From Covid-19 to Mpox: Africa’s battle for vaccine equity in a divided world

For millions of people across the world, 2020 to 2022 will forever be etched in their memories as a time when life came to a standstill. What started as a mysterious flu in China soon spiralled into a global health crisis that hit all corners of the world, including right here in Kenya.

Borders were sealed, hand sanitisers became essential, and masks turned into daily accessories. What we were witnessing was the full force of a pandemic — something few of us ever expected to experience in our lifetimes.

For Kenyans, the Covid-19 pandemic wasn’t just a health crisis; it was a season that disrupted every aspect of life. Schools closed, jobs were lost, and daily routines were uprooted. Many were isolated from family and friends, while curfews and lockdowns became the new norm.

Many lost loved ones, and the emotional scars left behind will remain for years to come. Even scientists and health professionals around the world, those we often look to for answers, found themselves navigating uncharted territory.

But pandemics, it turns out, are not new. They have shaped human history for millennia.  2800 years. That is how long the word pandemic has been in existence. 

When the term was first coined, it had nothing to do with diseases or global outbreaks. It comes from the Greek word "pandēmos," which means "all the people." But over time, its meaning evolved to represent exactly what we experienced with Covid-19 — a disease spreading across the world, crossing borders, and affecting millions. 

The World Health Organization (WHO) defines a pandemic as an epidemic that occurs worldwide, or over a very wide area, crossing international boundaries and usually affecting a large number of people. It’s not about how severe the disease is, but rather how far and wide it spreads.

On March 11, 2020, WHO Director-General DrTedros Adhanom Ghebreyesus made a declaration that would send shockwaves around the world: Covid-19 was not just an outbreak, but a full-blown pandemic.

“Pandemic is not a word to use lightly or carelessly. It’s a word that if misused, can cause unreasonable fear, or unjustified acceptance that the fight is over, leading to unnecessary suffering and death,” said Dr Ghebreyesus.

“Describing the situation as a pandemic does not change WHO’s assessment of the death rate posed by the virus, it doesn’t change what WHO is doing and it doesn’t change what countries should do,” he added.

He went ahead and said that it was the first time the global health organisation had seen a pandemic caused by the coronavirus.

At the time of that declaration, Kenya, among other 80 countries had not yet recorded any cases of the virus. But that would change the very next day when a 27-year-old Kenyan student returning from abroad became the country’s first confirmed case.

The initial shock quickly gave way to fear — the kind Dr Tedros had cautioned against. Suddenly, there was panic buying, masks became a must, and Nairobi’s busy streets emptied as lockdowns were enforced.

The pandemic was an uncharted path that led to the writing of a new medical history.  As more countries started recording new cases and deaths, scientists worked from one hour to the next until they found vaccines that were in record time proven to be the ultimate missile that would gun down the coronavirus.

While the fight against the virus unified the world in one sense — we were all battling the same invisible enemy — it also exposed deep inequalities. In wealthier countries, vaccines were developed in record time, and within months, citizens began to receive their doses.

But for Kenya and other developing nations, it was a different story. Vaccines were in short supply, and even when available, there were logistical challenges in distribution. For months, Kenyans waited, hoping that the long-promised vaccines would finally arrive.

Kenya received its first batch of vaccines on March 3, 2021,  seven months after vaccines had already rolled out in wealthier nations. Dr Willis Akhwale, chair of Kenya’s Covid-19 Vaccine Task Force, recalls how difficult it was to secure enough doses.

“We mainly had to go by the terms of what was said by the people who were supplying the vaccines,” he says. Countries like Kenya scrambled to meet the strict conditions for vaccine access, while wealthier nations hoarded doses, prioritising their populations first.

The pandemic turned into a pandemonium.

Fast-forward four years, and the world is still reeling from the aftershocks of the Covid-19 pandemic.  But have we learned our lesson? Are we any better prepared for the next pandemic?

One thing is that the lessons that the pandemic taught us did not significantly change how our public health systems operate. In the 148th session of the Executive Board, Dr Tedros aptly put it as a ‘me-first approach’, where those that have it will continue to consider themselves first.

However, a new wave of change joined when Charles Michel, President of the European Council during the Paris Peace Forum on November 12 2020, mooted the idea of a global Pandemic Treaty, currently preferred to be termed a Pandemic Agreement.

“I believe that this pandemic has caused the stark, even painful, revelation of some challenges which existed before the pandemic and which are leading our generation – not just politically and economically, but also in terms of civil society – to ask ourselves the right questions and to try to find the right answers,” said Michel in Paris.

“There is one thing we must never lose sight of. That we ultimately belong to a common humanity. And the conviction – so eloquently expressed in the Charter of the United Nations – that the dignity of every human being, regardless of origin, place of birth or social situation, the dignity and personal freedom of each human being requires us to take action against all forms of discrimination. This must bring us together,” he added.

Consequently, the WHO tasked the Intergovernmental Negotiating Body (INB) to draw up an international instrument on pandemic prevention, preparedness, and response to come up with a treaty.

Nine rounds of negotiations later, an agreement has still not been reached. Now,  the world is already grappling with new outbreaks such as Mpox. Once again, Africa is at the back of the line when it comes to accessing essential vaccines.

Just before the INB met for the final round of negotiations that unfortunately didn’t go as expected, the Lancet –a credible scientific journal- published an editorial analysing the draft text and critiquing the process at the time.

“Much of the language is greatly weakened from the initial ambition, filled with platitudes, caveats, and the term ‘where appropriate’. Even the anaemic commitments of the agreement are in jeopardy” the editorial forewarned.

Aggrey Aluso, Director Africa Region at the Pandemic Action Network explains to Healthy Nation that the Agreement was meant to look at the public health challenges we face globally and propose solutions.

He explains that there are more than 30 key articles in the accord that mainly deal with how countries should coordinate in terms of prevention, response and preparedness and how it is financed and governed.

There are also other articles that talk about the setting up of the treaty, which are not substantive, but more administrative.

“The key articles that have seen a bit of challenge generally are those on prevention, particularly the One Health concept,” he says.

“One Health, which is looking at environmental health, animal health, and how the world should manage the spheres of risks. What is becoming clearer in the current situation is that most of the outbreaks we experience are zoonotic spillovers. This means that they are coming from the animal kingdom spilling over to humanity just like the Mpox,” he explains.

“That was something that should have been easy to do, but it has become very controversial because it has a lot of financial imperatives. Already managing human health has been a challenge to us, so imagine you have to track animal health, like both in the wild and domestic, which is important, and it's still a problem, but it has financial implications,” explains Aggrey. He adds that while nobody opposed that, its operationalisation is contentious.

At the moment, Africa produces less than 1 per cent of the vaccines that it consumes. The Africa CDC points out that our manufacturing capacity mostly relies on form, fill and finish and not end-to-end production.

“The ambition is to provide for incentives in the distribution of capacity so that we can have capacity in regions that are impacted by these health challenges within Africa,” explains Aggrey.

This clause is also prickly because major vaccine manufacturers did not want the provision to be obligatory. It was also not easy to convince members of the INB to buy the idea of Pathogen Access and Benefit Sharing.

“When a disease is discovered somewhere, people are supposed to provide the genomic data for the pharmaceutical industries to be able to start developing both the vaccines and the therapeutics for it,” explains Aggrey.

He explained that in the case of Mpox, the genomic data for the current strain of the virus (Clade 1b) should be provided for by the Democratic Republic of Congo.

Mpox was first discovered in 1958 in Denmark, and so, one of the first vaccines for the disease was manufactured by a Danish Company.

Aggrey explains that the idea is to have countries give back part of the proceeds to WHO so that countries can distribute them to countries that need them.

Other proposals have also been fronted. For instance, anyone who is to use the genomic data from a genomic sequencing data bank has to pay at least 20 per cent of the proceeds to WHO. This, however, has not been agreed to.

Financing remains a big challenge. At the moment, the world financial model is more reactionary and the mobilisation of resources comes in when there is an outbreak. Aggrey explains that there needs to be a sort of finance meant for preparedness before an outbreak and now during an outbreak.

“Right now, we're struggling with basic laboratory capacities, like the genomic sequencing capabilities doing basic surveillance processes to test and identify diseases so that you're able to set things in motion,” he explains.

The proposal now is to have a coordinated way of bringing all agencies that can fund public health emergencies and having less philanthropic contributions which are mostly conditional.

The more negotiators have the push and pull, the diseases keep emerging and who knows when the next pandemic will be?

In the book, Story of Influenza published by the National Academies Press, the authors say that the world is vulnerable to the next pandemic, perhaps even more than in 1918, when the pace and frequency of global travel were considerably less than today.

When Dr Willis Akhwale, a senior advisor at the African Leaders Malaria Alliance (ALMA) was the chairman of the Covid-19 Vaccine Task Force in Kenya, he told Healthy Nation that it wasn’t easy to get vaccines into the country.

“When the benefits of the vaccination were established, the developing countries (like Kenya) did not have the technology, the manufacturing capacity and some even lacked the systems to deliver the vaccines like the cold chain,” he explains.

“We mainly had to go by the terms of what was said by the people who were supplying the vaccines. Countries were scrambling to meet the conditions to get the vaccines in the country, and at the same time there was also hoarding of the vaccines,” he adds.

It was during the pandemic that Dr Akhwale learnt that investment in genomic surveillance is necessary for all countries.

“These pathogens, new and even those that have pandemic protection will always be with us. There could be mutation, old ones that come back, the only way for you to be able to detect that is when you have stronger genomic surveillance,” he explains.

“The capacity to undertake genomic surveillance is key since you can pick things early. The quality of diagnostics is also very key. The method of detection is important and this should be done by local scientists. This then will enable you to know how to tweak a vaccine and address a potential threat,” he explains.

There is no specific country that is stalling the progress of the pandemic treaty. However, a joint letter addressed to  US President Joe Biden written by US senators ahead of the World Health Assembly asked him not to back the treaty, based on the draft text that was released at the time.

“The WHO’s most recent publicly available draft of its new pandemic response treaty is dead on arrival. Instead of addressing the WHO’s well-documented shortcomings, the treaty focuses on mandated resource and technology transfers, shredding intellectual property rights, infringing free speech, and supercharging the WHO,” wrote the US senators backed by Dr Bill Cassidy, US Senator for Louisiana. 

“We strongly urge you not to join any pandemic-related treaty, convention, or agreement being considered at the Seventy-seventh WHA. Should you ignore this advice, we state in the strongest possible terms that we consider any such agreement to be a treaty requiring the concurrence of two-thirds of the Senate under Article II Section 2 of the Constitution,” they added.

Even so, INB Bureau Co-Chair Dr Precious Matsoso, from South Africa, said in May that there was progress made during the last round of negotiations and it is generally not easy to come up with an Agreement.

“This is not a simple exercise. This is the first-ever process to develop a proposed agreement on pandemic prevention, preparedness and response. Getting this done means getting it right, and the INB Bureau is committed to helping finalise a meaningful, lasting agreement,” she added.

We spoke to Dr Matsoso, and she remains hopeful that the Agreement’s files will soon be closed as a special meeting will likely be held before November with consideration for its adoption. If not, she says that the next World Health Assembly which will be held in May 2025, will seal the deal.

She explained that amendments to the International Health Regulations (2005) were adopted in June this year by the World Health Assembly, and these have a bearing on the Pandemic Agreement negotiations, especially the use of terms and certain provisions that need to be coherent, and complementary across the two instruments.
“The question is whether the IHR wording can be the way to resolve the impasse on these issues or not.

There must be effective and systematic ways in which the consistent and unambiguous use of terms is identified and used in each instrument. Since the IHR has been adopted, some of the terms can be borrowed, especially where there are consistencies and alignment,” she said.

Africa has some non-negotiables. Some of these include those that Aluso mentioned as the most contentious issues.

On pathogen access and benefit sharing, for instance, Matsoso says that its implementation will ensure improved access to pandemic-related health products, as well as technologies with measures that establish regionally distributed production.

Africa is also calling for obligatory measures in line with equity-related provisions, as well as pandemic prevention and public health surveillance, preparedness, readiness, resilience, and health and care workforce.

All these should be done through WHO-coordinated mechanisms that are accountable to the Conference of Parties.

What happens when the curtains are closed?

Dr Matsoso explained that behind-the-scenes work entails outlining specific steps and timelines for achieving identified objectives. The Bureau members are tasked to conduct regular follow-up and informal meetings to iron out our difficult issues.

The meetings could either be conducted in regional meetings or with groups of countries to iron out sticky issues. The meetings allow members to assess progress, identify obstacles, and make necessary adjustments to stay on course.

A deal, or no deal? Only time will tell.

[email protected]