Covid-19 cases are on the rise again, offering a stark reminder of the lessons we ought to have learned from previous waves. Far from being confined to Covid, most of these lessons apply to infectious-disease threats generally.
The pandemic showed that we have the scientific and manufacturing capabilities to develop and mass-produce safe and effective vaccines quickly in the face of novel threats. But the success of the Covid-19 vaccines also reflected two decades of tireless efforts by scientists in academia and the private sector; and when the moment of truth arrived, a timely injection of public funds carried that work across the finish line.
If there was one technology that played an especially pivotal role, it was mRNA -- or messenger RNA -- which offers a level of adaptability and scalability that makes it highly suitable for pandemic preparedness and response (PPR). Already, mRNA vaccines and treatments are being tested for a wide variety of diseases, and efforts are ongoing to expand the technology's usability (such as by improving its temperature stability). When the next viral epidemic hits, mRNA vaccines will most likely be the first solution out of the gates.
But though this scientific breakthrough saved countless lives during the last pandemic, the benefits were not equitably shared. One year after the rollout of the Covid-19 vaccines, approximately 73% of administered doses were concentrated in high- and upper-middle-income countries, whereas only 0.9% had reached low-income countries.
This disparity was even more pronounced for mRNA vaccines, which were primarily used in wealthy countries that initially hoarded supplies. Meanwhile, pharmaceutical companies maintained tight control over licensing and production, allowing them to reap eye-watering profits.
Another lesson of the pandemic, then, is that the mRNA platform will not realise its full potential unless we adopt a new approach that emphasises equitable access and the common good. That means pursuing symbiotic public-private alliances that are better designed to share both risks and rewards.
When companies benefit from public funds -- be it subsidies, guarantees, loans, purchase commitments, or procurement contracts -- they should be required to maximise the public value of such investments. The conditions tied to public funding for mRNA-related research and development, production, and distribution, for example, could ensure affordability, equitable access, and reinvestment of profits into health innovation. The mRNA technologies that result from a collective effort should not be under the exclusive control of a few private companies; rather, they should be considered part of a global health commons, and made available and accessible to everyone in need.
A comparison of the Oxford-AstraZeneca and Pfizer-BioNTech (mRNA) vaccines shows why such governance matters. Both partnerships received considerable public funding -- US$445 million (15.8 billion baht) to BioNTech and $1.3 billion to Oxford-AstraZeneca -- and both benefitted from large advance-purchase commitments. But while public funding for production of Oxford-AstraZeneca's vaccine was conditioned on the company setting lower prices in the interest of accessibility, Pfizer-BioNTech was permitted to set higher prices, and then rebuffed calls for it to offer licensing agreements and technology transfers. Next time, governments must ensure that contract provisions reflect the common good and regulate excess profit-taking.
Likewise, intellectual-property governance should seek to facilitate knowledge transfers between countries, in the interest of more decentralised innovation and manufacturing. We urgently need to redesign IP rules and practices to ensure that critical health technologies -- especially those heavily reliant on taxpayer funds and human capital (from researchers to participants in clinical trials) -- are governed for the common good. That is why the World Health Organization's (WHOs) Council on the Economics of Health for All, which I chaired, has called for patents on mRNA technologies to be governed on the basis of a public-good perspective, rather than a proprietary one.
In practice, this means that the criteria for granting patents -- including secondary patents -- should be made more stringent, including by requiring additional disclosures of information that can help governments evaluate the scale of the market power they are granting. Patents should cover only fundamentally new innovations, and they should be confined more to downstream technologies, in order to prevent the privatisation of basic research tools, processes, and platforms. The purpose of medical innovation should be to improve "Health for All" -- the WHO's central mission -- which requires timely and equitable access.
Providing access to essential IP and capital is critical to establishing the local and regional infrastructure needed to produce mRNA-based products. The WHO has explicitly recognised this need by launching an mRNA technology-transfer programme, with a hub in South Africa and new technology-sharing partnerships between companies in at least 15 low- and middle-income countries (LMICs).
Strong financial and political backing, however, will be needed to ensure this initiative's success. For example, LMIC governments could go further by establishing regional R&D hubs to foster collaboration between public and private actors on joint R&D portfolios.
More broadly, as governments take a renewed interest in industrial policy, they should recognise the opportunity to mobilise more investment, innovation, and growth around the goal of Health for All. Brazil, to its credit, has already aligned PPR with industrial policy through its Health Economic-Industrial Complex, which will use public procurement to create a domestic market for locally developed mRNA vaccines, yielding important health and economic benefits.
As international negotiations on a Pandemic Prevention, Preparedness, and Response Accord make headway, the issue of ensuring timely, equitable access to medical countermeasures -- including mRNA technologies -- must take centre stage. The mRNA platform has immense potential to deliver groundbreaking treatments and vaccines for diseases that primarily afflict LMICs and could be produced locally and affordably under the right IP regime.
To build this form of resilience, we must empower those countries' researchers, manufacturers, and governments to shape regional R&D and manufacturing ecosystems in the interest of the common good. Only then will mRNA technology reach its full potential. ©2023 Project Syndicate