Miriam Alía (Madrid, 46 years old) has been vaccinating children for five years in the most difficult conditions: wars, famines, refugee camps. In the Democratic Republic of the Congo, he worked with Ebola immunization, which, like Pfizer’s against covid, requires temperatures of around 70 degrees below zero. He is responsible for vaccination and response to epidemics in the Spanish section of Doctors Without Borders and knows in depth the negotiations with pharmaceutical companies and the logistical and transparency complications that usually accompany these drugs.
Question. What are the challenges of a new coronavirus vaccine?
Reply. The first is access. Some vaccines are expensive, not all countries can afford them, or not enough are produced. The second is security, since we often vaccinate in conflict zones. And there is a part of geographic access. For example, to vaccinate in the Congo you need 4×4 cars, motorcycles, canoes and sometimes you have to walk 20 kilometers. The further away the recipient is, the less autonomy from the cold chain is. Vaccines are very complicated drugs with a series of safety and quality standards. The normal ones have to be between two and eight degrees all the time. This is already a challenge. Everything has to be very controlled because if they go above eight degrees or freeze they can be ineffective. It is to do all this journey and vaccinate with water.
P. Are we going to see a market competition for the covid vaccine?
R. There is a platform, called Covax, organized by the World Health Organization (WHO) and led by Gavi [un consorcio de colaboración público privada para la compra y distribución de vacunas en países de ingresos bajos y medios] which aims to have 2,000 million vaccines to be able to vaccinate 20% of the population in all the countries that need them. There are donors, such as Spain or the EU. Other countries advance money in exchange for a possible dose. There are two agreements: if you advance 1.6 dollars per dose they reserve them for you, but you cannot choose vaccines; if you put 3.10 you have the option to choose. Then there are the recipients: 92 low- and middle-income countries that will receive it at a funded price, not free. But Covax has failed to raise money Enough and being there is not incompatible with having your agreement with the pharmacist. And not all companies are part of Covax.
P. The agreement of 300 million doses of which Spain will receive 20 million is there framed?
R. No, those are bilateral agreements.
P. Has it become a market to the highest bidder?
R. It is very good that it is donated and that money is given in advance to speed up the process, that there are more vaccines, that the price drops. There are also several promising technologies and it is okay that doors are not closed. But we say from the beginning that if you are giving money you have to ask for information and transparency in return. The EU has said that if we get very vindictive we may run out of doses. In which head is it possible that the EU, which is one of the main donors and the main buyers, does not have enough power to establish control mechanisms. Why are funds given to private companies that are not audited? In 2017 a resolution was passed at the UN because the prices were confidential. This has caused many children to die of pneumonia from not having this vaccine. The resolution says that vaccine prices have to be affordable and transparent.
P. Is there a lack of transparency in the vaccine purchase processes?
R. A lot. We do not know the clauses even though the EU is one of the main donors and could ask for them. This level of vulnerability that they are showing is wrong. No laboratory can afford to lose the European market, as a donor and as a buyer. But the transparency clauses must be put in place from the beginning, from the moment you give them the money, because as long as they have the money put in vaccine vials, the negotiating power changes, although it should not. For the treatments, Germany already said that if any patented drug worked for the covid, it gave itself the right to put a compulsory license. Why is it not done with vaccines?
P. What are the consequences of this lack of transparency?
R. What it is going to do is make prices more expensive. The consequence of the Pfizer press release is a movement in sales. It is rushing agencies that had not yet committed. It is something like what happened to remdesivir. They tell us they have interim results and most of the production sold. The next day the EU buys it. Three weeks later the definitive results came out that the impact was minimal.
P. Pfizer had to report results as the study progressed, before the final ones. Do you think something similar can happen?
R. But they have not reported results to the WHO. They are the preliminary results, we must wait for the end of the project and for the safety results of a longer time. At the moment it is not known what the vaccine is for: if it has an impact on severe cases and mortality, on the acquisition of the disease or on transmission. The economic difference is brutal. And who you are going to put it on also varies. Until there is an official report officially endorsed by the group of experts consulted by the WHO, it is a hopeful result, but not a scientific one.
P. Are you skeptical of the end results?
R. No. I have no opinion. The result may be even better. But with the data that exists, I have no ability to analyze. As an expert in vaccinology I need a series of criteria. You have to have data by sites, since there may be genetic or geographical conditions that alter the results, by age group, by gender … All of this must be analyzed with confidence intervals. It is very hopeful. No laboratory should sell a vaccine that is bad, especially if it has other vaccines. Because the bad reputation of a drug without safety and efficacy controls can sink them. But the way they communicate through the press, you can see that there is a bit of marketing behind. Which may be true or even better. But for the moment of giving the information there is a commercial war with other pharmaceutical companies.
P. There is science, but also business
R. Pfizer does not stitch without thread. We have fought for the pneumococcal vaccine in humanitarian crises and they have even offered to donate the vaccine to us before allowing us to make the price public or before lowering it publicly for middle-income countries. And it was not until they saw that it could be detrimental from an image point of view that they sat down to negotiate.
P. Why do you prefer to give away vaccines to lower the price?
R. I give you a number of shots, but you shut up. The price was secret. They sign confidentiality agreements with the countries that include this vaccine on their calendar. There are three doses for children. If there is a new country that wants to put it on its calendar, it does not know how much it costs. The lowest price is the one they give Gavi, three dollars, and it also finances them to continue producing. We have come to pay 68 euros per dose in Greece to vaccinate children in refugee camps. And this is what the ministries pay in Spain. Pfizer folded when Glaxo said it was going to make it cheap for refugees and displaced people. But it does not sell it to us directly, the WHO has to certify that we are going to use it due to a humanitarian crisis. They established a control mechanism other than NGOs.
P. Are you afraid that something similar could happen with the covid vaccine?
R. All that comes out of Covax, all the national agreements, what they do is empty the possible stock common. And what worries us is that this lack of transparency, once the sharp peak has passed in some countries, everyone is going to have to pay more. This commitment to lower prices is self-limited by them in time. And many of these companies are subsidized with public funds.
P. BioNTech, Pfizer’s German partner in this vaccine, received German funding, but Pfizer has not accepted grants.
R. No grant, but he received $ 2 billion on account. All these countries with pre-agreements have given you the money in advance. At risk. It is not assumed by the laboratory if the vaccine does not work. The EU has a portfolio of five vaccines. Paid with money in advance or a large part. If one of these doesn’t work, the lab loses little or nothing. Countries lose. I think it is okay for them to take the risk, because a vaccine is needed, but if you take the risk it should be shared, or at least certified. I mean: I give you 2,000 million, but in return I want you to tell me how much it costs.
P. And this is not happening?
R. No. Countries have a lot of power and they don’t always exercise it, but I think this is the first time that it has been so blatant. But we are paying it with taxes. Don’t the government want to know how much it costs?
P. About the most logistical part. You have worked with the Ebola vaccine, which has similar conditions. What are the challenges with these temperatures?
R. International transport at less than 70 degrees and storage. That of Ebola thaws and can be kept between two and eight degrees. This makes it similar to other vaccines. With its difficulties in places without electricity. What is going to happen is that most countries are not used to central warehouses at -70. Unicef is committed to moving 2 billion doses in 2021, because they are the ones it moves routinely. These are paid by Gavi. They thought that nothing extraordinary would be necessary if the vaccine was between two and eight degrees. But there are already four that are at a lower temperature. And here there is nothing prepared.
P. Do you see it difficult to reach developing countries?
R. Countries have to be prepared to receive them. This includes the cold chain, but depending on how cold it is, it will vary. And until the countries are prepared, they are not going to send vaccines. And if they can’t pay for the vaccine, they won’t be able to pay for the cold chain either. There will be more vaccines and those with the least cold chain requirements will be the ones that first reach these countries.
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