine security. Yet “middle powers” could still build the coalitions that maintain and propel progress. As Mark Carney argued at Davos earlier this year, “The powerful have their power. But we have something too—the capacity to stop pretending, to name reality, to build our strength at home and to act together.”
If middle powers “act together,” they can benefit from promoting agreements on vaccine production. Such initiatives would have political value for leaders by providing a low-cost way to demonstrate their independence and resolve, along with an opportunity to weaken advantages enjoyed by large countries. In practical terms, it can give these middle powers access to more vaccines, larger export markets, and lower costs of production due to economies of scale.
Nevertheless, the headwinds for collaboration are very strong. Budget constraints make it difficult to fund long-term investments like vaccine production, especially if some of that investment occurs in other countries. And the specter of turning inward and reserving vaccines for domestic use in times of scarcity will always be present. One way to minimize that problem is to locate production in small countries whose output far exceeds their own needs. Binding treaties will only be as good as the commitment of the “middle powers” at the center of such agreements to enforce and abide by them.
Regional initiatives are currently underway in Latin America and Africa, but they will require much greater willingness on the part of wealthier and larger “middle powers” to take strong positions in enlisting collaboration. Whether this means leadership from Brazil, Canada, Indonesia, South Africa, or Egypt, only by banding together can middle and small countries have a chance of building the infrastructure, skilled workforces, effective regulatory frameworks, and demand needed to sustain vaccine production.
