Vaccines as a global public good and a matter of regional health sovereignty

Latin America and the Caribbean trapped in dependence on the global Medical-Pharmaceutical-Financial Complex

The SARS-CoV-2 pandemic accounted for 2% of all deaths from all causes in 2020. The 1.7 million deaths during that period represented a new scenario compared to the already severe average annual mortality rate of 3 million pneumonia deaths in 2019. This highlights the true scale of this global pandemic as an international health problem affecting both the Global North and the Global South.

Starting from this international scenario highlights that SARS-CoV-2 vaccines are an appropriate and necessary—albeit limited and insufficient—response to the global epidemiological situation. Given that it is a novel viremic with significant attack rates in the world population and excess mortality in certain age groups and populations, especially in Latin America and the Caribbean, exacerbated by social class, ethnic-racial, and gender inequalities, vaccination is undoubtedly one of the key strategies for responding to the current public health emergency.

From the CLACSO Working Group on International Health and Health Sovereignty We also believe that a thorough review of the response to the global pandemic and specific epidemics is and will be necessary in order to understand the socio-environmental determinants of SARS-CoV-2 within the Society-Nature metabolism. Likewise, it is necessary to review the institutional arrangements and capacities of our health systems, to critically assess the errors, improvisations, and malpractice in decision-making from both biomedicine and the dominant traditional public health perspective, as well as the geopolitics of global health security implemented through trial-and-error measures. A review of the processes of police militarization in addressing epidemics, from the perspectives of biomedicalization and public disease theory employed by "experts," necropolitics, and other factors, is also imperative.

However, approximately 85 to 90% of the Latin American and Caribbean population did not experience the Covid-19 infection, which is why vaccination is a valid public health measure in the current context.

From the overall review, it appears that all vaccines currently being distributed and used worldwide underwent research and development processes with efficacy evaluations in pre-clinical trials, pre-qualification clinical trials, and Phase III trials for qualification, definition of the range of action, and clinical effectiveness. For all vaccines, this process established a threshold of efficacy and biosafety with variability ranging from 60% to 95%. In all vaccines, the effectiveness would be significantly greater in preventing severe symptomatic cases and acute hospitalizations in COVID-19. However, it must also be said that profound questions arise, including: 1. the duration of immunogenicity of the vaccines currently being administered, with a dangerous scenario of global dependence on the production of an "annual" vaccine, creating a lucrative business for the pharmaceutical industry; 2. the effectiveness of the vaccines against the accumulating mutations and variants of SARS-CoV-2 that are currently being studied. 

Despite the ups and downs of the global economy, the pharmaceutical market remains a complex industrial, productive, and financial network that generates inelastic demand for the mass consumption of drugs and health technologies, with extraordinary profit rates and accelerated profit patterns for the 21st century. Its geopolitical influence on health (most "Big Pharma" groups are from the Global North) directly impacts the global health agenda, especially regarding an essential social and public good such as access to medicines and vaccines. 

The top 20 pharmaceutical companies, known as Big Pharma, mostly from the European Union and the United States, account for more than 60 percent of total global pharmaceutical sales. These include Pfizer, AstraZeneca, Novartis, Sanofi, Johnson & Johnson, GlaxoSmithKline, Janssen, Roche, and Bayer-Monsanto, among others. This reflects a clear North-South or Center-to-Periphery geopolitical dynamic, where research, innovation, and new drugs flow to countries in the Global South.

The 1995 Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) remains the primary mechanism by which a global multilateral organization like the World Trade Organization (WTO) imposes the interests of the pharmaceutical industry on states, societies, and healthcare systems, particularly in countries in the Global South that are dependent on pharmaceutical imports. These patent and licensing rights over products, vaccines, and drugs have effectively prioritized the profits of multinational and national pharmaceutical companies over public health. 

What is happening at the international and regional level highlights that the international medical authority of the World Health Organization (WHO) is colonized by the interests of the pharmaceutical industry itself, thanks to an accelerated privatization process that deprives it of any role in public health. 

Almost 90% of the WHO Medicines Programme is directly funded by the Bill and Melinda Gates Foundation. 80% of the WHO budget depends on voluntary public or private donations (not contributions from states).which are concentrated in various countries, in the Bill and Melinda Gates Foundation and in the pharmaceutical industry“In the case of GAVI (the Vaccine Alliance – a public/private fund), 60% of its funding comes from the pharmaceutical industry itself and from donors in those same core countries that defend their pharmaceutical corporations. When a donor gives money, for example, the pharmaceutical industry, its representatives request to be present on the expert committees of the different [WHO] programs or even on expert committees in our countries. Reviewing the Covid-19 Expert Committees in Latin America and the Caribbean would allow us to map this reality. The pandemic once again exposed this conflict of interest and the accelerated reproduction of capital. This had already happened with the H1N1 epidemic, where potential manufacturers of vaccines and drugs, such as Tamiflu, were sitting on the WHO expert committee that was deciding whether to declare an epidemic.” 

The Coalition for Epidemic Preparedness Innovations (CEPI) is a multinational public-private partnership created in 2015 by the World Economic Forum in Davos, especially promoted by the Bill & Melinda Gates Foundation and The Wellcome Trust (GlaxoSmithKline's philanthropic-capitalist fund). It had been conducting pandemic preparedness exercises and announced a global Covid-19 vaccination plan as early as January 2020. In fact, the Moderna (USA) vaccine is sponsored by this CEPI mechanism. 

These networks are what currently reproduce and govern the Global Access Facility for Covid-19 Vaccines, known as the WHO's COVAX Facility, along with the GAVI and CEPI alliance. They represent a network where vaccine "patent" rights are guaranteed under market logic, and they only commit to donating a "tiny" portion, which implies more of a sense of "global charity and philanthropy"with the Global South, which considers it a collective right given the need for immunization of 7000 billion people. In other words, it puts the interests of pharmaceutical companies and actors from the Global North in control of vaccines."

That's why it's no coincidence that over 90% of available vaccines have already been used up by the United States, Western Europe, Japan, and Australia. Even in these regions, immigrant communities and other populations are being left out.

In other words, this geopolitics of patents and health coloniality is what governs SARS-CoV-2 vaccination today and keeps governments and ministries of public health in Latin America and the Caribbean "captive" as peripheral-dependent buyers, with varying degrees of success in population coverage, but all trapped in the same dynamic. 

Around the world and in the region, states depend on their ability to purchase and stockpile high-value products from large pharmaceutical companies. One of the largest suppliers, Pfizer, expects revenues of over $15.000 billion for 2021. The cost of this “market-driven approach” to the COVID-19 crisis reaffirms the power of the global medical-pharmaceutical-financial complex and the need to re-establish a horizon of health sovereignty for the Global South.

Only the Russian Federation, China, and Cuba can be partially excluded from this trend. However, some of the vaccines from these countries are also commercially available and distributed through partnerships with private national laboratories in India, Brazil, Argentina, and other countries. 

This context of geopolitical adversities, commodification, and health dependence of our societies in the Global South shows that the development of a vaccine is a scientific-health problem, but access and distribution is a political-health problem (national, regional, and global). 

Under this premise, the CLACSO Working Group on International Health and Health Sovereignty considers that:

1. Declare Vaccines as a global public good and a matter of regional health sovereigntyLikewise, considering that vaccines alone are a limited and insufficient response to the multidimensional crisis of SARS-CoV-2, addressing this situation requires a comprehensive approach, of which the vaccine is just one.

2. An obvious and relatively quick solution would be to release the patents and allow consortia of countries in the Global South, such as India, South Africa, Brazil, Argentina, Mexico, and others, to mass-produce equivalent vaccines for the regions of the globally peripheral capitalist system. Big Pharma vehemently opposed, and continues to vehemently oppose, what it perceives as a violation of its patent “property rights,” with the support of the United States and the European Union, and following the “rules” imposed on global trade, including the WTO Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS). In fact, this is why the initiative of India and South Africa, along with more than 90 other countries, was rejected within the WHO itself. Safeguarding the WHO's COVAX agreement once again implies the colonization and control of vaccine access by GAVI and CEPI—that is, by the same donor states of the Global North and the corporations of the pharmaceutical and medical complex. 
   
   There is also the possibility of using the flexibilities of the TRIPS Agreement to declare compulsory licenses in the event of a health emergency, which would be a temporary solution that could be taken as an alternative by multiple countries in Latin America and the Caribbean, along with the Global South. 

3. It is necessary to put the reconstruction of a regional integration in health based on public structures of autonomy, health sovereignty, and South-South international health principles. This does not only concern and depend exclusively on intergovernmental relations between “States and Governments,” but regional health sovereignty is a strategic process embedded in the networks of territories, territorialities, and actors in the construction of a Greetings from the South. 
   
   Unfortunately, the disintegration and lack of regional coordination in Latin America and the Caribbean, demonstrated both in the Latin American and Caribbean response to the SARS-CoV-2 epidemics and in access to vaccines, has once again placed the States of the region in a position of “Buyers"Dependent peripherals fighting for vaccine dose quotas each separately, with fragmented vaccination strategies and not achieving significant Covid-19 immunization coverage in this first semester for obvious geopolitical reasons, the main one being the concentration of the global North's dose purchase market." 
   
   Undoubtedly, rebuilding regional integration frameworks in health is one of the post-pandemic challenges: it will involve reviewing the lessons learned from the former UNASUR Health, ALBA Health, and COMISCA-SICA, ORAS-CONHU, and CARPHA-CARICOM. The Community of Latin American and Caribbean States (CELAC) holds enormous potential for developing health sovereignty as a strategy for regional autonomy, given that this process could stem from strategic interactions between societies and states to forge new regional institutional frameworks for South-South international health with a Latin American and Caribbean focus.
   
   In this regard, we propose, amidst the current situation, that, with Mexico's leadership in CELAC, a regional Forum on Health Sovereignty be rapidly established and that the first priority be to address the “Universal and Public Access to the SARS-CoV-2 Vaccine” articulating the efforts of States with Latin American and Caribbean universities, academic networks, movements and social organizations. 

4. In this context, Latin America and the Caribbean were once again positioned as a geopolitical space in the health sector governed by the guidelines of liberal global health and regional Pan-American health policies, which, through their diplomacy, consistently maintain that following the mandates of global mechanisms is the only option. This means, among other things, remaining trapped in a matrix of peripheral dependency and the capture of funding to sustain liberal health diplomacy and technocracies that continue to be trained and prepared to reproduce a constant Coloniality of power and health knowledge in North-South or Center-Periphery asymmetries. 
   
   The above is clearly reflected in the PAHO document (2021)¹ in which it explicitly states:
   
   "The Pan American Health Organization has accompanied and provided the necessary technical support to Member States to assist them in each phase of their participation in the COVAX mechanism, in addition to the preparation of national vaccination plans for COVID-19.". 

5. It is necessary to support the scientific effort and humbly learn from the example of Cuba's health policy. We hope that the development process of the SARS-CoV-2 vaccines known as Soberana 01 and Soberana 02 (Finlay Institute) and Abdala and Mambisa (CIGB) will confirm their clinical viability in Phase III trials, which would allow Cuba to immunize its entire population this year (11.2 million) and supply the vaccine to other countries in the Global South. Cuba is the first country in Latin America and the Caribbean to reach this stage in developing its own SARS-CoV-2 vaccine, a scientific and health achievement in the adverse context of an international blockade, exacerbated by shortages amidst the global economic crisis caused by the pandemic.
   
   These same efforts in other national science and research systems in Latin American countries for the development of their own vaccines, public production of medicines and other necessary health technologies, show the potential of regional capacities in the production of applied knowledge if the articulations and networks from the South are deepened. 

6. Beyond the skepticism of certain specific social sectors that operate more on a matter of personal “beliefs” (known as “anti-vaxxers”), it is necessary to study in depth and monitor how the process of medicalization of life y commodification of disease treatment, brutally induced by the medical-pharmaceutical-financial complex, it was generating iatrogenia (damage) in its premise of expanding drug consumption as “magic pillsUnder the canons of Western “science,” but which also produced a constant discrediting of the development of drugs and vaccines for the protection of life and their use for the collective health of societies. In this process of disbelief and deterioration of therapeutic credibility regarding vaccines, we must not always “blame” those who are misinformed due to the ease of access to low-quality health information, but also what is happening within the networks of medicalization and commodification of health through the medical-pharmaceutical complex, global health cooperation organizations with associated national actors.

7. With the vaccine supplies available in each country, sustaining the organizational capacity for national vaccination campaigns over many months requires technical and logistical preparation, including equitable territorial distribution of the vaccine, ensuring the biosecurity of the cold chain, secure application sites, and the rational use of the vaccine, prioritizing key population groups at established stages. In this regard, the credibility of the entire process is crucial, requiring informed public participation and avoiding any unnecessary interference from mass media misinformation, situations of state political patronage or clientelism, or any privileged access to immunization. It is the credibility of the overall process, with participatory monitoring and informed public access, that holds the key to increasing public trust in vaccination.
   
   Given the rapid pace of research, development, approval, production, and distribution of COVID-19 vaccines, rigorous evaluation and monitoring through pharmacovigilance by states and health systems is of paramount importance. This entails continuously monitoring long-term effectiveness and biosafety, as well as adverse, rare, or novel reactions. This monitoring is as crucial as the vaccine's administration itself, as it allows for real-time assessment of whether the impact on public health is as expected and necessary, considering the financing, logistical, and distribution efforts undertaken by each state and society. 

8. From the CLACSO Working Group on International Health and Health Sovereignty, accompanying the regional network of institutions, movements, and organizations that came together at the Latin American and Caribbean Conference on Critical Thinking in Health, we call for strengthening health policy action to achieve timely and universal access to vaccines as a social public good at the service of the collective health of our peoples, and at the same time promote a campaign with the urgent need for the Refounding of our Health Systems and Public Policies for effective health sovereignty in Latin America and the Caribbean as an emancipatory horizon for living well.

February 2021
CLACSO Working Group
International health and health sovereignty

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This statement expresses the position of the Working Groups International health and health sovereignty and not necessarily that of the centers and institutions that make up the CLACSO international network, its Steering Committee or its Executive Secretariat.