COVID-19 in Africa: The pain of getting the jab

The COVAX Facility and the African Union are struggling to bring some relief to Africa which has been suffering from vaccine apartheid
Illustration: Ritika Bohra
Illustration: Ritika Bohra

Not heads of state or even popular celebrities have received the kind of reception that vaccine shipments are getting in Africa as it struggles against a resurgence of the novel coronavirus disease (COVID-19) pandemic. As the first tranche of the vaccines against the SARS-CoV-2 virus arrives in select nations, heads of government and senior Cabinet ministers have turned up to receive the precious vials, acknowledging their critical importance to a region that has suffered from COVID-19 nationalism — the tendency of developed countries to retain and corner supplies of therapies, equipment and vaccines for their own citizens while depriving needy populations elsewhere. 

On February 1, 2021, as an Emirates flight landed at Johannesburg’s OR Tambo airport carrying AstraZeneca Plc’s vaccine, the South Africa Broadcasting Corp was on hand to film the momentous event from the time the plane touched down in pouring rain at 3 pm. It was the first lot of vaccines to arrive in the continent and President Cyril Ramaphosa and top officials were present to receive the one million doses that the South African government had bought from the Serum Institute of India (SII), the major licensed manufacturer of the AstraZeneca vaccine. 

For South Africa (SA), burdened with heaviest caseload and fatalities in Africa, the SII consignment was critical to jumpstart vaccination of its most vulnerable people, starting with frontline healthcare workers. It had paid a much higher price for the vaccines than the rate SII had charged rich nations because supplies were tight.

However, Ramaphosa’s relief in wangling the deal was short-lived. The vaccine was found to be ineffective against B.1.351, the dominant variant of the virus ravaging the country and the government decided not to deploy it. Instead, it sold the consignment to the African Union in a controversial move that some public health experts slammed as ill-considered. 

“SA has squandered the opportunity to protect at least half a million of its most vulnerable citizens before the next resurgence, with massive healthcare and economic cost,” they said in a recent article published in the South African Medical Journal. The rollout has been extremely slow since then. According to the data put out by the Johns Hopkins University, less than 270,000 health workers had been vaccinated in SA till April 4, accounting for 0.5 per cent of the population.

These vaccinations were made possible through the one million doses which SA, an upper-middle income country, was able to secure from multinational Johnson & Johnson (J&J). The single-jab vaccine was the latest to hit the market and has been quickly approved by the World Health Organization (WHO) for emergency use, making it just the fourth to get emergency use authorisation.

There is already a scramble for supplies. Overall, the situation is dire, says the People’s Vaccine Alliance, a coalition of global campaigners for justice and equity. One year on from the declaration of the COVID-19 pandemic, developing countries are not only facing critical shortages of oxygen and medical supplies to cope with the fresh surge in COVID-19 cases but many are unable to administer even a single dose of the vaccine against the deadly disease.

“In contrast rich nations have vaccinated their citizens at a rate of one person per second over the last month,” said Oxfam, which is the lead voice for the campaign. 

In December, it had warned that nine of 10 people in poor countries would miss out on COVID-19 vaccine in 2021 because wealthy nations had bought up enough supplies to vaccinate their populations three times over.

The alliance calculated that 67 lowand lower middle-income countries, 42 of them in Africa, risk being left behind since rich nations representing just 14 per cent of the world’s population had bought up 53 per cent of all the most promising vaccines. 

The pay-and-grab attitude of the developed world also provoked a passionate outburst from WHO chief Tedros Adhanom Ghebreyesus. WHO warned that:

The world is on the brink of a catastrophic moral failure — and the price of this failure will be paid with lives and livelihoods in the world’s poorest countries. 

With more than 39 million vaccine doses administered in at least 49 higher-income countries, while around 130 countries had seen no vaccines at all, the promise of equitable access to vaccines has been receding fast. 

Africa has long suffered health apartheid. Recall the HIV / AIDS pandemic of 25 years ago, which underscored the stark inequalities in access to critical medicines — there is still no vaccine for the disease — that allowed millions to die in Africa.

The medicines that were developed went only to the rich and it was only after a decade, thanks primarily to an Indian generics company’s determination to break the monopoly of rapacious drug multinationals, that people in Africa and elsewhere could access the life-saving medicines.

There is the more recent history of the 2009 swine flu pandemic, albeit of a less serious nature. Then, too, rich countries had cornered the vaccines through advance orders, while poor nations were forced to wait. By the time they got access to supplies, the pandemic was over.

Some would argue that vaccine equity can no longer brushed aside since a pandemic of this nature has made it clear that no one is safe until everyone is safe. Vaccine nationalism, as the crusading WHO DG has been emphasising at every opportunity, harms everyone and protects no one. 

There is also one significant innovation: The COVAX Facility set up last year. Steered by GAVI, the vaccine alliance, and who along with Coalition for Epidemic Preparedness Innovations, a charity based in Norway, and UNICEF, it promotes itself as “a global risk-sharing mechanism for pooled procurement and equitable distribution of COVID-19 vaccines”.

COVAX buys vaccines through an advance market commitment mechanism and distributes them on two levels: One for fully self-financing countries and the second for donor-dependent countries. 

The COVAX Facility has its limitations and is struggling to secure supplies against the aggressive purchases made by countries like the United Kingdom, Canada, Australia and the United States, which have enough doses to cover as much as 453 to 182 per cent of their populations. 

As the first ever COVAX shipment arrived in Ghana towards the end of February and spread to 14 other African countries in subsequent weeks, the COVAX Facility was providing a lifeline to Africa and to the hope that the continent would be able to turn the tide against the new wave of the pandemic. That is, until SII threw a whammy. It informed COVAX that its scheduled supplies for March and April would be on hold till the Indian government permitted it.

The export hold-up — India itself is in throes of an alarming new outbreak of COVID-19 — will throw out of kilter the vaccination schedules of dozens of countries. SII was to supply 40 million doses in March and up to 50 million doses in April and if the delay is extended, the consequences would be “catastrophic”, John Nkengasong, director of the Africa Centres for Disease Control and Prevention said bluntly at a press briefing in Addis Ababa. 

With SII accounting for as much as 86 per cent of COVAX procurement, it underlines the fragility of the mechanism. It is likely that the African Union’s carefully worked out strategy to vaccinate 30-35 per cent of the continent’s population by the end of 2021 will go for a toss even if it has managed to secure 220 million doses of the J&J vaccine beginning in the third quarter of this year.

It is hopeful of tying up another 180 million doses from the company, but already other countries are circling the company in search of additional supplies. j&j’s vaccine is just one of four approved by WHO for emergency use, the others being the AstraZeneca vaccine manufactured by SII and South Korea’s SK Bioscience. The first to get the nod was the Pfizer-BioNTech vaccine which comes with onerous storage requirements and is not suitable for Africa and other poor countries. 

Rich countries are likely to deepen the vaccine divide in coming days since some of them, like the UK, are planning to give booster shots to health workers and to people over 70 to provide additional immunity against variants of SARS-CoV-2. Others, meanwhile, are proposing to vaccinate children, all of which will leave very few doses to be mopped up by COVAX. 

African governments have three options to access COVID-19 vaccines: the COVAX Facility, the African Union’s vaccine pool or to secure them through bilateral agreements with either countries or companies. The last is clearly a difficult exercise.

The competition for limited supplies is cut-throat since developed nations are aiming to vaccinate 70 per cent of their adult population by the middle of this year to achieve herd immunity. Such a prospect is unlikely African countries for quite a while. As COVAX made it clear when the 600,000 vaccine doses landed in Accra, its aim of vaccinating 20 per cent of its members by the end of 2021 would be jeopardised unless governments refrain from additional bilateral deals that take further supplies out of the market. 

For Africa, there are unique problems to contend with. One is the underestimation of COVID cases which has fed into the convenient narrative that African countries do not need vaccines as urgently as other nations. 

In fact, the continent’s much lower cases and mortality rates have worked against it. As such, theories that Africa’s younger popula-tion is better placed to fight the disease have been picked up by Western nations and their media. For instance, in a recent piece lauding COVAX, The Economist used this argument to defend vaccine hoarding.

“It is true that rich countries have vaccines in far greater supply than poor ones. But it is also true that rich and middle-income countries, with their older and fatter populations, have been much harder hit by COVID-19,” it said. 

The task ahead is daunting. According to one estimate, to achieve herd immunity Africa will need about 1.5 billion vaccine doses which will add up to an eye-popping $8-16 billion apart from the costs of adminis-tering the vaccines. So where does it get this kind of funding? Is manufacturing of vaccines in the region an option? 

The ground reality is not encouraging. Just five countries, Egypt, Morocco, Senegal, South Africa and Tunisia have vaccine manufacturing companies, most of them engaged primarily in pack-aging and labelling, while some do filling and finishing.

Setting up pharmaceutical manufacturing is expensive and impractical for most of the region’s poor countries. Even if some countries come together to set up manufacturing hubs they will have to deal with another challenge.

Most African countries are supplied vaccines by UNICEF; just a handful of countries are equipped to manage their own procurement. This has shaped the vaccine markets in Africa in such way that commercial enterprises would find it difficult to become sustainable without government support through adva-nce purchases. 

All the same, the Africa Centres for Disease Control and Prevention is pursuing a strategy to step up R&D in developing vaccines. It might appear to be a pipe dream to sceptical outsiders, but already there is some promising news.

The African Vaccine Acquisition Trust, which is negotiating with the J&J for supplies of 400 million COVID-19 vaccine doses, says SA’s Aspen Pharmacare, the largest producer of generic medicines in the continent, will be producing 300 million doses. Of this, 10 per cent will be used domestically and the rest will be distributed across the continent. 

There is something even more promising. Nigerian researchers had reported in June last year that they had come up with a vaccine for COVID-19. The team had been working on the genome of the SARS-CoV-2 virus prevalent in Africa. Nothing was heard of the breakthrough till the first week of April when the head of the presidential task force on COVID-19 announced that clinical trials had begun on two vaccines. 

Medical history may be in the making in Africa. Perhaps getting the jab to Africans may no longer be as painful as it is now.

This was first published in Down To Earth’s print edition (dated 16-30 April, 2021)

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