Faculty Voices

Episode 13: Vaccine Inequity

Episode Summary

Paul Farmer, chair of the Department of Global Health and Social Medicine at Harvard Medical School, looks at why some countries have lots of vaccines and others don’t...and our responsibility to improve the inequal situation.

Episode Transcription

June:

Well, COVID-19 is receding in much of the world. The pandemic is raging in South America and the Caribbean. With just 5% of the world's population, it now accounts for a quarter of the deaths [inaudible 00:00:24] the global death toll. Fewer than one in 10 people in Latin America, in the Caribbean overall have been vaccinated according to the Pan American Health Organization. That's raised a lot of questions about vaccine equity. Paul Farmer is our guest today. He is the chair of the Department of Global Health and Social Medicine at Harvard Medical School. He is also co-founder and chief strategist of Partners In Health, chair of the Division of Global Health Equity at Brigham and Women's Hospital. He's also the recent author of Fevers, Feuds, and Diamonds: Ebola and the Ravages of History. Welcome Paul.

Paul Farmer:

Thank you June. It's good to be back.

June:

Thank you. First of all, let me ask you a very simple question. What can you explain to us about the concept of vaccine equity?

Paul Farmer:

Well, just a very straightforward formula and one that would be familiar to readers of Robusto or anyone who's working on health equity in general. And that is, can we use the burden of disease? Can we use the degrees of risks that some people have faced in order to target those populations with either preventives-like vaccines or therapeutics? And of course as you point out, we're not doing that yet. So far the primary propellant, if you will, of vaccine rollout is the GDP of the country and whether or not the political elites in the country made orders early in the process. And so you have Haiti, for example, there hasn't been any major effort to roll out the vaccine yet. You have Brazil which is struggling with a monstrous epidemic like the American one or the North American one where again rates of vaccine uptake are still very low. So what we have here is the opposite of vaccine equity. And I don't think that when folks use the term vaccine apartheid that it's too far off base.

June:

Can you explain that to me?

Paul Farmer:

Well, just going back to the term which is an Afrikaans term, the idea of people being separate and equal which is a fiction, there was separate and unequal with black South Africans being denied access to the basics including health equity, but also housing, jobs, and civil and political rights. So if you just take that term and apply it to this very uneven vaccine rollout you see the same disturbing picture that you saw under some of the worst years of apartheid in South Africa. And the term has been used throughout the world to describe various kinds of everything from red lining in the United States to lots of other inequalities that we can readily see. And a number of folks are I think quite oppositely using the term to describe where we are with the global vaccine rollout now. Just take the continent of Africa and you'll see that less than 2% of the vaccines have gone there and that's going to cause third waves, fourth waves, there's going to be a lot more COVID in the places where there aren't high rates of vaccination. So I think... Go ahead. Sorry. June.

June:

Do you predict the same thing for Latin America?

Paul Farmer:

Well, that's already happening in Latin America, right? I gave the example of Haiti which is smack between Cuba and the Dominican Republic, so as we've discussed before, it's part of Latin America, and I'm sorry to tell you June that on Monday morning we lost the founder of Partners In Health father Fred Sloughonto to COVID. And you can't help but wonder, especially when you know so many people who are still being sick and perishing, isn't there something we might've done a few months ago. I got vaccinated last year, so it weighs on many people knowing that we've got to launch an equitable vaccine rollout based on the burden of disease. If you take a place like Peru which has also struggled mightily against COVID, where are the equity plans to get vaccine across that country. And so it is throughout the continent we're already living in.

June:

So do you think that this way that each country decides what kind and how much vaccine is going to get, is that effective? Or should we be looking at some other way of distributing vaccine?

Paul Farmer:

Well, we know that it's not effective. It leads to these disparities. So this a global pandemic and therefore by definition, transnational in nature. But the way that we report COVID is always along the lines of the nation state. You mentioned the Pan-American Health Organization, that's how they report everything as well. And so when you look at previous pandemics, influenza at the close of World War 1, HIV from the 80's on in any case, these were always trans-regional and transnational epidemics. And it was a big surprise to many of us that it was George W. Bush in launching the president's emergency plan for Aids relief who really saved millions of lives imperiled by HIV disease in Africa by saying, hey, where's the biggest problem and what can we do to address it? And we should apply similar logic in responding to COVID and in preventing it.

            Now, of course, I'm not suggesting that national leaders aren't doing their job by worrying about the countries for which they're responsible, but what happens if a ministry of health or a head of state doesn't order COVID vaccines? And then we're going to see really upsetting and frightening disparities grow over time. And it's worth saying that one more way June, first of all, when you have no tools at all, let's just say, at the beginning of the COVID outbreaks that would lead to the pandemic, you couldn't say, hey, we have a vaccine for this, we didn't. We have excellent diagnostics for this, we didn't. And we have therapeutics for this treatments. We had none of those things. 

            Even then, you're going to see social disparities making poor people, marginalized people, refugees, etc, do less well than those who are not living in poverty or in other ways, marginalized. But once you develop new tools like a vaccine then without an equity plan, you have the chance of seeing an even widening outcome gap. We saw that with Aids, we saw it with cholera just going to the recent pandemics and we're seeing with COVID. So it's a painful thing to say again and again over decades we need an equity plan whenever we develop a new tool.

June:

So if you were in charge of this equity plan, what would it look like?

Paul Farmer:

Well, this term that we really borrowed from Latin American theology, a preferential option for the poor, that's a pretty sturdy concept that could guide us in focusing our attention on those most likely to fall ill and most likely to do poorly afterwards. It isn't the only logic, of course, it's not only poor people as we know who are falling ill with COVID, it's a respiratory disease, it's spread through the air. But it is also following these well-worn grooves and fishers in society. We talk a lot about the variants and their differential infectivity or virulence but what we also see is that the social terrain is differentially virulent.

June:

Explain that to our listeners.

Paul Farmer:

So how do we account for the uniquely poor performance of the United States in Brazil? What do they have in common? Well, they have in common a lot of social pathologies, anti-black racism, people living in favelas or the equivalent in the United States, a lot of people who are incarcerated, these are the social faults that these pathogens follow. Now, they do it in different ways. And airborne disease is different from a sexually transmitted pathogen, or going back to Ebola something that's spread through direct contact, right? And if you look at vector-borne diseases, dengue, malaria, there are important differences in the pathogen but the social pathology determine a lot of what happens in a population. And I also believe June that people are more familiar with this now. Show me an American who doesn't know the irony of a term like essential worker now. What did that mean when we talked about essential workers? It meant that some of them were going to be sacrificial lambs and they were. Americans know too that people working in a meat packing plant or incarcerated in an overcrowded prison were at greater risk for a respiratory virus.

            I do also believe there's a heightened awareness. And I've certainly seen in another countries as well over this past 15, 16 months, but in the United States I think there's a very heightened awareness of how social inequalities of various forms structure risk for exposure to this pathogen and also risk of a poor outcome after exposure. And that could be ongoing transmission, people living in a crowded apartment, right? Or it could be a tardy diagnosis or it could be inferior quality care if they are fortunate enough to get care.

            That's one of the only civil silver linings I can think of is that we're living through a time where people are more aware of the importance of social equity of equity plans but also things like unemployment insurance, universal health care. So I'm hoping that that silver lining will propel us forward away from this kind of staggering risks that some people face while others are shielded. And across Latin America, this is a ranking concern how social equalities get into the body. 

June:

So you're the [inaudible 00:12:43] equalities are, you're going to implement this plan? Given this heightened awareness, what kind of practical steps could be taken to alleviate the situation particularly in Latin American and the Caribbean? 

Paul Farmer:

Well, I think we can make a long list. I mentioned some things, if I were [inaudible 00:13:03] the equities are, I'd certainly underline the importance of universal health care. And probably a publicly funded health insurance scheme that anyone would have access to. Of course, again, we'll be talking about citizens of nation states, right? But were those to be embraced across the board, that would be a good thing. What about local vaccine production? A lot of people in the world we're counting on India, right? Which is a powerhouse of vaccine production. But once they got smashed with another wave they shut down export of vaccines. So we also need to think about, do we need local production on this continent or on that continent? And that just another example. And then let me just add that in the face of neo-liberalism which we're soaking in across Latin America, we need to really fight hard to protect the idea of social goods for health.

            So selling the vaccine is a bad idea even in an affluent but in a Galatarian country like the United States. We know that we're not going to be able to reach a large fraction of the population without making it readily available, free of charge to the user. And again, it's important to note that these marvelous new vaccines, the mRNA vaccines were developed after a lot of investment of public monies into the research that made them possible. So those are just some examples that come quickly to mind June, and there are many more like really do we want the elderly and infirm to have to schlep into a hospital to get a vaccine? Do we want to spend another few decades without an adequate number of community health outreach workers. As you know, we've been fighting for that for decades and there's, again, this silver lining maybe that people are aware that's actually difficult to go to a clinic or hospital. 

            And one of the reasons they're aware is that during the pandemic, of course, they were encouraged to stay away from hospitals unless they themselves were sick with COVID or some other emergency. So I know I'm grasping a bit for that silver lining because the situation is really quite dire right now. Although here in the United States a lot of us are seeing the rapid decline of new cases and the rapid rise in new possibilities to resume everyday activities, in much of the world it's not like that at all.

June:

So you mentioned the local production of vaccine, there's a lot of argument back and forth about patent protection and what that means for the incentives of big companies to produce new products. Could you walk us through some of those arguments and where you stand?

Paul Farmer:

Well, I don't think it's going to surprise you June when you hear that I was very much in favor of what was called the TRIPS Waivers, meaning you suspend patent protections in the middle of a health crisis. And traditionally the United States has been hostile to that idea. And you'll remember back when antiretroviral therapy was developed for Aids, the US government actually sued South Africa for launching generic and local production of these drugs. This at a time when over 20% of some populations were infected with HIV. So if I had been their advisors, their public relations advisors, I would have said, don't do that in the middle of a devastating pandemic, but this time around and by the way, if you look at a map of opposition to the TRIPS Waiver, it's basically a map of colonial rule.

            So every country in Africa, I believe, was for the TRIPS Waivers and our waiver and Europe against it. And the big question this time around, at least for me as an American was, how would our government rule on this, the current administration in Washington, and they had sided granting the TRIPS Waiver. And I think other European companies they'll... Sorry. That was a Freudian slip. Other European countries will come around too but I'll just give an example not from Latin America but from Africa. Rwanda where I've spent a lot of time as you know has the capacity to do that meaning they have the managerial capacity. Obviously, the supply chain is very complicated but are we going to need boosters? Will these new variants be covered? Will the mRNA vaccines need to be redesigned in order to respond more effectively to the new variants?

            If the answers to those questions are yes and I think probably they are, there's going to be a need for local vaccine production on that continent. And I'm sure there are other countries in which it could be done, South Africa, maybe Senegal, but we're pushing... Well, first of all, I'd just say where I stand and I'm very proud that the Biden administration supported the TRIPS Waiver and whether or not which country it should be if necessary in Latin America for local vaccine production. I don't really know that very well. I look at some of the manufacturing capacity in Brazil and Peru and Argentina and Chile, Mexico for sure. So I think that that's something worth contemplating as well.

            It's attracted a lot of attention because of the political battles. It might not be the most important thing to do right now. I wouldn't be arguing for example, in Haiti, that we should suddenly stand up manufacturing capacity there, I would be arguing that we need to get the vaccines there and even Canada doesn't have vaccine production. So they have to rely on what they get from the United States mostly, and maybe that's fine, right? If there are reasonable ways, look, we're talking about a transnational pandemic, right? So the virus moves across the borders, can we make sure that the preventatives-like vaccines that diagnostics and the therapeutics move across borders? We can do that and we need to do that.

June:

So most of our listeners will have heard of something called Covax. Could you explain to us, first of all, what Covax is and then what are its limitations?

Paul Farmer:

Well, if you look at the capacity to manufacture vaccines across the world, it's very unevenly spread, right? So you wouldn't want just any place generating vaccines, right? Do they have good manufacturing capacity? Do they have adequate regulatory standards? And the answer is very often, no. So there's nothing wrong with local production. I mentioned India as a major vaccine producer, they have the know-how and skill in that Bass country to do that. The point of Covax is to say, how do we distribute the vaccines regardless of where they're produced? Right now the mRNA vaccines are produced in the United States and Germany, and that's about it. So that's a lot of pressure on both the companies in terms of their production capacity, but also the distribution. So we learned, and again, if you look at polio vaccine, measles vaccine, other vaccines, that there needs to be an international mechanism for the distribution of high quality, fully vetted vaccines. That's what Covax is.

            Covax is an idea that follows again, a well known tradition in the vaccine world but also with certain essential medications to distribute these as public goods usually across the world. So that's the strength of the Covax idea. The weakness is it's slow and it relies again on the foresight of health authorities and political authorities to order the vaccine. So for example, Haiti, which as you know is of special concern to me, and should be a special concern to all Americans given the long history of the two countries, the oldest two in the hemisphere. If the authorities turned down one vaccine or there's vaccine hesitancy among the authorities, I don't think we know that there's vaccine hesitancy in the population. Then that means that Covax or no Covax there won't be vaccine.

            So there they're waiting their first Covax delivery. Again, just knowing a little bit about the specifics in Rwanda, they had the foresight to order quite a bit but the amount that arrived so far, these are not mRNA vaccines, these are like the AstraZeneca vaccine, the amount that arrived was taken up very quickly with a focus on frontline healthcare workers. And they used it up in a matter of days and again have to wait for the next installment. 

            I'm a big fan of Covax and long may it flourish, but there need to be complimentary ways of speeding up. For example, in a place where there's a big upsurge of cases, how would you get the vaccine there rapidly to respond to the clusters? We're not even doing that yet. Even in the United States, if you look at the vaccine rollout, historically over the last few months, it was based almost entirely on demographic risk. And that makes sense too, right? The elderly, the frontline workers, the essential workers, but a lot of vaccines could be used reactively, strategically, also to respond to big outbreaks and clusters. Take China, take Australia, they have largely brought the pandemic under control, but I believe Sydney's locked down again because of an upsurge or a cluster of cases. And that's going to happen in China as well even though, China has done a good job controlling the virus.

            When there's an upsurge, are you going to vaccinate everyone all at once? Or are you going to be able to use the vaccine strategically to respond to clusters? And again, I don't think there's anywhere in the world where that's being done yet. Israel has very high rates of vaccination, but they're also still facing outbreaks. And so again, you can imagine vaccines, I think particularly the mRNA vaccines because they seem more effective in general, but also against these variants that seem to escape some of the other more traditional vaccines. Israel obviously has the capacity not only to vaccinate a large fraction of its population but also to respond to outbreaks with more targeted interventions. So in order to do that, you need a stockpile of vaccine that can be moved rapidly to the side of the problem. And again, we haven't done that yet.

June:

And how would that be done?

Paul Farmer:

Well, if you think of other threats to wellbeing that are unrelated to an illness or a pandemic, are there rapid response teams for earthquakes? I'm reluctant June to mention terrorism or terror attacks, but there are all sorts of other challenges, wildfires, flood, famine, we've seen a lot of that and you have too, do we have the ability to have a rapid response team with the tools of the trade meaning the vaccine, the supply chain, the equipment you need to have a vaccine campaign. We should have something like that, I believe.

June:

Do you think that could be done within the context of Covax or would you have-

Paul Farmer:

Why not? You could look at all the public health bureaucracies, the Pan American Health Organization is the oldest one in the world, the World Health Organization. When there's an outbreak of Ebola, for example, not only do those organizations respond with rapid response teams, so do groups like Doctors Without Borders, right? Or if there's a famine somewhere, and again, I'm not suggesting that we do that very well. I'm just saying that we're not really doing that at all yet, except through Covax and except through the largest of certain governments, those bilateral agreements. I am very grateful that the Biden administration has made a pledge to Haiti to supply mRNA vaccines, a pretty substantial a lot of them. I'm very proud of that. I'm very grateful, right? But we don't have the rapid response part down yet. And as we go forward as more and more people do get vaccinated, instead of these enormous surges that we're seeing right now, there are going to be smaller clusters and outbreaks among those who are not immune.

            And again, you wouldn't want to keep using the same old way of distributing vaccines once you have a large number of people vaccinated, unless these new variants escape even the mRNA vaccines, we need a more rapid response. And I think a lot of institutions or a multilateral organizations could do that. Again, I'm hoping that we're also going to move in that direction.

June:

To what degree would more funding solve the problem of vaccine inequity?

Paul Farmer:

Well, it's very often the primary obstacle in any kind of public good for public health, it's underfunded, right? So right now in the United States there are logistic challenges for vaccine uptake. I mentioned, again it's sad to see the elderly and infirm have to go into a hospital or a clinic, that doesn't make sense. But it's not primarily the financial obstacle that is still being faced, for example, in Haiti, right? I'm not saying it's all we need but there's adequate public investment in the vaccination response in the United States, but that's not true across the world. Even well-prepared Rwanda still has challenges even if it does not pursue vaccine production, buying all of the vaccine that they need, or the gloves or the syringes or the alcohol or the cold chain, right? I think if we were to make a list of here are the five obstacles that we have to a vaccine equity plan that inadequate investment is still going to be at the top.

June:

Can you discuss any good examples that you see in Latin America?

Paul Farmer:

If you take some good performers like Cuba, they've responded well on the prevention side. That's something to be proud of. On the clinical side, I was just helping a friend of mine get from Haiti to Cuba for care there but in terms of vaccine I think they're still struggling as well. So I'd have a hard time pointing to a standout country. When a place like Brazil which has a reputation of being innovative and investing in public health threats to public wellbeing, they've done almost as poorly as the United States and the mortality rate shows us that. So if Brazil hasn't done it maybe Chile is up there, is having done a better job, but Peru where they put enormous effort, I know that from our friends there and colleagues, they put enormous effort into fighting COVID and have done very poorly.

June:

Do you understand what happened in Peru why despite all the good efforts?

Paul Farmer:

Well, I do think that the large scale political and economic forces that we see in Peru, rapid urbanization, informal settlements, a lot of back and forth, influx of refugees from Venezuela. Those are pretty powerful forces, right? And they overwhelm some of the best intentions and best. I think I'm beginning to understand but I haven't been there since the beginning of the pandemic. And I can't do a better job than that June to say again these same forces that would move Colorado through Peru back in the early 90s or drug resistant tuberculosis. Look how hard we fought drug resistant tuberculosis and it's still a problem in Peru. So that's the basic equation in my mind is, large scale political and social forces can overwhelm even the best intentions and well-designed plans as well. And I think we're seeing that, we're not seeing yet in Rwanda, but we may, even a place like I said, it's got a very well-designed national strategy in most healthcare concerns. I could see it happening even there.

June:

As a doctor who's worked a lot with infectious diseases, I know it's hard to have a crystal ball, but how long do you see this pandemic as going on in Latin America and how do you see it evolving?

Paul Farmer:

Well, unfortunately, I don't see an end in sight. And Brazil is a rebuke to undue optimism, again, the largest country in Latin America, nowhere near the poorest, it's on the other end of the spectrum in Latin America and a history of wonderfully innovative interventions in health, and again the poorest performer on the continent. And again, I think we're going to look at those large scale, social and economic forces to understand what's happening and also a failure of leadership at the top as in the United States. So even without a crystal ball, we can start to understand, I think there are plenty of people who do understand what's going on. What I see looking forward though is that there's only one way really just to stop this and that's massive vaccination. 

            And as I said even in Australia where it's become the hermit nation, they're still having outbreaks and they have really taken this very seriously. Even there, they can't shut out the world forever. And of course, Latin America is at the other end of the spectrum, it's always tied from country to countries. They're all tied together. I think a global vaccine effort that takes account of the burden of disease but also is able to respond to flares, clusters, outbreaks, that's what I would look for in the crystal ball is when are we going to do that? How are we going to sustain it? And I think we're going to see a really rough COVID situation for years to come. 

June:

As co-founder and chief strategist at Partners for Health, what role has the organization been taking with vaccine equity?

Paul Farmer:

Well, I will say that we've been involved in the fight for the TRIPS Waiver. We've been involved in trying to promote vaccine production particularly the mRNA vaccines in Africa. And we've been involved in pushing for vaccines for the countries in which our sister organizations operate Haiti, Mexico, Peru, talking about Latin America. So we've done those things, but a lot of our efforts have really been on the clinical front. So in Haiti, for example, Partners In Health is home to the National Referral Center for people who are critically ill with COVID. That's in Mirebalais, that won't surprise you. And there are only a few beds in Haiti with ventilators which is pretty sad for us that's why we're losing people. 

            So our response has been largely the conventional public health interventions like we're doing in Massachusetts contact tracing with the public health authorities, we're doing that in Haiti, Peru, Mexico and taking care of people when they are sick. So you asked about vaccine equity though and we have an advocacy team that has been in Washington and working with members of Congress, the Biden administration as well, which has been very hospitable to our outreach, so that's another role that Partners In Health has played in this hemisphere.

June:

And of course, the other institution that you belong to is Harvard. What could Harvard be doing to play a role?

Paul Farmer:

Well, I would even go further that Harvard must play a role. First of all, it has played a role. The teaching hospitals of Harvard have... It's been hard on these hospitals. I know from Brigham how hard people have worked just clinically. So there's always that the basic science research that underpins not only the vaccines but also the therapeutics and the diagnostics, a lot of that has been done at Harvard. So on the research and clinical front, Harvard is doing something and must. And on the teaching front or the learning front as well, I think again, at least the department that I chair has been deeply involved across the world in direct clinical service, teaching and training, and learning, and also research. So Harvard can and must do that, I believe. 

            It is the oldest university in the United States and has a lot of resources that wouldn't be found in any other university. And you look at the medical school faculty and affiliates probably number 11,000. It's a huge enterprise, right? We have fewer than 200 medical students a year. So what are my colleagues doing? Well, they're doing all the things that I mentioned. They're doing research, they're training people, and always with training, you learn. And  many of them are clinicians, taking care of people. I would say, of course, Harvard has a big role to play going forward. And I think we've made substantial and substantive contributions from the very beginning of the pandemic.

June:

So as the David Rockefeller Center for Latin American Studies at Harvard, is this something we could be doing or should be doing?

Paul Farmer:

Well, I think even this podcast, we're talking about an urgent set of problems in Latin America. We're talking about some grievous losses. I mentioned some personal ones already but you look at 510,000 people dead in Brazil and then that's like one... So one in 400 Brazilians has died of COVID, that's catastrophic. And in some of these places as you know there's an under-counting of deaths, probably in most of them, not intentional, but it's very difficult to know how many people have died in the world. Even in places like Chile which is wealthier and not as socially disrupted in many ways as Brazil, right? So I think DRCLAS if we're still allowed to call it that.

June:

We are that.

Paul Farmer:

Just as at the medical school, I would say that certainly most of our faculty, whether at Brigham or at Harvard Medical School, most of our faculty have been involved in the COVID response, most. And what DRCLAS is not just obviously not just physicians or public health workers but historians, artists, it's got a wonderful university-style mix, but who is not concerned with COVID? Who among us? The artists, the anthropologists, the sociologist, the literary scholars, everybody has been touched by this pandemic. And that's very often the nature of a pandemic. And so even the work of memory, of honoring those who are gone, of imagining alternative going forward, I think DRCLAS has a lot to offer and especially given the very tight ties that DRCLAS has to Latin America. 

            And this is not an outfit that has a very distant relationship to Latin America. I know that from personal experience with DRCLAS. I know that especially in South America, but in the Caribbean and in Mexico as well, there are just so many wonderful ties and that could constitute and often does with DRCLAS a form of solidarity as well. I hope that everyone involved with DRCLAS can find a way to make some contribution to the fight against COVID because it's definitely the fight of our lives.

June:

Thank you very much, Paul. You've been listening to Paul Farmer. He's the chair of the Department of Global Health and Social Medicine at Harvard Medical School. He is also the co-founder and chief strategist of Partners In Health and the recent author of Fevers, Feuds, and Diamonds: Ebola and the Ravages of History. Thank you, Paul. 

Paul Farmer:

Nice to see you June.