Vaccine Nationalism and Building Equity in Global Health: A Conversation with Dr. Ingrid Katz

https://doi.org/10.56927/386460

Interview by Christopher Li

INTRODUCTION

HHPR Associate Editor Christopher Li interviewed Dr. Ingrid Katz, MD, MHS, who is an Associate Physician at Brigham and Women’s Hospital, Associate Faculty Director at the Harvard Global Health Institute (HGHI), Associate Professor of Medicine at Harvard Medical School, and an affiliated scientist at the Center for Global Health at Massachusetts General Hospital. Dr. Katz has worked extensively in global health, researching barriers in healthcare and developing sustainable, socio-behavioral interventions to improve care in low-resource settings. Dr. Katz has also served as an Editorial Fellow and National Correspondent for the New England Journal of Medicine, where she has written on many topics in healthcare, including a piece entitled: “From Vaccine Nationalism to Vaccine Equity–Finding a Path Forward.”

ARTICLE

Christopher Li (CL): Thank you so much for your time today, Dr. Katz. Could you tell us about your career path, what you do, and how you became involved in researching global health?

Dr. Ingrid Katz (IK): Sure. I’m a physician, and I trained in infectious diseases. I got involved in global public health in the mid-90s when I finished college. I was really very engaged in the HIV response: the 80s and 90s were a time of reckoning for us globally with another pandemic that still lives with us. A lot of us, when we talk about our interests and our engagement in global public health, got our start during the era of HIV. I had gone to Amherst College, where I was a liberal arts major: History and French double major, and not at all headed into global public health, but I got increasingly involved in HIV activism in the US, and then got a Master’s in Public Health at Johns Hopkins Bloomberg School of Public Health, where I subsequently was drawn into what was called “International Health” at the time. That was what started me on the road: I worked in Vietnam for a year, and then I subsequently decided to go into medicine. It was a bit of a journey, since I hadn’t done any pre-med courses, and I needed to do a post-Bac program to get all my pre-meds done. I ended up at UCSF for medical school in San Francisco. I then came to Brigham and Women’s Hospital to do my residency in Internal Medicine and then went across the street to Beth Israel to do a fellowship in infectious diseases. I came back to The Brigham to do another fellowship in global women’s health. That’s really the path; it’s been very organic. I’ve really followed the work. For anyone who’s thinking about global health, you really want to think about what it is that you’re interested in and what you’re committing to and ensuring that equity is front and center in your mind in terms of how to engage.

CL: Thank you for that answer. What were some of the most important lessons you learned as an activist in the HIV/AIDS movement of the 1980s and 1990s?

IK: I think what I learned is that everyone deserves a seat at the table. That was really the first time activists were very powerful and effective in terms of moving an agenda forward. Anthony Fauci, who we all know now (all of us knew him in the HIV world before, but now he’s obviously internationally renowned) was anchoring the NIH response. It was really the activists who pushed — I mean, they were literally lying down in front of NIH saying, “We need better drugs; we need faster clinical trials.” — it was one of the first times that a group of people assembled so effectively and really moved the needle. That’s what I’ve carried with me forward: that we have work in partnerships — and must be thinking about the communities that we’re serving in this journey.

CL: I want to transition a bit to some other topics, especially relating to global health equity, and more specifically, inequity in our current moment with COVID-19. How would you define vaccine nationalism, or what is vaccine nationalism?

IK: Vaccine nationalism is a term that got coined in relation — particularly during the COVID-19 pandemic — to countries prioritizing their own self-interests for purchasing vaccines for their population. It tended to favor high-resource countries that were able to procure vaccines early in the pipeline before it even reached the manufacturing stage. Essentially, it was a hoarding of supplies.

CL: You mentioned this idea of self-interest: it seems well established that a domestic recovery isn’t really congruent with the idea of vaccine nationalism, because “domestic” recoveries are dependent on a global recovery from the pandemic. Why do you think there’s such a disconnect between this nationalistic response from high-resource countries, especially when it is directly opposed to their own recovery, economic or otherwise?

IK: I think part of the challenge is a lot of people who are at the decision-making tables aren’t necessarily taking that view. There’s much more focus on short-term acquisition. Fundamentally, vaccines are incorrectly viewed as commodities instead of public goods, so when people are thinking about the commodification of something that should be publicly available, you’re already setting up an inherent inequality that shouldn’t exist. When a big pandemic like this hit, I don’t think, at least initially, the longer-term ramifications of only vaccinating one’s own population were fully considered, even though it was clear from the get-go that this was a global threat. This traveled all the way around the world and back again. There was no question that if you don’t pay attention to the whole globe there’s no way we have a chance at eradication.

CL: In relation to vaccine nationalism, it seems that high-resource countries would be able to pay more to these vaccine producers and that economic inequity already set the stage for something like vaccine nationalism. How do you view that sort of relationship of the private company’s interests and how that perpetuates vaccine nationalism?

IK: In this circumstance, relatively few pharmaceutical companies were involved from the get-go, which created a sort of monopoly, allowing them to set higher prices that may tip towards profit. I think this underscores the concern that many of us have around neocolonialist tendencies of for-profit industries in this space. Again, I don’t think there’s a singular individual at fault here. I think this is a system that’s set up to reward profit generation, as opposed to ensuring that we have an effective public health response. You can see that by how investments are made. One of the real disconnects we’ve seen with COVID-19 is the incredible efficiency and development of scientific technology and how it essentially got completely decoupled from the global public health response. That shows, and really represents, decades of investment in scientific discovery, and the under investment in public health, both domestically and globally. You have these two really distinct responses, one driving towards discovery, and then, of course, subsequently profit generation within the pharmaceutical industry, and then public health responses from cities, counties, states, nations, that are completely under-resourced, under-coordinated, and essentially unable to meet this moment. It’s essentially two different processes that are happening.

CL: Vaccine nationalism has often been reported in the context of hoarding doses to the extent that low-resource countries could not purchase from these pharmaceutical companies. But how does vaccine nationalism also affect each subsequent step of the supply chain beyond this initial step of purchasing doses, from the patent process or the manufacturing process?

IK: There are a lot of steps along the way that are impacted by, again, what I think is vaccine nationalism or neocolonialism that have played out throughout the world. We can talk about patents, for example. Some companies have really touted the fact that they have IP waivers. The problem is you’re essentially allowing people to make this good, but you’re not sharing the recipe. I often use the analogy of chocolate chip cookies — we will let you make them in your oven, but we’re not going to exactly tell you how to bake the chocolate chip cookies. So of course, there’s no way that somebody can make a vaccine like this without understanding the true process involved. Then I think the second piece is the procurement of goods necessary to make them. You have to have all of the ingredients for your chocolate chip cookies. If you don’t have the chocolate chips, how are you going to make it? A lot of places around the world don’t have access to all the materials they need. Third is, of course, the manufacturing capability itself and distribution. Manufacturing capacity exists in a few key countries: India, South Africa, and Brazil, among a few others, have a history of manufacturing vaccines that get distributed throughout the region. India is one of the most effective in terms of ramping up big vaccine campaigns. The problem, again, is that if you don’t ensure that you have hubs all over the globe, that have a waiver to produce these vaccines, have all the raw materials and have the exact way to produce it, there is no way that you can meet the needs of the globe with just a singular manufacturing capability in the United States. Essentially, along the way, you have all these steps that got highly regulated. A lot of the pharmaceutical industry said, “Well, we don’t want our vaccine manufactured at Point X because we can’t control its quality.”

I think this speaks to the lack of investments over time that have been made in manufacturing capabilities globally. If we could ensure that we have hubs all over the world that have this capability — I would argue we have some, certainly not enough — then we have ways to keep and ensure regulation and FDA standards can be met. Then we have the ability to truly address global pandemics, because I can guarantee you this is not the last time that we’re going to see a global pandemic. We need to make the investments now for the future so that we have these hubs all over the globe that can quickly ramp up and manufacture vaccines or therapeutics as needed.

CL: In your piece regarding vaccine nationalism and vaccine equity in the New England Journal of Medicine, you mentioned how India was able to obtain comparatively more doses to other low-resource countries because of their manufacturing capacity. As you’ve mentioned, this is a very neocolonial framework where the ways in which they benefited were due to how they could help the larger pharmaceutical company or the high-resource countries itself. What are some steps we can think about to decolonize vaccination from its current state?

IK: Vaccines shouldn’t be commodified. I think they should be global public health goods. I think you can have large bodies like GAVI [GAVI, the Vaccine Alliance and previously the Global Alliance for Vaccines and Immunization], which is a global partnership, that ensure that low-resource settings have access to both therapeutics and vaccines (but mostly vaccines) at steeply discounted prices. They essentially subsidize or underwrite the cost. GAVI and other organizations have the potential to leverage the collective power of multiple countries to ensure that there are contracts that are equitable. They can essentially write in equity provisions to make sure that there are adequate ways to distribute vaccines throughout low-resource settings. That means sharing IPs, tech, knowledge, training, and support in places that have emerging vaccine manufacturing capacity like India.

There has been some progress around this in production. South Africa has Pfizer-BioNTech, and J&J [Johnson and Johnson], but it’s unclear how much this has been produced within country. I think part of the challenge is prior colonialist structures set up a system where low and middle-income countries were competing against each other. You had countries that had slightly more resources competing against countries that had slightly fewer resources. Again, what you need are large multinational bodies, bringing everyone to the same level and building on the power of the collective, and not pitting countries against each other, because that is the legacy of colonialism. We have to collectively bring people together across multiple countries to ensure that everyone has access to these vaccines.

CL: Like you mentioned, these international and multinational coalitions like GAVI and COVAX [COVID-19 Vaccines Global Access] do exist. How do you think about their effectiveness, or how do you think about the way that they’re operating within the context of vaccine nationalism? Oftentimes, it seems like this is like something that high-resource countries put on the backburner as a secondary step to their domestic responses.

IK: I think that’s absolutely true. I think they are often put on the backburner. Again, this speaks to a somewhat myopic view of the global collective and need for collaboration. A lot of global health diplomacy has been used more as a foreign policy tool, instead of focusing on the humanitarian needs that people have throughout the world. It perpetuates the idea again of colonialism, where the tool is focused on leveraging soft power: the notion of the North American savior, that’s going to come in and save people in low-resource settings. I think this is the danger when you have both these inherent inequalities, while simultaneously the people sitting at the table making the decisions only represent the views of high-income nations. This goes back to the earlier point of how do you make sure that the people at the table are the ones who are getting directly impacted by these decisions, and not just the people who are going to now disperse the funds as they see fit? I do think if you can truly leverage the power of the collective and they have a voice and a seat at the table, that can be effective. But I think these tools have not been effectively utilized, especially in the context of COVID-19.

CL: As you mentioned, oftentimes these multinational tables that are set up aren’t built with low-resource countries in mind. How can we shift the idea of how we’re thinking about this table to become more equitable and to genuinely include low-resource countries in the conversation?

IK: That is really the question, isn’t it? I think it’s going to take conscious work. We can’t let it happen by chance; we’re going to have to ensure that we have a mindset towards this as we move forward. The same way we talk about thinking intentionally about diversity, equity, and inclusion in the United States, we have to be thinking about this as part of the work that we do globally: with a decolonizing mindset. That comes in very pragmatic forms. It isn’t just an ethos. It comes in every step of the supply chain, as we just talked about. From the creation of vaccines and therapeutics, we need to ensure that we have scientists in-country that get supported. That can come from important funders like NIH to ensure scientific training and capacity where they’re needed. It comes from leveraging opportunities to collaborate with partners, developing effective manufacturing, and then ensuring that people are fully trained so that they can be part of these global conversations. Again, turning back to the HIV pandemic, I do think we have a track record there. We’ve gone through some bumps with HIV: we made some huge mistakes globally, but I think we’ve also learned some important lessons along the way. I hope that we can really leverage that knowledge to ensure that we are incorporating the right lessons coming out of that, particularly making sure that we are completely intentional about bringing people to the table who are directly impacted by these decisions.

CL: We’ve talked about HIV/AIDS and vaccine nationalism in the context of COVID-19. How and where else do you see nationalism affecting global health responses and global health equity?

IK: Unfortunately, it’s in every aspect of global health. Vaccines are a really interesting and important example, particularly in the context of a pandemic. But if you consider every aspect of human health, there isn’t really a place that isn’t impacted by nationalism and a history and legacy of colonialism, along with the ripple effects of that. We were talking recently about the mental health effects of COVID-19 and those ramifications for people. In a low-resource setting where you don’t have infrastructure, you don’t have psychiatrists and social workers and people to ensure that you have adequate mental health services — and I would say in many low resource places in this country, we see this too–people are not getting the care they need. So, it’s a constant ripple effect. I feel like COVID-19 was a stone thrown into an already complex pond and we are seeing all the waves comes out of that. COVID-19 has not evened the playing field – it has served to magnify the inherent inequalities that were already there. Sadly, these inequalities were not novel, COVID-19 just exacerbated it.