By Meghan Podolsky, BA, Research Assistant and Patty Synnott, MS, MALD, Senior Manager, CEA Registry & Global Health Initiatives
What is your substance, whereof are you made,
That millions of strange shadows on you tend?
Since everyone hath every one, one shade,
And you, but one, can every shadow lend.
- William Shakespeare, Sonnet 53 in Shake-speare’s Sonnets (1609)
While the thought of immunizations may not fill all of us with the starry-eyed love Shakespeare felt, the population health benefits they confer are arguably more worthy of adoration.
The benefits are difficult to overstate. Globally, vaccines avert 3 million deaths every year, and are estimated to have avoided 500 million cases of illness and 9 million cases of long-term disability in the last 20 years. Their proliferation and integration in coordinated public health initiatives has resulted in the complete eradication of smallpox and the near eradication of polio. Immunization is consistently a highly cost-effective intervention; one systematic review found that 86% of vaccine interventions yielded incremental cost-effectiveness ratios of less than $1,000 per disability-adjusted life year (DALY) averted.
Vaccines are additionally one of the largest drivers of non-health benefits accrued from medicine. As CEVR researchers have detailed, individuals change their behavior in response to the fear of contagion. The impacts of this fear ripple through all sectors of the economy, with the potential for hundreds of billions of dollars in economic losses. Vaccines can alleviate this fear, which in turn may have a positive impact on consumption and bolster the economy.
While vaccines do provide immense public health benefits, they are very costly to develop. They require long clinical trials to detect efficacy and the regulatory requirements to develop and mass-produce them are complex and stringent; just 6% of vaccine candidates make it to market. These phenomena, along with concerns that the need for a vaccine could dissipate over time & erode the return on investment of late-stage development, have driven several large pharmaceutical companies to shy away from vaccine investment.
These potential roadblocks posed no problem for COVID-19 vaccine manufacturers, who were able to benefit from novel funding opportunities - such as the United States’ “Operation Warp Speed” and the European Union’s “Horizon 2020” initiatives, which have spent a combined total of over $19 billion - and guaranteed demand for the vaccines in high-income countries (HICs).
COVID-19 vaccine development succeeded beyond expectations, but the equity of its distribution leaves much to be desired and exposes the contrast between HICs and low- and middle-income countries (LMICs). The majority of COVID-19 vaccines obtained and distributed have been in a handful of economically powerful HICs accounting for just a fifth of the world’s population. COVAX, part of the WHO’s Access to COVID-19 Tools Accelerator, currently only has the capacity to meet 20% of the demand in the 92 eligible countries through advance market commitments. As vaccine supply begins to surpass demand in many HICs, aid to countries that struggle to obtain sufficient vaccine doses is critical; efforts such as the United States’ recent announcements of intent to provide raw vaccine materials to India and donate excess AstraZeneca vaccine supply need to be scaled.
One proposed tool for getting COVID-19 vaccines to LMICs was the exemption of intellectual property rights, which would theoretically enable other manufacturers to produce and distribute them without obtaining licenses from patent holders. Some have argued that vaccine manufacturers already engage in voluntary agreements with generic manufacturers and competitors to scale up production and meet consumer demand, and that the technology required to produce mRNA COVID-19 vaccines requires infrastructure and technological “know-how” that most manufacturers do not have. Regardless, COVID-19 vaccine manufacturers turned down the opportunity to share patent-protected information, with several chief executives citing concerns about removing incentives for future innovation.
One thing is certain; if we do not accelerate vaccine distribution in a more equitable manner, the duration of the pandemic could be prolonged due to the potential proliferation of variants. As Jerome Powell, the chair of the Federal Reserve, stated, "viruses are no respecters of borders, and until the world really is vaccinated, we're all going to be at risk of new mutations and we won't be able to really resume with confidence all around the world.”
As the Bard opined in his sonnet, “…everyone hath every one, one shade,/And you, but one, can every shadow lend”; or, in plain English, you make everyone’s life better just by being around. Vaccines “lend” themselves to all of our shadows, improving our lives, and providing health gains for generations to come. Let us then think critically about how we can continue to incentivize not only their development, but also their equitable distribution around the world.