This interview is part of Pandemic Discourses new series “Politics of Vaccine Equity: Conversations on the Frontline.” Rohit Malpani discusses how since the HIV/AIDS pandemic there has been from a shift from politics to geopolitics, the new role that emerging economies play in the global landscape of COVID-19 vaccine access, and the importance of technology platforms. This article was originally published in Pandemic Discourses.
Fukuda-Parr: You have been working on access to medicines for many years, working with these major campaigning organizations like Oxfam, and now doing very deep policy research. What do you think is the difference between now and twenty years ago, when there was a major mobilization for access to HIV/AIDS, antiretrovirals? How have the politics changed?
Malpani: The first thing that strikes me is, unlike 20 years ago, we are in a period in which it’s not as much about politics as about geopolitics. If the HIV pandemic ran along much more traditional North-South lines, the predicted emergence of multipolarity in global health has arrived with this pandemic. A U.S. based order may never return. And if it does, it probably would be after this pandemic ends. I think it’s fair to say the European Union and the Indian government did not have as much of a major role in setting out the AIDS pandemic response. And for India it really was a few companies and not the government. And then, of course, the rise of China and the animosity over the country’s role is coloring the debates about how to manage the response, despite the fact the country could play a much more important role in providing resources, possibly vaccines, and technical support. And then finally, a positive development has been that there are several leading entities that have emerged out of the African Union over the last decade. So, I think that geopolitics is driving the politics of access to medicines. As a final comparison with the early HIV response, what’s interesting looking forward is whether or not some governments that played a much more prominent role a couple of decades ago may still do so again. Thailand comes to mind, and maybe Brazil, depending on next year’s election.
A couple of other things to note. First, the end goal wasn’t really clear in 2000, right? You didn’t necessarily have ideas about what the right solutions were, but I think there was always this clear sense that they were going to get to that point. Whereas today, every side of this debate sort of says, this is the goal we all want to get to. But there’s no consensus and too many opinions and too much power at play, that prevents you from getting there in the way that probably a lot of health advocates believe is fair, just, and equitable.
What this reflects is that instead of a politics of solidarity, you have a politics of fear. The one thing I’ve heard repeatedly during the conversations I have with governments is: “we agree with you and we want to do more but we’re really worried we’re going to be slapped on the wrist by companies if we even move two inches in this direction.’ So, again, what’s governing the response is less solidarity and more fear.
And then the last point, I would say is, in 2000, we had a politics of solidarity. You had people in the North, either progressive leaders or people with HIV who were leaders in the response, working side by side with people in the South. And that really was the power of the response. Today, I don’t think that exists. Every time I read a perspective from progressives in the U.S. and Europe, I’m just left disappointed. Like Paul Krugman writing about penny pinching by the European Union. A lot of progressive columnists are just so inward looking, and I think that’s especially true in the United States. For example, on inequity issues in their own country, which is important, but with little to say about what’s happening globally. And then you have these so-called progressive leaders, such as Justin Trudeau, that I think are sometimes the worst practitioners of vaccine nationalism. What this reflects is that instead of a politics of solidarity, you have a politics of fear. The one thing I’ve heard repeatedly during the conversations I have with governments is: “we agree with you and we want to do more but we’re really worried we’re going to be slapped on the wrist by companies if we even move two inches in this direction.’ So, again, what’s governing the response is less solidarity and more fear.
Fukuda-Parr: There’s been an awful lot of grandstanding by governments about the people’s vaccine and global public goods and all that but the action has actually been the opposite. How do you think the current moment is different in African countries, especially since there are now many stronger organizations, compared with twenty years ago?
Malpani: The emergence of the Africa CDC, which has played an important supporting role across the African continent, has been valuable. The Africa CDC has been able to act as an interlocutor on behalf of countries across the African Union, although individual governments, especially South Africa, have also weighed in effectively. That has made a significant difference. Because otherwise, civil society groups, governments and foundations, all situated outside the continent, are guilty of saying, “well, this is what we think needs to emerge from this part of the world.”
There has also been an effort by development banks governed mostly by African countries to assist with financing the response. For example, the African Export Impact Bank has played an important role in providing financial resources to purchase commodities. There has also been the African medical supplies platform, which has played a role in working with the African Union to make large scale purchases of vaccines. And finally, though coming maybe a little too late for the pandemic, an umbrella regulatory system on behalf of the African Union is emerging. This is fantastic; that is a form of infrastructure that was not available twenty years ago and that will enable all countries to work cooperatively to manage quality, safety, and efficacy of medical technologies. I think if we were all doing our job better, we would be spending a lot more time investing in that infrastructure so that we do not have to use global health agencies to stand in for such entities.
Fukuda-Parr: Are these agencies getting international support from the UN, the World Bank, etc. Do they get much recognition?
Malpani: I think amongst people that I work with, they are acknowledging and recognizing the role they play. But I am not sure when looking at the ACT Accelerator, as the central organizing hub of the global health response, whether African-led agencies and institutions are being included adequately in its operations and policy debates. I think a lot of those organizations in the Accelerator are still operating on what existed before the pandemic, or how things were run prior to the pandemic, and not just with respect to African institutions, but to the role that all low- and middle-income countries should play in the response.
Fukuda-Parr: You indicate the politics of solidarity is shifting; that’s interesting. Can you elaborate a bit on how the actors have changed in this game?
Malpani: First thing, the actors that always come to my mind are the global health infrastructure that’s been built over the last twenty years. It’s been a massive failure. This is not hard to see, even if people within global health do not like to hear this verdict. We have what appears to be an impressive constellation of global health agencies, but it’s really hard not to look at it and say that these agencies have failed. And even if we want to be clear that not all of the blame sits with these agencies, we should recognize that it can appear that these agencies are mostly running interference on behalf of some governments and drug companies instead of challenging these governments and drug industry practices. The presence of these global health agencies, which did not really exist twenty years ago, allows certain Northern governments and drug companies to point to these agencies and keep saying, “look at all these things we’re doing and the money we’re putting in these agencies”. And that shields some of these countries and drug companies from some of the worst criticisms that they deserve. I think it’s also interesting to see how the drug industry has been able to transform itself from its pariah status of twenty years ago, to putting itself at the center of the response; for example, in the ACT Accelerator, Big Pharma is a partner, even though it really needs to be at arms-length since its goals and objectives are not necessarily aligned with international health needs. As I mentioned, the drug industry has caught on to the politics of fear that permeates the response, and have been able to take full advantage of this fear.
In terms of the actors that’s changed, what I know the most is civil society. You have this interesting breadth of civil society engaged today. And it’s fantastic. Two years ago, access to medicines was a limited and very discrete field. Today, you have incredible breadth of organizations engaging on the response. But I worry a bit about the depth of engagement, especially on some of the technical issues.
In terms of the actors that’s changed, what I know the most is civil society. You have this interesting breadth of civil society engaged today. And it’s fantastic. Two years ago, access to medicines was a limited and very discrete field. Today, you have incredible breadth of organizations engaging on the response. But I worry a bit about the depth of engagement, especially on some of the technical issues. I don’t think technical proficiency can overcome the underlying political barriers. But without technical depth, in the face of the very good push that civil society has made, the response from industry and government is to rely on technical arguments that are not getting answered.
I have two other concerns with the architecture of civil society today. First, even though the movement is quite broad and global, it also feels very segmented. We have islands of civil society groups doing work in different countries and regions but not necessarily communicating with and working with each other. I also think a lot of the groups have been a little too focused on working with the ACT Accelerator and the institutions running it and not spending enough time being critical about the Accelerator.
It is necessary to mention the role of the large foundations as so-called members of civil society, even though many treat them such as agencies or even governments, and their leaders as Heads of State. I’ve tried to be as critical as possible in public and private conversations of the Gates Foundation. They conceptualized the ACT Accelerator at the outset. They wrote the white papers for it. And through the ACT-Accelerator, they made a very deliberate choice to not focus on intellectual property and technology transfer, but instead to focus on advanced purchase commitments and capacity reservations, which I think has been a fatal mistake for which the consequences are being felt now in many countries.
Finally, the last thing I would say is it’s interesting to reflect on the role of Russia and China and how we, in civil society, relate to these governments and their response. A lot of us in civil society have a tendency of focus on the US, Europe, and India. And so the joke in my head is, you know, “is my enemy’s enemy actually my friend?” People in civil society haven’t really decided how to work with companies or with the Chinese and Russian governments, in part because there’s less connectivity with civil society in those countries, to the extent that such civil society has managed to survive the political changes in both countries. But the central role of Chinese and Russian science and companies is an important dynamic that didn’t exist in the past.
Fukuda-Parr: It’s not like twenty years ago when MSF worked with Cipla and Ranbaxy in India. What do you think are some of out-of-box approaches that can work moving forward? What are some of the new politics that can drive some new thinking?
Malpani: Something that has interested me in the U.S. government is the input of the Treasury Department on some of these issues. Making the economic case is something we’ve never really done well with respect to access to medicines. In part, because the economics has often focused on how it affects industry, and not how a lack of access to medicines affects everyone else and the rest of the economy. After the international Chamber of Commerce came out with their estimates of the cost of vaccine nationalism to the global economy, there has been some public posturing by the Treasury Department weighing in on ‘what are the costs of not having a more globalized approach to vaccine access’, and I would imagine this would help influence the U.S. government in the right direction.
Moving outside of the U.S., I think three things are interesting, long term. I was alluding to this earlier, but I want to highlight the emerging economies that are not seen as major economic powers but have always played an important role in global health and access to medicines. This includes counties such as Thailand, South Africa, and Brazil.
Moving outside of the U.S., I think three things are interesting, long term. I was alluding to this earlier, but I want to highlight the emerging economies that are not seen as major economic powers but have always played an important role in global health and access to medicines. This includes counties such as Thailand, South Africa, and Brazil. We are starting to see some of the vaccine projects that were initiated a bit later that include working with these countries researchers, ministries, and companies now coming to fruition. Even prior to the pandemic, organizations like DNDi have championed the middle-income country approach, marshaling scientific resources, to develop and bring new drugs onto the market. I think we do not do a good enough job of intentionally prioritizing and working with those countries and entities to generate public health outcomes.
We are seeing many new drugs, vaccines, and diagnostics, are dependent on certain technology platforms, even though as an access movement we tend to be very product focused. Going forward, we need to be more focused on platforms, and specifically that you can plug in different pathogens into these platforms.
The second is, we need to focus much more on technology platforms. We are seeing many new drugs, vaccines, and diagnostics, are dependent on certain technology platforms, even though as an access movement we tend to be very product focused. Going forward, we need to be more focused on platforms, and specifically that you can plug in different pathogens into these platforms. I actually think that the WHO plan to decentralize mRNA vaccine production, for example, through Centers of Excellence, that train people and transfer know how for manufacturing mRNA vaccines is a really excellent idea.
And third, and I’ve been thinking about this a lot, [is shifting to a global perspective.] I am a Canadian Indian, who lives in France, with family in the U.S., Canada, India, and my wife, who is French, has family in France and other countries. I am one of many, many people, I think historically unprecedented, who’ve migrated over the last twenty years. But that still isn’t reflected in the way we talk about who lives in our societies and how people think about the world around them. Speaking for myself, it is not possible for me to think about the pandemic from a strictly national perspective. And I think many people in the diaspora, like me, would not either. Yet that sentiment about how we see the world does not get translated into how our leaders talk about who to prioritize or what values to promote. At some point, our politics and our political leaders are going to catch up with these nuanced views in our societies. People aren’t tied to just their immediate surroundings, they have intimate connections to many, many places at once.
Rohit Malpani is a public health consultant, advocate, and lawyer, based in Paris, France, and represents non-governmental organizations on the Board of Unitaid. Previously, he was Director of Policy and Analysis at the Medecins Sans Frontieres Access Campaign, a Special Advisor to Oxfam, and a human rights advisor to the World Health Organization.