South Africa has been here before

In 2001, the Treatment Action Campaign and the Congress of South African Trade Unions called for worldwide protest against pharmaceutical companies; drug patents were barring the South African government from importing low-cost, generic, HIV medications. While litigation held up acquisition of cheap medicines, hundreds of thousands of South Africans died of AIDS-related illnesses. A report by the Medical Research Council found that, in the year 2000, 40% of the deaths of people age 15-49 in South Africa were related to HIV.

Activists in South Africa organized for years against pharmaceutical profiteering and their own government’s HIV-denialism, ushering in new local and global policy to allow for a broad introduction of antiretroviral therapy.

Now, with the number of confirmed COVID-19 cases in South Africa nearing 1.5 million, some of these same networks and organizations are fighting for access to coronavirus medications. Their contentions remain largely the same as they were in 2001: price gouging, internationally enforced Trade-Related Aspects of Intellectual Property Rights (known as TRIPS), the backing of pharmaceutical companies by wealthy nations, and a weak public healthcare system that lacks government transparency and accountability.

Fatima Hassan is a social justice activist in South Africa. She worked as a human rights lawyer in the 1990s, litigating against the government and pharmaceutical companies on behalf of people with HIV/AIDS. In July 2020, as history began to repeat itself, Hassan founded the Health Justice Initiative to address inequity in health and medicine access.

“It’s playing out again,” she says. ​“A lot of us who were in the access to medicines movement then are now trying to get people to understand what’s at stake and the gravity of the situation.”

Hassan continues:

Never trust drug companies’ benevolence. So that ​”no profit pledge” by AstraZeneca, we said: ​”Interrogate that. Look at the sublicensing agreements. Make sure there’s data transparency.” We said: ​”You’re going to have price variations, you’re going to segment markets… . They’re not going to respond to this from a public health [or] epidemiological perspective. The vaccines will go to the people who are the wealthiest. They’ll test vaccines in our country but decide if they’ll come into our country or not…” This is exactly what happened with HIV/AIDS.

The road to a global disaster

In an open letter to world health officials—including Dr. Anthony Fauci, director of the US National Institute of Allergy and Infectious Diseases and chief medical advisor to President Joe Biden—Cape Town Archbishop Thabo Makgoba and the People’s Vaccine Campaign of South Africa warn ​“we are on the road to a global disaster.”

The letter argues:

[The] dire shortage of vaccine supplies is not due to any inherent technological limitation in scaling up production, but rather a seemingly deliberate decision to not allow production scale up to what the global pandemic requires…And while we acknowledge that there is insufficient manufacturing capacity, right now, in the world, a combination of investment in immediate capacity scale up … and a concerted effort to facilitate technology transfer could help rapidly solve this problem.

The broader Southern Africa region is battling a new and highly contagious strain of the coronavirus. Health workers, reports Médecins Sans Frontières (MSF), ​“are currently struggling to treat escalating numbers of patients with little prospect of receiving a vaccine to protect themselves or others from the virus.” According to Christine Jamet, MSF’s director of operations, ​“While many wealthy countries started vaccinating their health workers and other groups nearly two months ago, countries such as Eswatini, Malawi, and Mozambique—which are struggling to respond to this pandemic—have not received a single dose of vaccine to protect the most at-risk people, including frontline health staff.”

But no country on the African continent has been hit harder by the pandemic than South Africa. The South African economy is more stable than that of Malawi or Mozambique, which allows South Africa to buy vaccines directly from the pharmaceutical companies. But it has done so in a market system that prices these medicines exorbitantly.

South Africa’s healthcare system is also stronger than the rest of the region, but doctors, nurses, and other care workers have been pushed to their breaking point. Sasha Stevenson is the head of health at Section27, a South African public interest law center and social justice organization:

Our health system is already creaking under the weight of COVID, because it was creaking under the weight of HIV and [tuberculosis] beforehand. And we’ve now got TB numbers going through the roof, because we can’t maintain all of these programs at once. And we’re being asked to pay huge sums of money for vaccines that are needed to keep us and the rest of the world safe.

We have a health system that’s [been] struggling for a long time. So, the idea of a rollout that requires everyone in the country to register on an electronic database, and then potentially come back for two shots when sometimes clinics are far away from people, and we struggle to get ambulances to rural areas in life-or-death emergencies, is very daunting.

Claire Waterhouse, MSF’s regional advocacy coordinator, explains: ​“healthcare workers are exhausted. There was just significantly less human resource capacity to deal with the second wave when it did arrive. A lot of them had been sick in the first wave.” Meanwhile, MSF is working to dispatch mobile units of doctors and nurses to coronavirus hot spots to ensure the sick receive the medical attention they need. But with frontline healthcare workers— rom physicians to ambulance drivers to clinic cleaners—denied access to vaccines, that job has become much more difficult.

“It’s really hard here right now to see developed countries being able to roll out these vaccines and people getting vaccinated before we’ve even managed to put one needle in one arm,” Waterhouse says. ​“And it’s so frustrating and so heartbreaking for our healthcare workers, who [just want] some protection. We’re really hoping that when the vaccines roll out, that will give them a layer of confidence, which will hopefully help them to deal with what is frankly an inevitable third wave.”

Hassan puts things more bluntly: ​“Everybody’s bullshitting us.”

Pharma in the driver’s seat

“The research and development of this vaccine was publicly funded and conducted at Oxford University,” Global Justice Now says in a statement: ​“The vaccine should have been a global public good—openly licensed to allow as many manufacturers as possible to make it.”

But the (often secret) agreements between pharmaceutical companies and a particular country allow Big Pharma to set different prices for different markets. AstraZeneca, despite claiming a ​“no-profit” pledge during the pandemic, is charging South Africa $5.25 per dose and Uganda $7 per dose. The European Union, by contrast, has paid just $2.16 per dose.

South Africa, meanwhile, received its first vaccine supply of 1 million AstraZeneca shots February 1, and it may already be too late to use them, amid concerns the vaccine is ineffective against the new n501 strain of virus.

With the rollout of AstraZeneca stalled, South Africa is turning to Johnson & Johnson, which signed an agreement with Aspen Pharmacare’s South African subsidiary in November 2020 to produce up to 300 million doses. Those doses, however, despite being manufactured in South Africa, will primarily be exported as part of Johnson & Johnson’s global inventory.

Initially, South Africa wasn’t going to receive any of the Johnson & Johnson vaccine, but Johnson & Johnson has now agreed to secure nine million doses for the country. This deal may include an agreement by South Africa to speed up regulatory approval as well as a no-fault compensation scheme in which South Africa, rather than the pharmaceutical company, takes responsibility for any vaccine-related damages.

South Africa has been the site of clinical trials for numerous vaccine candidates, including AstraZeneca, Pfizer, Johnson & Johnson and Novavax, sharing its data with the international community. Despite this collaboration, Hassan says that the pharmaceutical companies ​“are in the driver’s seat” when it comes to dictating the terms of the sale of the vaccines and any partnerships with local drug manufacturers to scale up production.

Your life or their patents

For years, South African civil society has been pushing to overhaul of South Africa’s patent system to make use of the legal safeguards available through TRIPS. Waterhouse explains:

Intellectual property and patents are not new topics in South Africa. We don’t want to repeat the same kinds of issues that we had with [antiretroviral drug treatment for HIV] and which we are now seeing with the pandemic. It’s depressing that we’re still fighting this fight, and really concerning that access to medicine has not evolved beyond who can afford them. Because that’s really what it boils down to. It’s that old line of profits over people, profits over patients.

While activists organize locally to revamp South Africa’s patent laws, the governments of wealthy nations could reprioritize global health over the profits of pharmaceutical companies. As Stevenson observes, ​“Governments have power over pharmaceutical companies that they don’t often exercise. And now is the time to exercise that power. Now is the time to stop being beholden to pharmaceutical companies, particularly given the really enormous levels of public funding.”

To ensure profits are not prioritized over public health, activists are organizing on several fronts, pushing for local reforms while supporting calls for a TRIPS waiver at the World Trade Organization (WTO). South Africa and India have proposed waiving patents and other intellectual property (IP) restrictions related to COVID-19 drugs and vaccines for the duration of the pandemic. Internationally, these steps could be critical for generic drug manufacturers to scale up vaccine production.

A small group of wealthy nations—including the EU, the UK, the US, Japan, Canada, and Australia—has blocked the waiver proposal so far, claiming that limiting the patents would stifle future innovation. Research by Public Citizen, however, indicates most of the leading COVID-19 vaccine candidates are ​“using a spike protein technology developed by the US government” through grants from the National Institutes of Health (NIH).

Indeed, most medical innovations are taxpayer-funded collaborations between the public and private sectors, with pharmaceutical companies typically spending 20% or less of their revenues on research and development.

“It’s really interesting the way that the scientists have been talking for the last year about how wonderful it’s been to collaborate on development and share information and to move as quickly as possible,” Stevenson points out. ​“The moment that it comes to production, and there’s billions of dollars in profits to be made, there’s suddenly no such collaboration…Instead, these manufacturing companies are twiddling their thumbs.”

As the open letter to Fauci makes clear, healthcare advocates are also calling on the US and the UK to pressure pharmaceuticals to share their technology and know-how, commit to low pricing and break open manufacturing capacity to scale up production of the vaccine. Because the US is a co-owner of the vaccine co-developed by Moderna and the NIH, it has significant legal rights to make those demands. The Biden administration could also utilize the Defense Production Act to increase vaccine manufacturing.

Activists in the US and other wealthy nations could help force governments to support mass vaccine production and distribution. While Biden has reversed the course of the previous administration by reengaging with the World Health Organization and the COVID-19 Vaccines Global Access initiative (known as Covax, a voluntary, if insufficient, project to buy vaccines for developing countries), he has not backed the waiver request from South Africa and India, nor has he made any promises to use the US government’s leverage with Moderna to share its science and technology.

As a matter of global solidarity, the US has a responsibility to support an equitable production and distribution of vaccines. But as the virus mutates in frightening ways, it is also in our self-interest.

As WHO cautions: None of us will be safe until everyone is safe.