A Covid-19 jab could cost hundreds of rands. Or not. It's anyone's guess. Could another pandemic almost a century ago hold clues for handling the coronavirus today?
Richer countries have already bought more than 4.2 billion doses of Covid-19 vaccines, before jabs have been shown to work. If you think countries in the Global South aren't playing the game, you'd be wrong, but the odds have never been in their favour.
The town of San Angelo sits where three rivers meet on the Texas prairie in the United States. "A place nature itself set aside as a beacon unto the frontier," a narrator says over footage of a wide, muddy river flanked by wild grassland shrubs. In the video, the local chamber of commerce cheerily describes the city as "a west Texas oasis".
The first cases of the pandemic came in May. Soon, the city banned public gatherings.
"Theatre [signs] went dark in San Angelo Thursday night," a local journalist wrote in the town paper. "There were no youngsters splashing in the municipal pool during the day. No San Angelo churches will meet on Sunday."
A local doctor remarked: "We got to the point no one could comprehend, when people would not even shake hands."
The year was 1949 and the plague was polio, captured in David M Oshinsky's book of the same name. One out of every 124 people in the town would develop symptoms, Oshinsky writes. It was one of the most severe recorded outbreaks at the time. Similar tales played out globally with epidemics that same year in countries such as the United Kingdom and Canada.
"There was no telling who would get it and who would be spared," writes the Pulitzer Prize-winning author. "It killed some of its victims and marked others for life."
Soon, scientists would find themselves racing to invent a vaccine.
Vaccine nationalism, not only for the rich
Today, more than four dozen potential Covid-19 vaccines are in human clinical trials, according to the World Health Organization (WHO). Two are being tested in South Africa. But even before any pharmaceutical companies have proven the effectiveness of these immunisations, rich nations have secured deals with them for future stock.
A recent analysis by essential medicines expert and Oxfam senior policy adviser Mohga Kamal-Yanni found that the US, UK, European Union and Japan have already earmarked what she calls "the lion's share" of vaccines. Some of these vaccines, however, will prove ineffective in clinical trials and never make it to market.
But countries in the Global South haven't stood by helplessly. Indonesia, for instance, struck a pact with drug firm AstraZeneca for 100 million doses. Many more deals are likely ongoing but will not be made public. The Netherlands has declared agreements like these state secrets, Dutch lawyer and activist Ellen 't Hoen recently told the G20 Civil Society Summit.
This kind of vaccine nationalism is nothing new. During the H1N1 flu outbreak in 2009, high-income countries able to produce vaccines refused to export them until domestic need was met, researchers wrote in The Milbank Quarterly journal in 2019.
R350 for a coronavirus jab?
To help level the playing field, public-private vaccine partnership GAVI launched the Covax initiative. Covax aims to pool nations' purchasing power to secure a minimum number of affordable jabs for all participating countries. There's no way to know the eventual price tag of a coronavirus vaccine, but a current working estimate is around R350 each, according to Doctors Without Borders (MSF) senior vaccines policy adviser Kate Elder.
Middle and high-income countries such as South Africa, Namibia and Botswana will pay for stocks procured through Covax. When it launched, the initiative intended to provide impoverished countries with free, donor-funded jabs, but these countries will now pay a subsidised price of up to R67 for a two-dose vaccine.
Richard Mihigo is the programme manager for immunisations and vaccine development at the WHO's Africa office. He says the organisation knows some countries cannot afford even heavily subsidised vaccines and is working with the Africa Centres for Disease Control and Prevention and the African Union to raise the money to help fill this gap. Ultimately, Covax hopes it can guarantee participating countries enough vaccines to immunise 20% of their populations.
The initiative has already penned contracts for hundreds of millions of doses from manufacturers in the Global South, says GAVI managing director Thabani Maphosa. "The upshot of this is a more diverse, more competitive market for vaccines that has been proven to bring down costs dramatically in the long run."
But for decades, the way medicines are developed, priced, patented and made has disadvantaged people in more impoverished countries. It goes beyond the actions of a single drug company and involves a complicated global system of research and development, production and patents.
In May, more than 140 global leaders responded to a call for a "people's vaccine" for Covid-19. The United Nations and other organisations asked that countries and international partners agree to share all knowledge, data and technologies related to the coronavirus with a WHO-led patent pool, which launched just days later. The aim of the pool is to allow countries to license the technology freely.
"The MSF's experience has shown that by holding and enforcing patents on lifesaving vaccines, pharmaceutical corporations maintain overall control of the scale of production, competition, price and supply of their vaccines," the humanitarian organisation wrote in June.
But patents may be only one piece of a complicated puzzle to secure a Covid-19 vaccine for all, and it may not be the world's most immediate problem.
Covax isn't designed to change how the world patents medicine. Instead, it hopes to shape markets. Maphosa says it is not patents but a shortage of supply that is the biggest threat to equitable access to a future vaccine. By 14 October, 82 countries had signed binding contracts to join Covax. Only two African countries, Libya and Mauritius, are among them.
Recently, self-paying countries such as South Africa were expected to make Covax down payments for their vaccines.
Still, the GAVI cannot assure nations how many doses of a vaccine they will get. And making down payments without a guarantee is likely a tough ask for many nations already struggling to fund Covid-19 responses. In June, South Africa's National Treasury rearranged its budget to devote a further R21.5 billion to healthcare amid the Covid-19 pandemic. But it issued a warning, saying "the public finances are dangerously overstretched" and that "a fiscal reckoning looms".
A 'people's vaccine' is born
In western Johannesburg, the sprawling Sizwe Tropical Diseases Hospital rises up from the banks of the city's iconic Jukskei River. Today, the facility serves mainly tuberculosis patients. But almost a century ago, its grounds were home to the national polio research foundation.
In the 1950s, children and an increasing number of adults in their 20s and 30s were still feeling the wrath of polio around the world. Some were doomed to live out their days in the confines of an iron lung. One of these hunkering, full-body, negative-pressure ventilators still stands at the National Institute for Communicable Diseases down the road from the Sizwe hospital.
By 1955, scientist Jonas Salk had emerged the winner in the race to discover the world's first polio vaccine, an endeavour that had been funded mainly by public donations.
The foundation that had bankrolled much of the work and an American university had hoped to patent the new vaccine, Oshinsky writes. He notes that Salk was sceptical and soon after the scientist's discovery was announced, Salk appeared on national television. A show host asked Salk who owned the patent to his new polio vaccine.
"Well, the people, I would say," Salk replied. "There is no patent. Could you patent the sun?"
Without a patent, Salk's vaccine could be produced anywhere in the world by any firm with the means and will. 'T Hoen says: "Indeed [Salk's vaccine] was, and still is, a people's vaccine."
No quick fixes
Covax makes no provision to license future Covid-19 vaccines to new manufacturers to increase supply or reduce the cost. The WHO is hoping companies will voluntarily issue licences for coronavirus drugs, equipment and vaccines, but no pharmaceutical company has yet offered to do so publicly. Meanwhile, many countries cannot produce vaccines locally, says Maphosa.
"It is important that Africa, along with other regions of the Global South, builds its own vaccine manufacturing capacity and ... that leaders from the public and private sector do everything they can to drive forward this goal," he says. "Today, sadly, it is just not realistic to believe that the provision of technological know-how to every country in the world will enable us to produce the amount of doses we need, in the time we need them, to defeat the pandemic."
South Africa launched a private-public partnership to manufacture vaccines in 2003. Almost 20 years later, the institute cannot produce a vaccine from start to finish, says Mihigo, who manages the WHO's immunisation and vaccine development programme in Africa.
"In acknowledgement of the fact that supply constraints, not intellectual property issues, will be the biggest barrier to achieving global coverage of Covid-19 vaccines," Maphosa says, "Covax is instead focusing on raising enough cash to incentivise manufacturers to make enough doses to satisfy global demand."
It's certainly about increasing manufacturing capacity, says Elder. But it is also about reducing intellectual property barriers for any manufacturer that could produce the vaccines. "The two don't have to be mutually exclusive," she says.
But patents alone, 'T Hoen warns, won't solve the dilemma of who gets a vaccine and when: "Breaking the stronghold of intellectual property in the form of patents is only one of the measures that needs to be taken and it will not be enough ... You also need ... access to the knowledge, the data, the material and the technology [to produce them]."
Patents or not, there is ultimately not enough capacity in Africa to produce Covid-19 vaccines and won't be anytime soon, says University of the Witwatersrand professor of vaccinology Shabir Madhi.
"I wish patents were an issue," adds Madhi, who is leading the two Covid-19 vaccine trials in South Africa. "But the reality is that if all the companies [were to] tell South Africa [it had] open access to all the vaccines developed, there simply isn't manufacturing capacity, not only in South Africa but in the whole of sub-Saharan Africa."
Should one of the two coronavirus jabs being tested, the Novavax vaccine, prove to work, South Africa will be prioritised for future jabs - made in India - as part of an agreement between vaccine makers and the Bill & Melinda Gates Foundation, Madhi adds.
Meanwhile, he says, Covax may not be perfect but for many of the world's most impoverished countries, it may be their best option at a timely and "reasonably equitable" access to a future coronavirus vaccine.
From polio to HIV
In October, India and South Africa wrote to the World Trade Organization (WTO) asking it to waive aspects of protection for copyrights, patents, trade secrets and product designs for Covid-19 medicines and vaccines for several years. International trade law already allows for this during times of public health emergencies, but the law remains difficult for countries in the Global South to use.
The waiver proposed by South Africa and India would allow nations to, for instance, manufacture or import a patent-protected invention, such as a vaccine, without fear of economic reprisals from countries keen on protecting pharmaceutical interests, South Africa's Health Justice Initiative head Fatima Hassan told the Mail & Guardian newspaper recently. The proposal has been co-sponsored by Kenya and eSwatini, but the WTO has yet to pass it.
Oshinsky writes that in Salk's last years before his death in 1995, the US scientist turned his attention to trying to discover an HIV vaccine. His view on the profitability of an HIV vaccine that never came to be? "This time, however, there was no talk of giving it to the world as a gift - no illusions about patenting the sun," Oshinsky writes.
That unfortunate plot twist in the story of the man behind "the people's vaccine", whose young leftist leanings -- including advocating for socialised medicine as well as racial equality -- were once the focus of a federal investigation, is not often remembered.