Leading the COVID-19 Vaccination Response: Lessons Learned from the Smallpox Eradication Campaign
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This expert column was written by Adi Radhakrishnan.
With more than 40 million known cases worldwide, and many countries already experiencing a second surge, the global recovery from COVID-19 still appears far away. Experts recently forecast that that the full course of the pandemic will likely run for two years and will only subside if there is adequate scientific innovation in developing vaccines and treatments to confront the virus.
But, just as the development of a COVID-19 vaccine is necessary to lift country-wide lockdown measures, so too is the assurance that all nations will have equitable access to an effective vaccine. Any semblance of “treatment nationalism” will only exacerbate the longevity of the virus, and the stockpiling of resources thought to have some curative benefit for COVID-19, such as Remdesivir or Dexamethasone, has already been a cause of concern. Ultimately as long as one country continues to grapple with COVID-19, the whole world remains at risk.
At first, it would appear that the World Health Organization (WHO) is the natural entity positioned to ensure equal access to medicines worldwide. However, while the WHO has the operative authority to articulate standards for vaccine development and distribution, it is not necessarily best situated among international organizations to implement these standards themselves.
To engage in implementation would pull the WHO away from its normative strengths in scientific knowledge sharing and coordination. Unlike U.N. agencies, such as UNICEF which runs on-the-ground field operations providing essential items like vaccine doses for children, the WHO lacks any sort of robust field capabilities that would make frontline implementation of vaccine distribution feasible. Thus, the international community should look to the WHO for its ability as an advisory body built on scientific expertise for a COVID-19 vaccination strategy, rather than ask it to engage in an implementation scheme for which it is ill equipped.
The Smallpox Eradication Programme
The WHO has had great success embracing its normative strengths in the past when it coordinated a vaccination campaign designed to eradicate smallpox, a disease of pandemic proportions itself. The WHO initiative, launched in 1967, placed the organization as a central hub for smallpox expertise, convening stakeholders and enabling a mass vaccination and monitoring campaign designed to address and contain smallpox outbreaks. While characteristics of the smallpox disease itself did aid eradication efforts, such as the high visibility of symptoms that made track and trace policies easier to implement, the successful vaccination effort provides key lessons that can inform an effective WHO-led COVID-19 effort.
In its role as an expertise-built advisory body, the WHO brought together vaccine distributers, country managers, national government epidemiologists, primary health workers, and field workers to establish clear guidelines and infrastructure in order to supply and administer a quality vaccine. The effort was successful due to the active efforts to engage most countries, strong coordination among national authorities, and intensive ongoing research to evaluate progress and deal with any issues that arose. The WHO developed solutions to problems attuned to the virology of smallpox and specific country needs, such as using freeze-dried vaccine material for temperature stability and introducing a bifurcated needle that required only one-fourth of the amount of vaccine previously needed.
Central to the smallpox strategy was the WHO negotiating political, economic, and social coordination among a wide array of actors. In envisioning its role in ensuring access to COVID-19 vaccines, the WHO ought to focus on setting such standards and coordinating efforts among member states, just as it did during the smallpox immunization plan. Certainly, WHO leadership in establishing a special program was central to the success of the smallpox effort. But as Dr. William Foege, the epidemiologist credited with establishing the smallpox strategy, described in his book, the smallpox success required a combination of strong communication, effective leadership, and building successful coalitions between central governments, international organizations, and private industry working together for the sake of achieving a common goal.
Leading a COVID-19 Response Strategy
COVID-19 presents a novel threat, which requires pharmaceutical innovation for a quality vaccine. For a successful pandemic response, a WHO-led coordination effort for COVID-19 must build a cohesive coalition capitalizing on public-private partnerships and leading the private, philanthropic, and public sectors to improve upon access to medicines worldwide.
Efforts to bring public and private sectors together have already begun through the WHO sponsored COVID-19 Vaccines Global Access (COVAX) initiative, a global funding mechanism that seeks to accelerate vaccine development, mitigate risk by pooling resources, as well as help buy and distribute vaccine doses. Engagement from over 170 countries ensures increased economies of scale in production, and enables distribution networks established by Gavi, the Vaccine Alliance, and the Coalition for Epidemic Preparedness Innovations (CEPI) to provide the vaccine to low- and middle-income countries.
COVAX is a large, and arguably necessary, step in ensuring equitable access to an eventual COVID-19 vaccine. But, concerns of the impact of intellectual property rights on vaccines, limited transparency of the contracts entered into with manufacturers, and low civil society participation loom large. But, the development of precise procurement and public distribution standards from the WHO will enable more effective results. Normative recommendations will establish clear and objective global allocation policies, which will clarify what exactly is necessary from producers, procurement agents, and distribution entities for a successful mass vaccination strategy.
First, the WHO should continue to build on existing equitable distribution guidelines, elaborating on ethical standards regarding how and when to prioritize vulnerable populations when vaccine supply is scare. Next, the WHO should set principles defining equitable distribution between countries, establishing a multilateral governance framework that could address accountability, transparency requirements, and participation requirements to increase country commitments for equitable vaccine distribution. Then, the WHO should then continuously update recommendations, relying on their scientific expertise, to update recommendations to be precise and targeted to known dynamics of COVID-19 transmission and virulence. The WHO should also develop a coherent communication strategy to apply throughout the COVAX framework to combat the rise of anti-vaccination sentiment.
Finally, the WHO ought to empower national authorities to plan distribution scenarios, accounting for bottlenecks, logistical constraints on the grounds, or even emergence of new COVID-19 epicenters within national borders. A robust advisory role by the WHO would ultimately provide guidance on clarifying roles, responsibilities, and medical chain management attuned to the specific epidemiological characteristics of COVID-19.
When it comes to addressing access to medicines issues for COVID-19, the WHO need not take on an implementing role by soliciting contributions, building a vaccine stockpile, and investing in warehouses, vehicles, and a field team to effectively distribute a vaccine. Rather, it ought to focus on its technical capabilities, and rely on other entities such as UNICEF or OCHA to engage in field-level immunization efforts.
Just as it did with smallpox, the WHO should establish recommendations that articulate a set of multilateral and cross-sector principles for a COVID-19 immunization response. Then, the WHO can work in tandem with nation states, distributors, procurement agencies, and established international humanitarian response entities to adopt and enforce the scientifically based standards deemed best suited for an effective worldwide vaccination program.
Adi Radhakrishnan is a JD candidate in international human rights and global health law at Columbia Law School.