156 countries are teaming up for a Covid-19 vaccine. But not the US or China.

When SARS-CoV-2 started spreading, the countries of the world had no pandemic vaccine plans in place. But a lot can happen in six months.

Today, there are 40 vaccine candidates for the coronavirus being studied in humans — including nine in the final phase of testing.

There’s also the world’s first attempt at a global effort to ensure that, when we have a working vaccine or vaccines, all countries have access, no matter their GDP.

The initiative is called Covax, and it aims to support the development and equitable distribution of 2 billion doses of Covid-19 vaccines before the end of 2021. It’s the biggest multilateral effort since the Paris climate agreement, according to Seth Berkley, the CEO of Gavi, the Vaccine Alliance, one of the partners behind Covax, along with the World Health Organization and the Coalition for Epidemic Preparedness Innovations (CEPI).

It’s the “busiest period of my life,” he told Vox recently.

Paul Morigi/Getty Images for Concordia Summit

As of Monday, 156 high-, low-, and middle-income countries — representing 64 percent of the global population — signed up to Covax, the WHO said in an announcement. That’s a remarkable feat of collaboration, particularly at a time when globalism and multinationalism are under threat.

Covax has two major parts: The “Facility” is a purchasing pool for higher income countries, and the “Advance Market Commitment,” or AMC, is a fundraising effort for poorer countries.

By promising to buy a certain number of vaccine doses from manufacturers, countries that join the Facility get access to any vaccines that are approved in Covax’s portfolio, while also creating a global market for the shots and driving prices down. The AMC, meanwhile, directs development aid as well as private sector and philanthropy donations to low- and middle-income countries that may not otherwise be able to afford a coronavirus vaccine. (So far, the AMC is partially funded with about $700 million of the $2 billion needed by the end of 2020, according to Gavi.)

Together, all countries that are part of Covax are supposed to follow a plan for fairly distributing the vaccine in order to prevent self-interested hoarding at the national level. By working together, the highest-risk people in every country can get immunized, instead of all residents of the wealthiest nations.

But despite the great promise, Covax has also faced numerous challenges and some criticism. Many higher-income countries in the Facility have also inked bilateral deals with manufacturers, which Anna Marriott, an Oxfam health policy adviser, called “double dipping.” “[It] means that they are not truly working fully and fairly ... to see equitable access to a vaccine,” she said.

Meanwhile, two of the world’s largest economies — the US and China — have decided to sit Covax out, causing some observers to question whether the initiative will achieve its goal. As Lawrence Gostin, a global health law professor at Georgetown University, put it: “[Covax] will be an enormously helpful initiative, pushing the world toward equity. But with major countries like the US and China sitting on the sidelines, Covax won’t have the financing and political muscle to assure global equity.” He added: “I still foresee millions of poor people not having rapid and affordable access to a Covid-19 vaccine.”

I recently called Berkley to find out more about how Covax will work, and why, despite the challenges, he thinks Covax can get the world vaccinated for Covid-19 — if, that is, at least one of the vaccines in Covax’s portfolio works. What follows is a transcript of that conversation, edited for length and clarity.

Julia Belluz

Can we start with the historical context in which Covax was created? What happened in the past with vaccine manufacturing in an outbreak and what will happen now?

Seth Berkley

Well, in the past, you’ve had outbreaks where the wealthy buy all the [vaccine] doses and there’s none available for the developing world.

[The Covax effort] isn’t going to be perfect, obviously. But the idea is to have vaccines available simultaneously in developed and developing countries.

So the fact that the world is coming together to try to put together a shared vision and a shared facility itself is historical. And I believe that this is the largest multilateral effort since the Paris climate agreement. So at a time of not a lot of interest, or reduced interest in multilateralism, I think that’s a positive thing.

Julia Belluz

The bigger picture that I keep coming back to is that the world was overdue for a pandemic. You and many others have talked about this for years. So if we expected one, why is Covax happening now, six months in?

Seth Berkley

It’s a very good question, and I think the answer is quite clear. With smaller pandemics, you capture people’s attention — including the media. I remember during the West African Ebola outbreak, it was called the “ISIS of infectious disease.” It was the news story of the decade. Then, as soon as it’s over, people just go back to life and that’s yesterday’s problem. It hadn’t really captured people for [the] long term.

So my hope is that the silver lining [of the Covid-19 pandemic] will be that people will say, “Okay, now we understand that infectious diseases really can make a difference.” If you think about it, the International Monetary Fund is talking somewhere between $9 trillion and $12 trillion [the amount countries need to invest to counteract the economic effects of the pandemic]. And that’s assuming that we get life back to normal at the end of next year.

Given that cost, the type of money you’re talking about to do a little bit of prevention is not even a rounding error. And the challenge has always been, during the acute time people are interested, and then afterwards people lose interest and don’t want to invest.

So I think it may be different this time.

Julia Belluz

If Covax is successful, could the architecture you’ve created be used in future pandemics?

Seth Berkley

That’s correct. This type of solidarity is critical because otherwise what you’re going to end up with is just constant reintroduction of infections and the inability to go back to normal.

Julia Belluz

Countries that join Covax will have access to the dozen vaccines the organization invested in, assuming clinical trials prove they are effective and safe. How did you choose which vaccines to bet on?

Seth Berkley

The original idea was to try to get to 12 to 15 different vaccines. And this is a partnership. CEPI [the Coalition for Epidemic Preparedness Innovations] is part of it, and they already have nine vaccines in their portfolio, but of course, we’ll see how those vaccines play out. Originally, CEPI was looking for speed, scale, and access, and vaccines that could be produced at scale in 2021 because the idea is to try to get up to 2 billion doses by the end of 2021.

We’re also having conversations with other manufacturers that haven’t been working with CEPI, and then also with the Gates Foundation, which has a portfolio. The Gates Foundation ... is looking for vaccines that might be complementary to [CEPI’s] — to have different types, ease of delivery, low cost, and scalable manufacturing. So, we’re looking at different types of vaccine to get the broadest portfolio possible.

Julia Belluz

So there is a chance all the vaccines in Covax’s portfolio fail?

Seth Berkley

Nobody knows whether any of these are going to work or not. Obviously, data’s beginning to come in to show [the vaccine can generate] immunologic reactions, and showing antibodies to the spike protein. But of course we don’t have definitive proof that antibodies provide durable protection against the virus. So these are questions that are going to have to come, which is why this whole collaboration is so unique.

Julia Belluz

Assuming we have vaccines that work, can we talk a bit about how they would be rolled out in countries. I read that the idea is that 20 percent of the population — the most high-risk groups — in each country in Covax would be vaccinated in the first year?

Seth Berkley

Originally, we started with a 20 percent suggestion, and that was calculated based basically on an average — the numbers of health workers who were front-line and at risk, particularly in developing countries, [as well as] elderly and other high-risk groups. But you have countries like Japan, where the demographics of the population are such that there’s many more elderly. And then you have countries like Nigeria, where the average age is 19. So that balances out, and that’s why we [now] allow countries to have a range — 10 to 50 percent — to choose where they start.

[There are likely to be] supply limitations in the first 12 to 18 months. And therefore we would try to get some vaccine to every country rather than a few countries fully vaccinated and everybody else having none.

Julia Belluz

Already, a bunch of high-income countries and regions — Australia, Canada, the United States, the United Kingdom, Japan, the European Union — have signed bilateral agreements with manufacturers to guarantee doses of vaccines for their populations before they’re even licensed. Don’t these deals undermine the Covax initiative?

Seth Berkley

I mean, would the world be better off in a situation where everybody worked multilaterally? Absolutely. Because you could then use the resources most appropriately. You could scale up the promising [vaccine] candidates.

But the reality is that countries, or some countries, are going to do bilateral deals. So my job is not to bemoan that, my job is to try to work with those countries and try to make sure that we end up with fair allocation. And for those countries, for the ones, frankly, that can afford a full portfolio of [vaccines] themselves, if you want to spend $10 billion or $11 billion like the US does, you can build a big portfolio. And that has huge advantages for the community because they pay for a lot of clinical testing, including phase 3 trials. They do manufacturing scale-up and process engineering.

And so that has a value for all the other groups; many other [developing] countries can’t afford to do that. So the challenge for those countries is either they invest in seven, eight, nine, 10 bilateral deals, or they try to work with somebody who has a large portfolio with the understanding that if their product falls out then they have access to other products.

Julia Belluz

You had to push back the deadline by which countries could join from the end of August 31 to September 18. What challenges did you face in that period in trying to get high-income countries on side?

Seth Berkley

During that period we added the optionality side of the agreements, [where countries can make an optional commitment, paying a higher amount for vaccines later but avoiding any guarantees of a purchase]. And that was because many countries wanted to have some ability to opt out of certain vaccines. So that was the adjustment we made. And the obvious challenge for all of us is trying to move as quickly as possible to go ahead and put deals in place because over time more and more bilateral deals are getting done and doses are getting promised to others.

Julia Belluz

But will the fact that countries can opt out make it difficult for manufacturers to scale up and make enough vaccines for everybody?

Seth Berkley

I don’t think that really changes anything. All it says is, if I’m a country that has done a few bilateral deals, I want to join Covax because you might have some interesting vaccines, and because I want to be supportive of the global effort. But it doesn’t make a lot of sense for me to come in and get the same doses I already bought.

So in that case, I’m willing to join, but let me opt out of the ones that I already have. And it’s still good for the world because then their funding is being used to move other vaccines forward, and that’s the insurance they want anyway, and they’re supporting this global effort.

Julia Belluz

It seems the big three countries that haven’t joined are Russia, China, and the US. Is there any movement on getting the US to join?

Seth Berkley

We’re having conversations, obviously, with all the countries. And when you say join, I don’t think the US, right now in their current situation, feels like they would need to purchase doses from the Facility because they’ve spent $11 billion on building out their own portfolio.

That being said, I think they fully understand the importance of what we’re trying to do to deliver a vaccine to the rest of the world, particularly developing countries. And they’re supportive of that. So we’ll see if, at the end, we figure out a way to work together on some of those other issues.

As you know, China and Russia both have their vaccines. Russia’s is already licensed. And China has a range of vaccines in their portfolio. But of course, again, it’s going to be an important issue for them to think about their vaccines for other countries, but also perhaps vaccines that have certain characteristics for them as well. So we’ll see.

Julia Belluz

That’s interesting because the EU also has a big portfolio of vaccines they’ve invested in, and yet they’ve joined the Facility. So just to be clear, the US also hasn’t committed anything yet to the AMC?

Seth Berkley

That is correct.

Julia Belluz

With the US and other countries making their own bilateral deals to purchase doses directly for their populations, will there be enough vaccine to go around for the rest of the world?

Seth Berkley

I mean, that is going to depend obviously on the manufacturers because this is a pass-through facility. So at the end, a country buys vaccines for its population. And we facilitate the engagement and we go ahead and put the reservations in and make sure the doses are produced.

But it’s not like we just buy all the doses, put them in a warehouse somewhere. So the issue is going to be working with manufacturers ... to make sure that there is manufacturing capacity scaled up. And that’s the important part of it. CEPI has done a number of studies to look at manufacturing capacity. Obviously the more doses that get promised, the more of the capacity gets pushed. But with investments, one can increase the manufacturing capacity, that’s the hypothesis.

Julia Belluz

How will you define success with Covax?

Seth Berkley

If we can deliver a vaccine simultaneously, in developed and developing countries, if we can get protection everywhere, even if it isn’t full, even if it doesn’t cover everything — [we] change the dynamic [of the pandemic] locally, [and] also show the power of working together.

If this was an outbreak of diabetes, [countries] could make an argument that we got to take care of our people. In a highly infectious pandemic, the idea that you’re just going to protect your people and ignore everybody else leaves vast reservoirs of virus circulating. And you’re not going to be able to go back to normal trade, tourism, travel, any of those things in that circumstance. So, basically, we need to have a global perspective and not a local perspective, even though normally people think about protection locally.

Julia Belluz

Getting countries to think globally about disease risk has always been challenging — but it seems particularly so today.

Seth Berkley

That’s why it’s so amazing that we’re able to get this type of buy-in. The other thing that’s important about this — you have to think about [vaccine development] as a global commons and a global solution to this problem.

Remember with the Ebola vaccine, we had every country trying their technology, and they all thought they were going to win. And what [vaccine] actually won? It was a Canadian vaccine, transferred to an American biotech, transferred to an American multilateral manufactured in Germany. That’s the way science works. So imagine if everybody said, ‘I just want my vaccine, my manufacturing, my assays, my adjuvants. That’s it.’ You would not have the best science. You would not have the best possibility of success.

Julia Belluz

In terms of a timeline, do you have any predictions for when we might have an effective vaccine?

Seth Berkley

Well, I mean, there are nine vaccines in phase three trials right now. So in the fourth quarter we’re likely to begin to get some data. And we have no idea if it’ll be positive or negative, or if trials will get stopped because of side effects. But I think in the next three or four months we’ll begin to get some sense of whether we’re going to see protection or not, and how effective the vaccines are.

Julia Belluz

So you’re hopeful, but also clear-eyed, about the road ahead.

Seth Berkley

I have to be honest about what we know, but obviously I’m optimistic. We have lots of signals that suggest that things are moving forward. But as an old vaccine friend of mine, a vaccinologist, said, ‘mice lie, monkeys don’t always tell the truth — it’s only people that matter.’ In a sense that’s true on vaccines.

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