A safe, effective and accessible vaccine would be a major turning point in the pandemic but we can’t just wait, we need a zero-Covid strategy now

Reposted from Springmag.ca

After more than 50 million infections and a million deaths worldwide from COVID-19, there are now vaccines on the horizon. Both Pfizer and Moderna have released preliminary results that their vaccines are at least 90% effective. This potential of ending the pandemic has caused a collective sigh of relief, but also sparked a range of debates—from the conspiratorial anti-vaxx movement that dismisses vaccines, to a broader sentiment of vaccine hesitancy, to the hope that pharmaceutical companies will deliver a panacea.

A people’s history of vaccination

Anti-vaxxers often claim that vaccines are unnatural products, peddled by the medical establishment, which are both unnecessary to prevent disease and cause greater harm. On the other hand many dismiss vaccine hesitancy as ignorank folklore that doesn’t recognize the supremacy of Western medicine. But the history of vaccines helps to inoculate against these myths.

The English physician Edward Jenner has been called the “father of immunology” for pioneering vaccination in the late 18^th century. But inoculating fluid containing infectious material in order to prevent disease was widely practiced throughout Asia and Africa for centuries before its “discovery” in the West. The first written description of inoculation in the US, more than 80 years before Jenner’s famous publication, was learned from African slaves.

Cotton Mather, the puritan minister notorious for his role in the Salem witch trials, learned about inoculation from his slave Onesimus, whose labour and medical knowledge he expropriated. As Matter wrote in 1716, when he asked Onesimus if he ever had smallpox “he answered, both yes and no; and then told me that he had undergone an operation, which had given him something of the smallpox and would forever preserve him from it…whoever had the courage to use it was forever free of the fear of contagion. He described the operation to me, and showed me in his arm the scar which it had left upon him.”

When another smallpox epidemic struck Boston in 1721, Mather “instructed our Physicians in the new Method used by the Africans and Asiaticks, to prevent and abate the Dangers of the Small-Pox, and infallibly to save the Lives of those that have it wisely managed upon them.” In the same year, Mary Montagu introduced inoculation to Britain after learning about it from Turkish women. As she described, “The small-pox, so fatal, and so general amongst us, is here entirely harmless. . . . There is a set of old women, who make it their business to perform the operation, every autumn.”

But there was widespread opposition: religious opposition to interfering with divine will, health concerns of exposing people to a contagious disease, medical elitism that dismissed other healers, and racist and sexist opposition to learning from people other than white men. Ironically, physicians were initially on the side of the first wave of anti-vaxxers: US physician William Douglass claimed concerns about smallpox were overblown and threatened trade, and warned that inoculation itself was the greater danger. He also criticized Mather for following the medical advice of Africans. In England, the physician William Waggstaffe called inoculation as “an experiment practiced only by a few ignorant women, amongst an illiterate and unthinking people” while also claiming it was a dangerous conspiracy, “an artful way of depopulating the country.” But other physicians supported it, and the debate produced one of the first documented studies in inoculation: half of Boston was infected “naturally” with smallpox and 15% of them died, but this dropped to 2% for those who had been inoculated—winning over the medical profession.

Traditional inoculation still carried risks, not because it was “unnatural” but because it was too natural: inoculation with smallpox could induce the full-blown disease, and transmit other infections through lack of sterile procedures. Vaccination solved the first problem, by using a much less harmful substance in order to trigger the same immune response without the risk of transmitting the actual infection. As Jenner described in 1798, “the Cow Pox protects the human constitution from the infection of the Small Pox.” This was not the brilliant discovery of a physician but the knowledge learned from milkmaids. As medical historian Jacalyn Duffin explained, “folk wisdom about cowpox (vaccinia) was the inspiration for the discovery of the physician and naturalist Edward Jenner. As a student he had learned that milkmaids who had contracted the mild pustular eruption from infected cows considered themselves immune to smallpox. Common knowledge for milkmaids was news to the young doctor.” Jenner translated this common knowledge about passive immunity from prior exposures into active prevention, inoculating with vaccinia (vaccination) to prevent smallpox. Vaccination’s greatest triumph, the eradication of smallpox, originated not with physicians or pharmaceutical companies but slaves, milkmaids, and women healers.

Public health or public control?

Some of the legitimate hesitancy about vaccines comes from the uneven way they have been applied by state’s that prioritize public control over public health. Whereas George Washington ordered in 1777 that the entire Continental Army be inoculated against smallpox during the American Revolution against the British, the US state denied inoculation to Indigenous nations to allow smallpox epidemics to rage—and then only offered vaccination in the 1830s as a means to accelerate land removal. The US also used mandatory vaccination as part of the border control of immigrants and the colonial control of Puerto Rico.

Meanwhile the British government, which narrowed public health to sanitation rather than improving working and living conditions, imposed compulsory vaccination in the 1850s. By now physicians supported vaccinations on medical grounds, so the second wave of anti-vaxxers included alternative healers who objected to “unnatural” remedies, ongoing religious opposition interfering with God’s will, middle class libertarians who saw public health as interfering with personal freedom, and working class communities who were disproportionately targeted by repressive laws.

In Canada the fur trade depended on Indigenous labour, so the Hudson’s Bay Company launched the first vaccination campaign. But colonial warfare, starvation and loss of land undermined vaccine effectiveness and fueled high rates of infection. Meanwhile the national oppression of Quebec sparked a backlash, as Duffin describes: “The 1885 epidemic [of smallpox] in Montreal killed more than three thousand people. Riots broke out over control measures; some feared that vaccination could spread the disease. The conflict was fuelled by class and linguistic tensions between Anglophones, who held power and promoted vaccination, and fracophones, who were less affluent and were largely unvaccinated for reasons of finance, neglect, or fear.”

Because vaccines emerged alongside other public health measures, there’s been debates about their merit. At one extreme is anti-vaxxers who claim that vaccines only cause harm. But there’s no way that smallpox—a highly transmissible and highly fatal disease—would have been eradicated without a vaccine, and the series of childhood vaccines clearly helps keep deadly infections like measles at bay. While there is no evidence to the fraudulent claims that vaccines cause autism or a host of other conditions, there is clear evidence that lack of vaccination kills—including local outbreaks in the US among communities who are not vaccinated, or globally where measles kills more than 100,000 a year despite being preventable.

On the other extreme is the claim that vaccination is the only way to prevent infection. Malaria is considered a “tropical disease” in need of a vaccine, but it once raged through Canada, the US and Europe and was eradicated through improved social, economic, housing and medical conditions. In general, infectious disease declines through improved social and economic conditions, alongside access to vaccine prevention and medical treatment—and resurges through a combination of social and economic disruption and lack of access to vaccines and medicine. The irony of anti-vaxxer hostility to Big Pharma is that they are both sides of the same coin of vaccine denial: anti-vaxxers deny the science of vaccination, and Big Pharma denies access to vaccines.

Patenting the sun

Of course Big Pharma profits from vaccines, but the problem is not vaccines themselves but the profit motive—which actually undermines production and distribution of vaccines. First of all, preventing or curing disease is not as profitable as chronic treatment. As a Goldman Sach report said of gene therapy, “The potential to deliver ‘one shot cures’ is one of the most attractive aspects…However, such treatments offer a very different outlook with regard to recurring revenue versus chronic therapies…While this proposition carries tremendous value for patients and society, it would represent a challenge for…sustained cash flow.” Existing vaccines do offer a sustained cash flow, but it is by no means a main source of revenue. For example, Merck’s combined sales of vaccines for measles, mumps, rubella and chicken pox made $1.4 billion in 2014, which was only 3% of their sales and a tenth of what their top selling cancer drug makes. The lack of interest in the annual flu shot caused Wyeth (now owned by Pfizer) to stop making the vaccine in 2002.

As a result, developing new vaccines has not driven by private innovation but massive public investment—like the Coalition for Epidemic Preparedness Innovations (CEPI) or Gavi the Vaccine Alliance. These have received hundreds of million of dollars from governments around the world, and contributed to Moderna’s COVID-19 vaccine. But the pharmaceutical industry puts their profits above vaccine distribution. As Doctors Without Borders explained last year, “Pfizer and GSK have reaped more than their fair share of donor money for the pneumococcal vaccine, on top of the combined nearly $50 billion in sales on the vaccine they have made over the last 10 years, so it’s time for Gavi to stop this big pharma payout. Instead of lobbing more money at Pfizer and GSK, Gavi should start supporting countries to prepare for the alternative supplier that promises lower pneumococcal vaccine prices for all countries…It’s unconscionable that almost 20 years after the pneumococcal vaccine first became available, over 55 million children in the world still aren’t receiving it.”

Preparing for unpredictable pandemics is even less profitable, as long-term planning and collaboration and universal access to vaccines is the antithesis of the free market. As a Yale public health professor explained, this has undermined preparedness for COVID-19: “Had we not set the SARS vaccine research program aside, we would have had a lot more of this foundational work that we could apply to this new, closely related virus.”

The greatest pandemic in a century—which thrives on poor housing and working conditions—has now created a huge market for a vaccine, but patents will interfere with its distribution. When Jonas Salk pioneered the polio vaccine in the 1950s and was asked who owns the patent. His response: “The people, I would say. There is no patent. Could you patent the sun?” But that is what pharmaceutical companies are trying to do. As pharmaceutical campaigner Heidi Chow explained, “It’s positive news that Pfizer may have found an effective COVID-19 vaccine, but right now it will only be for the few. We need governments to step in and make it available for the many—including by suspending patent rights…We are heading towards artificially created scarcity for this vaccine, which is completely unacceptable in a global pandemic. Pfizer and BioNTech need to share this vaccine with the world, not hoard it for profit.” While Pfizer CEO Albert Bourla dismissed the idea of suspending COVID-19 vaccine patents as “nonsense”, he cashed out on $5.6 million in stocks after the press release announcing the vaccine.

The quick cash out on the press release is also concerning with respect to the actual effectiveness of the vaccine. During the first wave of the pandemic, preliminary results suggested that Gilead’s drug remdesivir reduced COVID-19 mortality. The company made millions, as the US bought up the entire global supply and Trump announced he was taking it. But a large study has now found no benefit to the drug, which Gilead is disputing. Pfizer and Moderna have now announced preliminary results without the details of the study and without final results of a large unbiased study. This “science by press release” is an increasing phenomenon, used to get around scientific protocols, make a quick buck, and then undermine an objective analysis of the final results.

Preventing COVID

Vaccines play a major role in preventing infections, but they have to be effective and not treated as a panacea. As the Lancet medical journal warned: “Deployment of a weakly effective vaccine could actually worsen the COVID-19 pandemic if authorities wrongly assume it causes a substantial reduction in risk, or if vaccinated individuals wrongly believe they are immune, hence reducing implementation of, or compliance with, other COVID-19 control measures.”

There’s also the challenge of rising vaccine hesitancy fueled by the record of state repression, pharmaceutical profiteering, and anti-vaxxers who cast doubt on the whole history and science of vaccines. The new generation of anti-vaxxers combine 18^th century ignorance about inoculation, 19^th century libertarianism about personal freedom trumping public health, 20^th century myths about vaccine and autism, and 21^st century conspiracies. But while they’re suing the government for supporting masks, frontline workers–disproportionately women, racialized and migrant workers–are literally dying for PPE. The real threat is not government support for masks in the face of a “fake epidemic”, but government denial of paid sick days in the face of a real disease—which has disproportionately claimed the lives of racialized, disabled and elderly people.

But to maximize the effectiveness of a COVID-19 vaccine it has to be universally accessible. This means challenging pharmaceutical patents and stopping them from hoarding “intellectual property” that has received much public funding and is based on humanity’s longstanding practice of preventing infectious disease. Rather than seeing a vaccine as a for profit venture, we need to demand that vaccines should be treated as a public good available free to everyone across the world.

Enhancing vaccine access also requires supporting policies that encourage workers to get vaccinated, like paid sick days. Workers with paid sick days and their children have higher vaccination rates, US jurisdictions that expanded paid sick days during COVID-19 prevented 400 infections per day, and expanding paid sick days in Canada would both reduce the second wave and improve access to a vaccine and other forms of health prevention.

While a safe, effective and accessible vaccine would clearly be a major turning point in the pandemic, we don’t need to wait for a vaccine to start preventing COVID-19—and in the midst of the second wave it’s urgent that we take other actions until a vaccine is available. The fact that infection and mortality rates are so drastically unequal shows that ensuring equity can help prevent the spread of COVID-19 and make the world better. As chief of public health Theresa Tam explained in her report, there area multiple areas of action—from higher wages to paid sick days, and from affordable housing to support for migrant workers. These steps would not only help reduce COVID-19 immediately, but also increase access to an eventual vaccine and help protect society from future pandemics.