Joining COVAX could save American lives

In one of its latest strikes against global solidarity in the midst of the Covid-19 pandemic, the administration of US President Donald Trump has declared that it will not participate in the Covid-19 Vaccine Global Access (COVAX) Facility, a global partnership that aims to support the development of a vaccine and share access to it. Trump apparently prefers, instead, a go-it-alone approach that could undermine Americans' access to an eventual vaccine and disrupt efforts to ensure equity in its global distribution.

This move is one of a string of administration actions that have undermined the now distant-seeming tradition of US global health leadership. The same week as its COVAX announcement, the Trump administration also said that it would withhold $62 million that the United States owes to the World Health Organization (WHO) for its annual dues. The administration plans to redirect the funding to other United Nations health programs. Congress had already appropriated the WHO funding, making Trump's move the latest among his strikes against the rule of law; he has no authority to redirect funds that Congress has already allocated.

The administration's effort to undermine WHO reached a climax in July when the United States began the yearlong process of withdrawing from the organization. By law, the country can't withdraw from WHO without giving a year's notice. And it must continue to meet all of its financial obligations to the organization through the end of WHO's fiscal year, in this case, 2021.

Not only is Trump's behavior illegal, it has also shown that, from the start, he has not grasped that shortsighted national solutions cannot defeat a global pandemic. At the beginning of this pandemic, rather than fully using the Defense Production Act, Trump left it to US states to participate in a global bidding war for personal protective equipment and ventilators, impeding access for low-income countries, which could not pay top dollar. Once research demonstrated that the Gilead drug remdesivir reduced how long some Covid-19 patients spent in the hospital, the administration snatched up nearly all of the next three months' global supply, leaving the rest of the world wanting.

Since then, the administration has virtually invented "vaccine nationalism," making exclusive deals with several vaccine manufacturers to ensure a supply of their vaccines for Americans, the consequences for the rest of the world being of no concern. The administration shares responsibility with Congress for a pitifully small authorization of new funds to respond to Covid-19 globally—about $1.6 billion. (Congress appropriated $5.4 billion in emergency Ebola funding in December 2014, most of which was directed to the international response.)

And now, as the world anxiously awaits a safe and effective vaccine for Covid-19, the administration announced that it will not participate in COVAX. The decision stands to undermine the most consequential area of global cooperation around Covid-19, a crisis otherwise marked by a stunning lack of global solidarity. And by denying Americans the benefits that all countries participating in COVAX will receive, the decision poses a direct health and economic threat to Americans.

The US is shunning COVAX because of its link to the WHO, which the administration wrongheadedly views as being controlled by China. The vast majority of countries, 172, have joined COVAX, which is co-led by WHO, the Coalition for Epidemic Preparedness Innovations (CEPI), and Gavi, the Vaccine Alliance. For participating countries, COVAX aims to make available three safe and effective vaccines, drawn from the nine that CEPI is supporting, along with another nine under consideration. The 92 lower-income country participants would receive enough doses to cover, first, their health workers, then the remaining most vulnerable 20 percent of each country's population, with further distribution based on need and vulnerability. The doses that the other countries, which can afford to self-finance vaccines, receive would vary based on their financial contributions to COVAX.

Although self-financing countries may secure doses for up to 50 percent of their populations, following the principle of global equity, no country will receive more vaccine than will cover 20 percent of their populations until all COVAX participants have received doses to cover their most vulnerable 20 percent. Self-financing countries' participation and upfront payments guarantee a market for all participating vaccine manufacturers and will help fund scaled-up production capacity. All countries will receive vaccines at low, Gavi-negotiated prices. While high-income countries will likely pay more than low-income countries, this is ethically justified: The rich can afford to cross-subsidize the poor.

There are aspects of COVAX that need to be strengthened. The structure of its market commitments has been controversial, with organizations such as Doctors Without Borders voicing concern that the structure will not ensure affordability and equity in access. Greater transparency is needed for COVAX and other WHO-sponsored Covid-19 initiatives. Meanwhile, a call for a true "people's vaccine" and the pooling of technology to ensure open manufacturing has a strong moral—and notable political—backing.

But Trump's decision deals with none of this and is simply bad for the world. A failure to buy into, and politically back, COVAX means fewer funds to encourage and support increased production of a suite of COVAX vaccine candidates to achieve an adequate global supply. Other countries such as China may decide to follow the United States by refusing to join, or even withdrawing from, COVAX (binding commitments are not due until Sept. 18). If that happens, it would reduce the upfront payments which COVAX needs to expand production capacity for the full set of COVAX vaccine candidates.

Already, the United States, Japan, the United Kingdom, the European Union, and Canada have struck their own deals with pharmaceutical companies to secure millions of Covid-19 vaccine doses for their citizens, ignoring clear warnings that vaccine nationalism will impede equitable global distribution. These agreements may result in high-income countries getting effective vaccines first, with poorer countries at the back of the line.

Vaccine nationalism, and a rejection of COVAX, is not only bad for the world, it will also significantly undermine US national security. Slower global vaccine distribution would lead to even deeper economic harm around the world, reducing demand for US goods and services. Moreover, vaccine-preventable outbreaks in other countries would eventually make Americans less secure, risking a resurgence of Covid-19 in the country. Furthermore, countries that see the United States as working against the common good will be less willing to cooperate on issues as diverse as traditional national security concerns and climate change.

And the Trump administration is taking a major gamble with the US population's health, betting that a US-supported vaccine will be first and best. But developers and manufacturers of four of the nine vaccines now in the third phase of clinical trials, along with one manufacturer of a three-company collaboration, are based in China. The United States may well not win the vaccine race, leaving it on the outside looking in.

Yet the harm to Americans will be even more direct than this. Most importantly, even as the Trump administration enters separate agreements with vaccine manufacturers, COVAX has a larger set of vaccine candidates than these separate agreements cover. At the very least, joining COVAX acts as an insurance policy, ensuring access to all of the promising vaccines. If the vaccines that the United States has been betting on through its separate agreements do not prove safe and effective or take a longer time to be approved, Americans may find that they are the ones who are at the back of the line for doses. Clinical trials for one of these vaccine candidates, produced by AstraZeneca and the University of Oxford, was temporarily paused after one participant came down with a "potentially unexplained illness."

It is not too late for the United States to reverse course. Funding is urgently needed. The Gavi COVAX funding mechanism has only about $700 million of the $2 billion it needs this year—and it will need at least another $3.4 billion in 2021. Meanwhile, other higher-income countries must not follow the United States' ill-chosen path and should proceed with their plans to participate in COVAX—and enter into agreements with COVAX if they have not joined.

Trump seems obsessed with being able to announce that a vaccine is ready (or nearly so) before the Nov. 3 election, whether or not Phase 3 placebo-controlled clinical trials have proved one safe and effective. The US Food and Drug Administration (FDA) should stand ready to be an institutional guardrail for science and ethics—unlike in countries such as China or Russia, which do not have strong institutional checks on the executive. Yet, even the FDA is under considerable political pressure. A reckless ploy by the president risks causing untold numbers of avoidable deaths, whether because of the rollout of a subpar vaccine or because the distrust his preelection announcement creates leads people to avoid a high-quality vaccine. At present, only 21 percent of US registered voters would be willing to get a vaccine right away.

An "America First" approach to Covid-19 is working out poorly for the United States indeed. If the White House were instead serious about putting America first, the United States would join COVAX in a cooperative global strategy to help free the world from this pandemic—because that is the best way to free America from this scourge.

Eric A Friedman is the O'Neill Institute's Global Health Justice Scholar and the Project Leader for the Platform for a Framework Convention on Global Health (FCGH).

Lawrence O Gostin is University Professor at Georgetown University and director of the O'Neill Institute for National and Global Health Law and is the Founding O'Neill Chair in Global Health Law.

Matthew M Kavanagh, PhD is assistant professor of global health at Georgetown University and director of the Global Health Policy and Politics Initiative at the O'Neill Institute for National and Global Health Law.

John T Monahan is a senior fellow at the McCourt School of Public Policy and a senior scholar at the O'Neill Institute for National and Global Health Law.

Harold Hongju Koh is a professor of international law at Yale Law School and a founding editor of Just Security. He was legal advisor at the State Department from 2009 to 2013, and assistant secretary of state for democracy, human rights, and labor from 1998 to 2001.

Disclaimer: This article first appeared on foreignpolicy.com, and is published by special syndication arrangement