Global health

Not a bit wise

A review of global health policy four years after the outbreak of the corona pandemic. A conversation with South African health scientist Dr. Lauren Paremoer.

Corona has revealed that the fight against a global pandemic can only succeed through globally equitable measures. Be it universal primary healthcare, sufficient production and equitable distribution of medicines or knowledge and technology transfer - four years after the outbreak of the coronavirus pandemic, the necessary changes to global health policy have still not been realised. We spoke to Lauren Paremoer, lecturer at the University of Cape Town and member of the People's Health Movement South Africa, about what this has to do with the WHO in times of geopolitical power shifts and what potential an international pandemic agreement would have.

medico: Our last conversation was two years ago. Back then, the world was in the middle of the Omikron wave. The campaign for the waiving of patents and the associated globally fairer access to medicines and vaccines against Covid19 had not yet been completely lost. Health was in the headlines every day. In the meantime, it has (again) slipped into the background of public attention in Germany. Have you also observed this development in South Africa?

Lauren: No. There is a big discussion about healthcare in South Africa. One of the reasons for this is that South Africa has been working for decades on the introduction of universal healthcare and a national health insurance scheme. Last year it was finally enshrined in law. For this reason, access to health services is a big issue. The second reason is that national elections are coming up this year. Access to basic health services, medicines, but also access to basic food and social services are politically important because many people - I guess it's the same in Europe - are struggling to afford their cost of living. The next problem is austerity. The government wants to keep public debt as low as possible. This leads to many cuts in the budget. This affects the wages of healthcare workers, but also other cuts to healthcare facilities. Only recently, medical professionals sent an open letter to the government calling on it to reconsider its austerity measures.

The fight against patents and thus the restriction of the production of and access to vital medicines by corporations is a long line of defence for global health. The corona pandemic has made the need for this more obvious than ever. Despite this, the campaign for a TRIPS waiver for the worldwide provision of vaccines against Covid-19 failed, not least because of Germany's behaviour. How did the South African public react?

The fact that the government had bought vaccines and they were therefore available minimised the importance of the waiver campaign in the eyes of some South Africans. Of course, they were also preoccupied with other issues, the waiver seemed less important, so to speak: we had vaccines, so why fight for a waiver?

On a continental level, however, healthcare remains very much a political issue. There are institutions such as the Africa CDC that are working very intensively on the consequences of the pandemic. They are thinking about how to create a research innovation system that meets the needs of the public health system. And how a production structure can be created that makes it possible to compete with multinational pharmaceutical companies on a global level.

The World Health Organisation has apparently also drawn its conclusions from the pandemic and is trying to realign itself. What role does the mRNA hub in Cape Town play in this?

The hub is a WHO initiative that aims to enable countries in the global South to produce mRNA vaccines independently of multinational pharmaceutical companies through the transfer of technology and knowledge. In my opinion, the hub has shown that scientists in developing countries can carry out successful drug research and development if they have the right resources.

The most important success was that the Hub was able to develop at least the concept version of an mRNA vaccine within a year without the support of patent holders. This provides an empirical basis for rejecting arguments that there is no capacity in the so-called developing countries. And it creates an epistemic community of scientists working together and sharing information. But the Hub also works within the existing intellectual property system and does not challenge patent protection. This limits the possibilities in the field of research and commercialisation. In South Africa in particular, Moderna has been granted a comprehensive bundle of patents covering all types of vaccines that use mRNA as a basis. This means that even if the hub uses mRNA as a platform for the production of tuberculosis vaccines, these could fall under Moderna's patent protection and cannot be reproduced locally. This is a problem.

The mRNA hub is just one of the initiatives developed by the WHO in response to the failures during the pandemic. The international pandemic agreement, in which the WHO member states want to commit to regulations in the area of pandemic prevention, preparedness and response, is more comprehensive. However, the ongoing negotiations on the agreement clearly reflect the intergovernmental controversies in dealing with the coronavirus pandemic - for example, how strongly the focus is placed on prevention and early detection measures or the extent to which equitable access to vaccines and medicines is prioritised. From your perspective, what kind of agreement would be necessary to learn from the mistakes of the past?

The agreement was proposed by the EU at the beginning of the TRIPS waiver campaign. The EU's response to the campaign was actually that the flexibility of intellectual property was not really the problem. Rather, it was to set up a binding treaty that would supposedly address all dimensions of equity in pandemics. What we are now seeing, however, is that the points proposed by many African countries, Bangladesh and others - also known as the equity bloc - regarding equity are being neglected and are not reflected in the text. Instead, it is becoming apparent that Europe is emphasising surveillance systems and access to pathogens, but equitable access to medical products, guarantees of technology transfer, suspension of intellectual property rights during pandemics, and financing are being marginalised . So far these proposals seem to be a no-go for the Global North. Furthermore, efforts to institutionalise surveillance measures should not result in developing countries having to make investments or use public health budgets to set up control systems that are not adequately compensated through new financing mechanisms. This would risk moving funding from investments in basic health services to invest in the surveillance of pathogens with pandemic potential. There is currently very little time left to negotiate the pandemic treaty and there is a high risk that the final agreement will be a hollow agreement unless we mobilise for binding regulations on equity.

At the same time there are fears that the increasing polarisation between the WHO member states will hinder its future work as an evidence-based entity

Yes, the meeting of the Executive Board (EB) in preparation for the World Health Assembly at the end of January, for example, was a stage on which the geopoliticisation of health issues could be observed. On the opening day of this year's EB meeting, Russia proposed that climate change be removed from the agenda. Another example is the fact that the decision on WHO accreditation of the Centre for Reproductive Rights was prevented because its work was argued to be too political by some regions. The WHO, as an institution responsible for advising on global health issues, is thus becoming a venue for geopolitical power politics and is being blocked in its actual function.

From Covid to the Ukraine war to the Gaza war: the international power shifts are palpable.

This was already the case before Covid, but it has intensified. Geopolitics is more on the agenda than it was a decade ago. Before Covid, it was the issue of trade: the Trump administration's dispute with China and the US's dependence on certain key imports from China. And before that, there was the whole issue of energy security, which also had a geopolitical dimension. The disputes over the influence of hegemonic powers such as Russia, China and the EU on the African continent also existed before Covid, for example as part of the Silk Road Initiative. China had already invested heavily in the African continent before. We should observe how the new expanded BRICS alliance will deal with these geopolitical tensions. The original position of the alliance was to represent the interests of developing countries rather cautiously vis-à-vis the global North. I think it will be interesting to see how the BRICS will position themselves in the future.

Do you interpret the South African lawsuit against Israel at the International Court of Justice (ICJ) as a manifestation of this new positioning? No Western country has yet been sued there for genocide. Is this further evidence of the decline of Western hegemony and the increasing geopolitical power of the BRICS?

I don't see the ICJ case so much as a geopolitical shift. I am sceptical about how much political influence it gives South Africa. The important thing is that it raises the same question that was raised by the TRIPS waiver campaign: Do we as a community of nations all want to act according to the codified rules of the multilateral system? The experience of developing countries in the past has been that the rules are applied unevenly. In relation to the TRIPS waiver, this meant: Can we as a community of states promise ourselves to apply the flexibility already recognised in the TRIPS agreement and endorsed in the DOHA declaration? If we stick to the agreements already in place, can we be sure that there won't be a political backlash? The way the waiver campaign unfolded has given a very clear answer: No, we can't. The situation is similar with the ICJ case: can we apply the law that the international community has formulated and ensure that genocide does not occur? The answer to this question is just beginning to emerge.

The same applies to COVAX, where countries promised to procure vaccines globally and distribute 20% to the most vulnerable populations in each country, which also did not happen. The rules were circumvented by wealthy countries that could afford to enter into bilateral agreements with manufacturers, but also by middle-income countries. South Africa also made bilateral agreements. While elsewhere the drugs could not be consumed as quickly as they were stockpiled, vaccines for particularly poor countries were therefore de facto deferred and not accessible or only accessible after a delay.

Based on the experience that successful efforts against the pharmaceutical industry at multilateral level are very unlikely, health activists from the People's Health Movement are of the opinion that the matter must be taken into their own hands. Among other things, they are calling for pharmaceutical research and production to become a public good. What potential do you think such an initiative has?

Healthcare is a genuine task of the state, which should also include a public pharmaceutical industry. With its initiative for pharmaceutical research, development and production, PHM wants to show that a pharmaceutical industry orientated towards the common good is possible. Such initiatives are important, because even when it comes to something like TRIPS flexibilities, we are always dealing with the private pharmaceutical industry, which is the most important innovator and producer. It is interesting that there is a kind of political opening in the EU itself, for example by rethinking the pharmaceutical strategy, driven for example by the high costs for healthcare systems when medicines are sold with huge profit margins. Changing the structure of pharmaceutical production is the right initiative, at the right time: while Germany reveals itself as a champion of patent protection and the disappointment over the lost TRIPS waiver campaign is great. It will not be an easy fight, but it will be a fundamental one.

So it is also possible to raise wider issues: If the mRNA hub has developed capacity to produce drugs based on technology and knowledge transfer, do we want to ensure that the commercial phase takes place with the help of a state-owned pharmaceutical industry, or do we want to privatise the profits, for example through public-private partnerships? We should fight for a production strategy in public hands. Because then we really have the power to decide which pathogens should be prioritised, what kind of drugs should be produced and how they should be administered, orally or by injection, depending on the purpose. When public interest, rather than profit margin, is the main point of reference, products are created that are better suited to the context and also have a higher priority in terms of public health needs.

We have the same debate in Germany. Pharmaceutical companies are failing to supply essential medicines for children such as ibuprofen or antibiotics. There is exactly one manufacturer still producing paracetamol syrup in Germany. All the others have withdrawn from the market because it is not profitable for them to sell it. At the same time, production in Germany is too expensive. The global market is dominated by just a few manufacturers and the square of the circle is how to ensure access to and distribution of medicines without spending too much money on local production and at the same time reducing dependencies.

If the goal is still profit over health, then there is no viable solution. The Covid pandemic has shown that if you don't have enough expertise and infrastructure in a region to produce basic medical products, if there isn't even a factory that could be repurposed for the production of medicines, you are at a disadvantage: you are forced to import. A good and very concrete example of the public pharmaceutical industry is Brazil.

You mean the research, development and production of medicines under the Fiocruz government programme?

Yes, and Bangladesh and other countries in the equity group, for example, during the negotiation process for a pandemic treaty has been advocating for setting up production facilities for pandemic products worldwide and especially in regions of the global South. These kinds of proposals are important from a regional perspective, and it also means that there is more for everyone, and that is a net gain.

The interview was conducted by medico health referent Felix Litschauer.

Published: 27. March 2024

Donate Now!