Under an ‘America First’ president, will the U.S. corner the market on Covid-19 vaccine?

The United States is sprinting headlong toward the development and distribution of Covid-19 vaccines. But under an “America First” president, public health experts worry, the United States could seek to gobble up early supplies — and set the stage for prolonged devastation in the rest of the world.

Under “Operation Warp Speed,” the Trump administration hopes to have 300 million doses of vaccine ready for domestic use by January 2021. That outcome would largely satisfy domestic needs in the United States, experts say, but it would mean prioritizing low-risk individuals in one the world’s richest countries over high-risk health care workers and other vulnerable populations elsewhere in the world.

Such concerns prompted more than 140 world leaders and other dignitaries on Thursday to sign an open letter to all governments demanding that Covid-19 vaccines be considered a “global good” to be shared equitably. The letter came just a day after Paul Hudson, CEO of pharmaceutical giant Sanofi, angered the French government by indicating the U.S. would have first access to his company’s output.

“I do think that there’s a significant risk, at least under the current plan, that the U.S. will vaccinate not only health workers and high-risk populations and priority populations for breaking transmission chains, but also low-risk individuals first,” said Tom Bollyky, director of the global health program at the Council on Foreign Relations.

Bollyky warned any U.S. effort to inoculate its entire population could incentivize other countries to refuse to share peripheral materials needed for mass vaccination, including vaccine vials and syringes.

While it’s impossible to know which, if any, of the current vaccine candidates in development will prove effective and reach the market, the United States, along with China and India, appear poised to perhaps have first access to vaccines, given the scale of vaccine production capacity in those countries. Furthermore, in the United States, President Trump could invoke the Defense Production Act, giving the administration broad power to force companies to manufacture vaccines for domestic purposes — even against their will.

Pandemic planners for years have recognized that in the event of a dangerous pandemic, countries would be under pressure to nationalize essential products made within their borders. It happened in 1976, during the swine flu scare, when it was thought the world was on the brink of a 1918-like influenza pandemic. The United States — intent on vaccinating “every man, woman and child” — would not allow vaccine producers to export their product.

Determined to protect U.S. interests, the Biomedical Advanced Research and Development Authority, an agency under the Department of Health and Human Services, has spent billions of dollars to support the creation or expansion of vaccine manufacturing operations on U.S. soil, the agency’s former director, Robin Robinson, told STAT recently.

While the U.S. is perhaps being the most forthright about its intent to meet domestic needs first, experts believe many countries may succumb to the same type of pressure, especially if vaccine becomes available when a resurgence of transmission is underway.

“This may not be just a phenomenon of the U.S.,” said Bollyky, who noted several countries have barred exports of personal protective equipment worn by health workers and ventilators.

Scott Dowell, deputy director for surveillance and epidemiology at the Bill and Melinda Gates Foundation, said the foundation is working to try to ensure countries without production capacity have access to Covid-19 vaccine. One of its approaches is to support production capacity in small countries — places like Singapore and Switzerland — so that even if output is nationalized, local needs will be met quickly, after which, vaccine exports could begin.

Using the earliest available doses for health workers around the world would be in everybody’s best interest, Dowell said, though he acknowledged that arguments of equity may not “carry much water” these days.

“If you end up using your first 100 million or 300 million doses on low-risk teenagers in Switzerland, Singapore, the U.S., or other places — that could be a year’s worth of vaccine,” Dowell noted. “So you could lose a year immunizing really low-risk groups rather than using your vaccine in the most effective way that you could.”

Prioritizing vaccine in ways aimed at minimizing the impact of the pandemic globally would be to everyone’s advantage, experts argue. “If Covid-19 is circulating in any country, we’re all still at risk,” said Dowell.

Bollyky noted that the earliest vaccines to hit the market may not be the most effective ones, which would mean people vaccinated with them might still be susceptible to infection. Some vaccines that take longer to develop may actually produce a more robust immune response. “And if the U.S. doesn’t share in a timely manner initially, others will not either,” he noted.

Vaccinating all the citizens of a few countries won’t solve the economic problems of those nations. If the pandemic continues to rage in most parts of the world, global travel will remain disrupted, supply chains broken, economies in tatters.

“This is a global problem. It requires a global solution,” said Seth Berkley, CEO of Gavi, the Vaccine Alliance.

“It is the job of countries and political leaders to protect their own people and I certainly understand that,” Berkley added. “But it is also the job to have a longer-term view and understand the global nature of infectious diseases, as well as the global nature of science.”

“If we nationalize science, we will not optimize science,” he said.

Bollyky said there needs to be a public dialogue about how to deploy Covid-19 vaccines when supplies are scarce so that people can understand the consequences of the various approaches to their use.

“At the end of the day, if this comes across as some tree-hugging argument, it’s just not going to resonate,” he said. “And that’s not just here in the U.S., it’s in other countries as well.”

Dowell agreed, saying there are “huge incentives” for countries to maximize the impact of the rollout of Covid-19 vaccines.

“In the big picture, I’ll be surprised if we don’t see a planetary public health intervention implemented more effectively and faster than we’ve ever seen before,” Dowell said, though he acknowledged it will be “messy, for sure.”