Africa: From 2020 quandary to 2021 anticipation (2)

AS THE WORLD ANXIOUSLY waits to put the COVID-19 experience of 2020 behind, the coming year 2021 may or may not be an extension of the outgoing year, depending on how well the pandemic is tamed. The variation in pandemic prevalence, the associated mortalities and the effectiveness of policy and administrative interventions in containing the spread of the disease will determine – to a great extent – what to expect globally within the year ahead. That COVID-19 is not going away soon is now a known fact. While some parts of the world, including a greater part of the Sub-Saharan Africa, seem to have “flattened the curve” according to many commentators turned emergency medical statisticians in trying to interpret the reduction in caseloads and mortalities, new waves of infections are rising elsewhere in Europe, Asia and America. Fears and anxiety are high about the prospects of more cases in the countries within the temperate region in the northern hemisphere as fall gives way to winter.

The most popular response to COVID-19 has been the emphasis on vaccines and vaccination, with a disproportionately less public discourse on therapy, perhaps because of the widely held view on reliability of prevention in viral infections. What about the consequential disease complications? With the progress made so far, more billions of dollars of private and public money might be poured into vaccine procurement, distribution and use beginning from early 2021, and lasting through the year and beyond. These may justify the efforts, investment and push by vaccine producers in response to the pandemic, but they are not expected to come easy. At play will be considerations for sound science, humanitarian concerns and politics, all at the same time. Although the political considerations may not work in Africa’s favour, the humanitarian considerations may. But that again may be hindered by the urgent need to attend to those countries most at risk, a category into which most Sub-Saharan African countries may not be easily classified now – except perhaps South Africa in this context. To a great extent, therefore, many countries in Africa may have to purchase their own vaccines if they consider vaccine intervention as urgent. That would mean huge budgetary commitments, herculean for the mostly poor countries within the continent.

So, although COVID-19 vaccines are out, they may yet not be for all comers. For the most part, markets may succeed in setting the pace of delivery, access and use. The same law applicable to mass produced new products of extensive research may apply, in which case the vaccine manufacturers will bring down the prices much later after recovering their costs from initial high prices. Africa may thus have to wait a fairly long while. Competition may further intensify among the vaccine producers, exacerbating what has been described as “vaccine nationalism” and further dimming the expectations of those envisaging collaborative efforts among nations and vaccine manufacturers in the fight against COVID-19 globally. Signs of price wars might soon be apparent as   the promotion of the candidate vaccines that are likely to make it to the market soon take the centre stage. Development institutions, particularly multilateral development finance institutions and other corporate lenders, have either forgiven many African countries enormous amounts of debts or have delayed the repayment dates because of the COVID-19 pandemic as a way of helping the debtor nations adjust to the realities of the time. To expect these same indebted countries to pay hefty sums in direct purchase of vaccines would be somehow burdensome.

In the African context, the impact of markets on COVID-19 vaccines looms large, even though it may appear distant. The extent of effective coverage of Africa – though desirable – will be evident when the vaccines make inroad to the continent. Whether the widespread distribution of these vaccines will be determined by the supply side or demand side would become clearer as they are released by relevant regulatory authorities. The various manufacturers have provided some hints about the prices per dose, thereby providing the broad basis for decisions on preferences by various countries. Every other consideration may just be subservient to pricing. Few days ago, Russia announced that its COVID-19 vaccine candidate Sputnik V vaccine would cost less than $10 a dose in international markets. But Sputnik V is a two dose vaccine. Two doses recommended will therefore be in the region of $20 at the end markets. Its expected multi-locational production may or may not ensure a reduction in prices. By contrast, AstraZeneca seems to elevate social services consideration over immediate pecuniary gains as it relegates profit motives in the vaccine sale during the pandemic, charging between $3 and $5 a dose, and promising to sell “at cost price to developing nations in perpetuity.” How long the “perpetuity” would mean in reality and whether the price can be retained even for the short term remains to be seen. Meanwhile, Pfizer and BioNTech, its partner, will be charging $19.50 per dose for the first 100 million doses, about the price of two doses of Sputnik V. That means two doses of the vaccine will cost $39 per person. Moderna’s CEO, Stéphane Bancel, has announced a rather broad price range of between $25 and $37 per dose, depending on order size, referring to this highly elastic pricing “a fair price.”

Instinctively, the purchasing decision of many countries will depend on pricing, with its own downsides. But poor countries have to decide on what they can afford in the circumstance of restricted revenues. Here too, it is reasonable to expect politicians’ proclivity for financial scandals to come into full display as their choices may or may not be altogether informed by altruism and public trust. This is the intersection between decisions based on qualitative or quantitative criteria. Comparing the efficacies of all the emerging vaccines is very important. Many countries would want to strike a delicate balance – or rather exercise trade-offs – between quality, efficacy and pricing based on available information. The Russian Direct Investment Fund (RDIF) has announced that its Sputnik V vaccine has an efficacy of over 95 per cent. The British vaccine version from Oxford University and AstraZeneca was described as 70 per cent effective, or up to 90 per cent if dosages are adjusted. Recently, the drug makers Pfizer and Moderna announced that late-stage trial results suggested their respective vaccines were about 95 per cent effective in preventing COVID-19.

But the biostatistical errors in AstraZeneca’s clinical trial reports need to be taken seriously and corrected in a repeat trial process so as to avoid self-inflicted irreparable reputational damage. Spirited efforts by AstraZeneca’s research and development executive, Dr. Mene Pangalos, to reframe the statistical errors as “serendipity” may therefore not help matters as it exposes what has been described as a “poor grade for transparency and rigour.” Although the higher immune response to half-dose of Oxford-AstraZeneca’s COVID-19 vaccine initially appears a statistical anomaly, it may turn out to be a scientific breakthrough. But this can only be proved in a repeat trial with the same result within the same type of population, across demographics and geographical expressions in such a representative manner that minimises opportunity for misgivings. Analysis of field data obtained also needs careful handling to avoid muddling things up, as it may affect regulatory approval. The upside could mean that we now have a far cheaper vaccine when approved by regulators. This, hopefully, could be an advantage.

Storage of COVID-19 vaccines in Africa warrants some attention. The University of Oxford and AstraZeneca’s COVID-19 vaccine can be stored at normal fridge temperatures for at least six months. Russia’s Sputnik V vaccine is expected to be in lyophilised (dry) form, stored at a temperature of 2^oC to 8^oC. It therefore doesn’t require an ultra-cold storage and transport system, making it cheaper to distribute globally. Such an attribute enables its distribution in international markets, as well as expanding its use in hard-to-reach regions, including areas with tropical climates. Oxford and AstraZeneca’s candidate is said to be stable, which means it can be stored, transported and handled at normal fridge temperatures of between 2.2^oC and 7.7^oC for at least six months. Pfizer’s vaccine, however, requires a complex “cold chain” transport system as it has to be transported at -70^oC through a temperature-controlled system of deep-freeze airport warehouses and refrigerated vehicles, using dry ice and GPS temperature-monitoring devices. This needs expensive cold storage devices. Moderna’s vaccine can be transported and stored at fridge temperatures, but only for a month. To last this long, it has to be stored at minus 20^oC. Those with good understanding of tropical medicine will have no difficulty in figuring out the implications of these and will be concerned about the differences. Maintaining the cold chain and ensuring integrity in the supply chain and in the chain of custody is quite crucial.

Expect politics in vaccine race, among the producers, suppliers, purchasers and end users. There are fears that “black markets” may become popular and entrenched in the COVID-19 vaccine business as many countries seek to urgently purchase and use. Intermediaries or middlemen springing up might cause artificial hike in price, compromising the chain of custody, particularly the cold chain, thereby damaging the potency and efficacy of vaccines that pass through them. Where countries have to purchase for universal coverage, the cost may be prohibitive. This could provide opportunities for such backdoor surreptitious players who may offer or pay lower or higher prices than the price set by manufacturers depending on availability. If Nigeria, with an estimated population of 200 million, considers buying for universal coverage, it will have to budget about $2 billion, an equivalent of one tenth of its annual budget in recent times. Considering the other competing needs and limited resources, this vaccine project will probably be relegated further down the scale of preference as food and defence spending take a centre stage. It is easy then to imagine how smaller and poorer countries would cope.

Responses of African countries to COVID-19 vaccine are therefore not likely to be the same. A lot of comparative studies are supposed to be going on in Africa on this burning issue. Philanthropists’ support is urgently needed. Africa’s Centre for Disease Control needs to play prominent roles in this case as we expect WHO, GAVI vaccine alliance and CEPI to step in. Even where a lot of research works are going on, the world is yet to understand the virus in full details. With poor reporting of COVID-19 cases and the consequential suppression of data, Africa may miss any preferential benefit meant for high risk countries and may remain a silent reservoir, spreading the infection back into the wider world, including where immunity conferred on vaccinated populations has waned. It is necessary to ask if coronavirus vaccine has to be mandatory and how many African countries will be their brothers’ keepers and be ready to bear the expenses for other countries in addition to their own. For much of Africa, the help needed to overcome COVID-19 will have to come from outside the continent. But how prepared are we to capture the help and decimate the pandemic? These are at the crux of the fight against COVID-19.