June 17, 2020 8.16am EDT

Ana Santos Rutschman, Assistant Professor of Law, Saint Louis University

Hundreds of COVID-19 vaccine candidates are currently being developed. The way emerging vaccines will be distributed to those who need them is not yet clear. The United States has now twice indicated that it would like to secure priority access to doses of COVID-19 vaccine. Other countries, including India and Russia, have taken similar stances. This prioritization of domestic markets has become known as vaccine nationalism.

As a researcher at Saint Louis University’s Center for Health Law Studies, I have been following the COVID-19 vaccine race. Vaccine nationalism is harmful for equitable access to vaccines – and, paradoxically, I’ve concluded it is detrimental even for the U.S. itself.

Vaccine nationalism during COVID-19

Vaccine nationalism occurs when a country manages to secure doses of vaccine for its own citizens or residents before they are made available in other countries. This is done through pre-purchase agreements between a government and a vaccine manufacturer.

In March, the White House met with representatives from CureVac, a German biotech company developing a COVID-19 vaccine. The U.S. government is reported to have inquired about the possibility of securing exclusive rights over the vaccine. This prompted the German government to comment that “Germany is not for sale.” Angela Merkel’s chief of staff promptly stated that a vaccine developed in Germany had to be made available in “Germany and the world.”

On June 15, the German government announced it would be investing 300 million euros (nearly US$340 million) in CureVac for a 23% stake in the company.

In April, the CEO of Sanofi, a French company whose COVID-19 vaccine work has received partial funding from the U.S Biomedical Advanced Research and Development Authority, announced that the U.S. had the “right to the largest pre-order” of vaccine.

Following public outcry and pressure from the French government, Sanofi altered its stance and said that it would not negotiate priority rights with any country.

In India, the privately held Serum Institute is developing one of the leading COVID-19 vaccine candidates. The Serum Institute signaled that, if development of the vaccine succeeds, most of the initial batches of vaccine will be distributed within India.

At the same time, India, alongside the U.S. and Russia, chose not to join the Access to COVID-19 Tools Accelerator, which was launched by the World Health Organization to promote collaboration among countries in the development and distribution of COVID-19 vaccines and treatments.

Vaccine nationalism is not new

Vaccine nationalism is not new. During the early stages of the 2009 H1N1 flu pandemic, some of the wealthiest countries entered into pre-purchase agreements with several pharmaceutical companies working on H1N1 vaccines. At that time, it was estimated that, in the best-case scenario, the maximum number of vaccine doses that could be produced globally was 2 billion. The U.S. alone negotiated and obtained the right to buy 600,000 doses. All the countries that negotiated pre-purchase orders were developed economies.

Only when the 2009 pandemic began to unwind and demand for a vaccine dropped did developed countries offer to donate vaccine doses to poorer economies.

The problems posed by nationalism

The most immediate effect of vaccine nationalism is that it further disadvantages countries with fewer resources and bargaining power. It deprives populations in the Global South from timely access to vital public health goods. Taken to its extreme, it allocates vaccines to moderately at-risk populations in wealthy countries over populations at higher risk in developing economies.

Vaccine nationalism also runs against the fundamental principles of vaccine development and global public health. Most vaccine development projects involve several parties from multiple countries.

With modern vaccines, there are very few instances in which a single country can claim to be the sole developer of a vaccine. And even if that were possible, global public health is borderless. As COVID-19 is illustrating, pathogens can travel the globe. Public health responses to outbreaks, which include the deployment of vaccines, have to acknowledge that reality.

How nationalism can backfire in the US

The U.S. in notorious for its high drug prices. Does the U.S. government deserve to obtain exclusive rights for a vaccine that may be priced too high? Such a price may mean that fewer U.S. citizens and residents – especially those who are uninsured or underinsured – would have access to the vaccine. This phenomenon is a form of what economists call deadweight loss, as populations in need of a welfare-enhancing product are priced out. In public health, deadweight loss costs lives.

This is not a hypothetical scenario. U.S. Secretary of Health and Human Services Alex Azar has told Congress that the government will not intervene to guarantee affordability of COVID-19 vaccines in the U.S.

Secretary Azar has said the U.S. government wants the private sector to invest in vaccine development and manufacturing; if the U.S. sets prices, companies may not make that investment because the vaccines won’t be profitable. This view has been widely criticized. A commentator has called it “bad public health policy,” further pointing out that American taxpayers already fund a substantial amount of vaccine research and development in the U.S. Moreover, as legal scholars have pointed out, there are many regulatory perks and other incentives available exclusively to pharmaceutical companies.

If COVID-19 vaccines are not made available affordably to those who need them, the consequences will likely be disproportionately severe for poorer or otherwise vulnerable and marginalized populations. COVID-19 has already taken a higher toll on black and Latino populations. Without broad access to a vaccine, these populations will likely continue to suffer more than others, leading to unnecessary disease burden, continued economic problems and potential loss of life.

What needs to be done

Nationalism is at odds with global public health principles. Yet, there are no provisions in international laws that prevent pre-purchase agreements like the ones described above. There is nothing inherently wrong with pre-purchase agreements of pharmaceutical products. Vaccines typically do not generate as much in sales as other medical products. If used correctly, pre-purchase agreements can even be an incentive for companies to manufacture vaccines that otherwise would not commercialized. Institutions like Gavi, an international nonprofit based in Geneva, use similar mechanisms to guarantee vaccines for developing countries.

But I see vaccine nationalism as a misuse of these agreements.

Contracts should not trump equitable access to global public health goods. I believe that developed countries should pledge to refrain from reserving vaccines for their populations during public health crises. The WHO’s Access to COVID-19 Tools Accelerator is a starting point for countries to test collaborative approaches during the current pandemic.

But more needs to be done. International institutions – including the WHO – should coordinate negotiations ahead of the next pandemic to produce a framework for equitable access to vaccines during public health crises. Equity entails both affordability of vaccines and access opportunities for populations across the world, irrespective of geography and geopolitics.

Insofar as the U.S. can be considered a leader in the global health arena, I believe it should stop engaging in overly nationalistic behaviors. Failure to do so harms patient populations across the globe. Ultimately, it may harm its own citizens and residents, and perpetuate structural inequalities in our health care system.