Hello does anyone want an extremely long thread with thoughts on global covid vaccine manufacturing, brought to you by delaying hoovering the house? (This is a rhetorical question I'm not hoovering)

The biggest barrier to mass global covid vaccine access right now is manufacturing/supply, which links directly to patents. Let's start with the Oxford/AZ vaccine, developed with 97% public/charitable funding and intended as the workhorse for LMICs

There was a decision early on to partner Oxford's vaccine candidate with AZ. Ideological reasons aside, I'd guess this was done to ensure supply. If Oxford simply released the 'recipe', it's possible, over time, generics would have cobbled together a manufacturing chain

But that was a risky calculation. The Oxford vaccine was the forerunner candidate, and intended as the workhorse for LMICs. To ensure mass manufacturing, someone had to act as the puppet master, lining up suppliers, supplies, plants etc into a smooth chain. This takes $$$

Either the UK govt took the role of putting together a manufacturing/supply chain for the Oxford vaccine (it ended up doing some), or a private sector player did. It wouldn't happen organically in the timeframe we needed. For pharma to take on that cost, they needed the IP

AZ has largely (with UK govt support), recruited suppliers, got them to the plants, and scaled up manufacturing. No mean feat with a chain that spans multiple countries and legal jurisdictions. To invest in doing this, they wanted a guarantee of profit. That means the patent

The alternative was a multi-govt-led initiative to put together and scale up a manufacturing chain. That likely required US involvement, and given multilateral relations at the time, nobody trusted US involvement even if it were possible

My strong belief is that pandemic preparedness means filling the lack of State-controlled pharmaceutical manufacturing capacity. We cannot be reliant on the goodwill of for-profit companies. I'd suggest regional manufacturing hubs in LMICs, controlled by WHO-Gavi-GFATM

It's quite possible rich countries will get booster shots in 2022, while poor countries still haven't vaccinated their population at all. That's appalling. So how do we now increase global Covid vaccine supply *and* get it to LMICs?

What are the barriers to increasing global Covid vaccine supply *and* getting it to poor countries. Two big ones - manufacturing and pharma/IP, and sadly, probably human nature

On pharma, they have an incentive to slightly constrain Covid vaccine supply. Enough to fill contracts, but not enough to flood the market. Tight supply keeps prices high and customers on the hook. Scaling up supply means big investments without a real incentive to spend

Govts either set up their own manufacturing (costly, time consuming, ideologically unattractive to some, big governance questions), or they use a carrot/stick approach to make pharma do it

Govts have various levers to push pharma to increase supply:
- patent overrride. If you won’t produce more vaccines, we’ll open up the patent and allow anyone to try. This is the nuclear option and is currently being used to convince pharma to play nice on voluntary measures

-Voluntary options - govt buys the patent and technology transfer from pharma. Expensive ($40bn+ per product) and still doesn’t include actual manufacturing capacity. Govt could then waive the patent itself, or put together a consortium of generics to make it

- voluntary license: a company/govt pays pharma for the recipe and know-how, to make their product in another market. Pharma has issued limited licenses, but only where they can’t/don’t want to supply themselves. We could incentivize pharma to issue more

-Voluntary option: govt puts together and pays for increased manufacturing capacity, for pharma. This is the current Biden approach, paying Merck to retool its factory to produce another company’s vaccine. Quicker, easier, but lots of state subsidy for little control

Picking up this mammoth thread. Second big factor preventing global access to Covid vaccines - lack of solidarity, and rich countries guessing sadly probably correctly, their populations want them to hoover up supply and vaccinate domestic populations first

Rich countries know and are happy to say we won’t end the pandemic at home til we end it everywhere. But when they perceive a zero sum game over vaccine supply, they prioritise domestic populations

Covax, the global vaccine facility, was supposed to be an antidote to vaccine nationalism. It was supposed to be the major vaccine buyer for the world, uniting rich and poor countries in solidarity and using leverage to get good prices for all

Rich countries fundamentally undermined COVAX from the beginning by doing bilateral vaccine deals. COVAX sources most of its vaccines from India, where thanks to philanthropic money, Serum Institute was scaled up to produce the AZ vaccine

The US is now refusing to export raw vaccine ingredients to Indian plants, which are the pharmaceutical engine for most LMICs. India is refusing to export the assembled vaccines because of their own domestic crisis

There’s a big philosophical question about where COVAX goes next. It was intended to be a global vaccine solidarity project in effect. And solidarity ended for both pharma and wealthy countries where profits or domestic borders began

Is vaccine colonialism a term because..... https://twitter.com/v_j_freeman/status/1385173986376654852?s=20

You can't work on global covid vaccine access and not feel profoundly dismayed....gutted? at what South Africa has termed vaccine apartheid. It is. There is no reason Americans or French or Canadians deserve vaccines more than Nigerians, Kenyans or Sudanese. And yet here we are