Listen: A Forever Pandemic

Vaccine shortages frustrate countries around the world. The lines for vaccines are illogical. But residents of wealthy nations will likely get access to doses in the coming months. It may be much longer for the rest of the world—and, as epidemiologist Gregg Gonsalves explains on the podcast Social Distance, that affects us all and should prompt dramatic action.

Listen to his conversation with co-hosts James Hamblin and Maeve Higgins here:

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What follows is a transcript of the episode, edited and condensed for clarity:

Maeve Higgins: A listener named Chris left a voicemail:

“I have a question about vaccine manufacturing. I was wondering if they could do what we do for generic drugs. Could Pfizer, Moderna, or Johnson & Johnson give their formula—just make it public—and allow other countries or other vaccine makers to just copy their process and increase the supply? I know obviously there are business reasons. They want to make money. But I think it would make sense for maybe the Gates Foundation or a country to just pay them, and say: We’re just going to make this available to everybody to manufacture, so the whole world can have vaccines as quickly as possible.”

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Higgins: What do you think? There’s a vaccine shortage. That seems like a cool solution.

James Hamblin: That does sound like a cool idea. It’s more complicated than that might seem, but I’m also not sure it needs to be more complicated.

Higgins: I saw your tweet about how the shortage doesn’t need to exist.

Hamblin: Yeah, I want to address that specifically, because it became a source of much discussion. I didn’t word it exactly as I would have if I could go back, for the exact same reason: It’s more complicated than that. I think I implied—or at least I know the way people reacted to it, they thought I was saying—that they could snap their fingers and this would happen, and it would be swift and easy. And I didn’t mean that.

It’s like when you say something like: We have enough money in the world for everyone to have food and shelter. We have the wealth and capacity to do that. And then you get a bunch of people that say: Well, but there are all these laws where extremely wealthy people don’t have to pay [much in] taxes, so we actually don’t.

And both are right. I didn’t mean that this is going to be easy and happen tomorrow. But I do think it’s the solution that’s starting to happen and should have happened already. In any case, I’d like to talk to an expert on this, so we’re going to call Gregg Gonsalves. He’s an epidemiology professor at Yale School of Public Health (where, full disclosure: I’m also a lecturer). He was also on the show in May to talk about his career as an AIDS activist. I couldn’t think of anyone better to talk to about this than Gregg, so let’s give him a call.

~ Gregg Gonsalves joins. ~

Hamblin: Hi, Gregg. We got a listener question asking if we could just have governments produce generic versions of the vaccines. What do you think?

Gregg Gonsalves: As you know, vaccines are complex biological molecules. In the case of the mRNA vaccines, [they’re] nucleic acid wrapped in these lipid nanoparticles. Most therapies we put in our bodies in pill form are simple molecules. They’re easy to produce. You have the recipe. You can make the recipe in another factory.

The problem with vaccines is: They are complex amalgamations of different kinds of chemical entities. You can’t just follow a recipe. If I started a company and I wanted to make Moderna’s mRNA vaccine, I probably wouldn’t know exactly how to construct that vaccine in the same way, and I’d have to do new clinical trials. It’s not a simple question of making a generic vaccine.

That being said, many people, including my colleagues who had an op-ed a few weeks ago, [have called] for a President’s Emergency Plan for Vaccine Access and Relief. They made a case that we should have public production of vaccines. A company like Moderna or Pfizer would be asked by the government, in no uncertain terms: Help us build a government factory to make your vaccine, or help us retrofit another factory to do so.

Lonza is making Moderna’s vaccine as a contracted manufacturing plant, so it’s not impossible to do. It requires the ability to exactly reproduce what Moderna does for its vaccine in a set of other plants. Public production would not just be to expand access in the United States and deal with these vaccine limitations, but to do it for the rest of the world.

Hamblin: A smaller pharmaceutical company is doing contract work with Moderna. I know other smaller companies are doing the same. How is it possible that they’re able to produce these vaccines, but companies that aren’t under contract from Moderna aren’t?

Gonsalves: At some point in the development process of Moderna’s vaccine, they said: We’re going to need to scale up. So they went to Lonza and [showed them] exactly what to do: the kinds of machinery, the kind of vats, the kind of lipid-particle processing, RNA-synthesizing machines, et cetera. They gave them very explicit, line-by-line instructions on how to do it. The reason that you and I couldn’t, as theoretical pharmaceutical company owners, just do it on our own is because we don’t know those details.

If they did an actual formal tech-transfer agreement with a company, that would be fine. That’s what we’re talking about in public production. The government could say that it’s not that expensive in the long run to build up mRNA vaccine capacity. We’re not going to do it today, but in six months to a year—just as Moderna had to do over the course of 2020—we can build up capacity to do this. Moderna took billions of dollars from us. We can say: You’re going to do this. You’re going to help our new contractors around the country and in Canada and Mexico set up production facilities so we can pump out more of your mRNA vaccines.

Hamblin: Right.

Gonsalves: It’s totally possible.

Higgins: The stakes are so high. There’s such a shortage in the U.S. and worldwide in the global South. Why is there a reluctance to hurry that along?

Gonsalves: Cash is king. I don’t want to be crude, but Moderna is pretty clear that you pay to play. We bought up a whole bunch of the vaccine supply in the global North because we were where you were going to get the best bang for your R&D buck.

Since the early AIDS epidemic and the early 2000s, when we had these discussions about generic medicines, many foundations—like the Gates Foundation and others—said: If you’re going to develop vaccines, drugs, and diagnostics for the globe, you need to have some sort of global-access policy.

Many foundation agreements said that if you take our money, you have to agree to affordable pricing and access to the rest of the world—largely for drugs, but [the Coalition for Epidemic Preparedness Innovations] also initially did this for vaccine development. And in 2019, they reneged on it. Right before the pandemic, they took this affordable-pricing global-access clause out of their licensing agreement, leading Doctors Without Borders to go after them in no uncertain terms and say they were rolling the clock backward right before COVID-19 hit.

The point is: Corporations don’t want to give away things for free. In the case of Moderna, taxpayers in the U.S. invested billions in the development of that immunogen. We’re not asking for something for free. We already paid for it.

Countries are paying to ensure their own domestic needs. What we need to do—and what we’ve said across the past 20 years—is: Make your buck back in the global North, but you need to make it free and accessible across the rest of the world. Nobody’s planned for global distribution and scale-up. COVAX says maybe we’re going to hit around 20 percent of coverage in 92 low-income countries by the end of this year. Others are going to have to wait until 2022 or 2023 to get access.

Higgins: So, one in five people in 92 low-income countries...

Gonsalves: Yeah. And when you include all the low-income countries, around three percent of the world’s poor will get access to these vaccines. It’s grotesque. From an ethical perspective, it’s criminal. But if we’re talking about all these new variants, it’s also really dumb.

If you’re interested in pushing a virus to evolve to evade your vaccines, the best way to do it is low-level pressure from incomplete, partial vaccination of your population over a long period of time. We know that some of the variants have already had expanded transmissibility. Think of three years of low-level vaccination around the world—and the plethora of variants that’s going to come spewing out across the globe, potentially being resistant to the current Moderna vaccine, the current Pfizer vaccine, the current Johnson & Johnson vaccine...

We’re going to be chasing variants around the globe for the foreseeable future and basically have made a death pact for endemic spread of this virus. It’s never going to go away. We’re now on a path where we’re going to have these cycles of coronavirus outbreaks as there are gaps in vaccination across the U.S. and across the world, and as new variants emerge that might be less susceptible to vaccines that we put out into the field.

Hamblin: So the half-measures can ultimately be dangerous for the world. Even if wealthy countries didn’t have a sense of morality or obligation to basic equity issues, it’s just not in their own interests. It’s dangerous to their own citizens to not think about this problem.

Gonsalves: Yeah. And we said this in the context of the AIDS epidemic. Unless you deal with HIV, it’s always going to be haunting the planet. And people were like: You know what? We have antiretroviral therapy in the U.S. We can manage the disease. Sorry.

Now we have a disease where it really doesn’t care where you live. It doesn’t need sex or drugs to transmit itself: just close contact without the requisite preventive measures. The self-preservation instinct right now should be really strong with us about getting global vaccination coverage quickly and broadly across the globe. But I don’t think people are thinking straight. I think they’re looking inward at their national situations. They really don’t understand that we’re all at risk until none of us are basically at risk.

And who knows what happens as viral variants emerge and people start to scramble to develop vaccines targeting the new variants and forget about the needs of other countries once again?

Hamblin: Right. We could be like: Sorry, we need our second round of updates before you even get one.

Gonsalves: Yeah. Sorry, we screwed it up the first time. And then they’re going to screw it up again … Everybody wants to go back to normal. [But we’re going to have] waves of coronavirus infections across the planet that we’ll have to tackle with new vaccines every few years when a variant emerges. So, we’re just going to be living in a new normal.

And it could reshape our lives very much like the big catastrophic moments in modern history have to generations before us. We weren’t prepared for it. We’re not rising to the challenge in a way that’s going to make quite a bit of difference. And this isn’t going to be our last time at the rodeo. Pandemics will come at us. AIDS, Ebola, H1N1, swine flu, this now. What’s going to be next?

We had a chance to scale up worldwide vaccine production and readiness. If you can’t do it in the midst of a global pandemic, when does it ever get real for anybody? That’s the thing that scares me the most. As a species, we are playing with fire.

Hamblin: It sounds like we’re in a moment right now where we could either accept this new normal where, indefinitely and globally, large numbers of people are sick and dying from SARS-CoV-2 and from future variants. Or we could aggressively try to stamp this out by ramping up vaccination in creative ways, like making these a public good.

We started talking about a tweet that I had that was not well-worded and got a lot of criticism for the idea that a lot of places around the world could produce these vaccines if we were to think out of the box. I got a lot of pushback—that it’s not possible and only Pfizer and Moderna can basically make these vaccines.

Gonsalves: Could we make double the amount of Moderna vaccine with another contractor tomorrow? No. But it took a year for the company to scale up their production capability. And we know that’s true, because there was no SARS-CoV-2 vaccine development in our imagination [not long ago].

If there was political will, the U.S. and other rich countries could underwrite a global production plan for mRNA vaccines. We could make a plan, figure out who’s going to pay for it, and then tell Moderna, Pfizer, and Johnson & Johnson: We’re going to do this as a global community.

If NIH wants to exercise its patent rights and tell Moderna to use it or lose it, we can do that too. They’re going to have to provide tech transfers. We can remunerate them for whatever they want. We get that up and running so that, in six months to a year, there’s more capacity to get these highly effective vaccines out there.

It’s totally possible to do. People are saying we can’t flip a switch and change everything. And Derek Lowe, who writes for Science magazine, said this in a column. We can’t do this right away. The point is: We can do it; we just can’t do it tomorrow.

Hamblin: Yes. I didn’t mean to imply we could do it tomorrow. I realize it kind of read that way, but just because we can’t do it tomorrow doesn’t mean it’s not doable.

Gonsalves: They wanted to shut you up. They wanted to tell you it isn’t possible, and that it’s not like a generic drug. No, we can’t do it. We can’t do the capacity. There’s a lot of people throwing up obstacles—when I just think it’s about making a large global business plan about how we’re going to do this.

Higgins: Are you saying this vaccine-manufacturing step is about the pandemic either becoming permanent or not becoming permanent?

Gonsalves: Well, being permanent and not being permanent—or being worse or worst-est. If we accept the status quo, it’s going to be gruesome for the planet. Horrifying. Both from an epidemiological and a humanitarian perspective. President Biden is a far better steward of our pandemic future [than was President Trump]. But I don’t think he’s thinking globally right now. I don’t think any of the European leaders are thinking this way.

This is a much larger global health lift than anything we’ve done before. It’s not impossible. But people have to say vaccine coverage—as broadly and as quickly as possible—is an international goal. It’s not based on charity. Maybe slightly, a little bit. But mostly it’s self-preservation. Because we’re going to be asked to do this again with another pandemic.

At some point, we’re gonna have to make a collective decision to act together for our collective self-interest. But right now, it’s every man and woman for himself; every pharmaceutical company for themselves. We’re not on the right path yet. Things are looking up in the United States in terms of the national leadership, but the global situation is pretty catastrophic.