Covid-19: What will it take to vaccinate the world?

This is one of a series of interviews by Bloomberg Opinion columnists on how to solve the world's most pressing policy challenges. It has been edited for length and clarity.

Clara Ferreira Marques:  You're a veteran advocate for global health, vaccines and tropical-disease control, and served as a US science envoy during the Obama administration. You've now developed a low-cost Covid-19 vaccine, Corbevax, using a tried-and-tested method. It's a recombinant protein vaccine, which means it should be easy to scale. The technology will be available for anyone to reproduce. How do you expect it to contribute to global vaccination efforts? 

Dr. Peter Hotez, Dean of the National School of Tropical Medicine, Baylor College of Medicine and author, "Preventing the Next Pandemic":  This is a traditional technology vaccine. It's similar technology to what is used to make the recombinant hepatitis B vaccine that we've used for decades and even give to infants. It's got a tremendous safety profile and it's actually a vegan vaccine. The technology has been around for years and is in place in many low and middle income countries — they can make their own hepatitis B vaccine, and therefore can make our Covid-19 vaccine.

The Texas Children's Hospital Center for Vaccine Development, based at Baylor College of Medicine, is co-headed by myself and my science partner for the last 20 years, Dr. Maria Elena Bottazzi. We've been making parasitic disease vaccines for diseases such as Chagas disease and schistosomiasis. About 10 years ago we started developing coronavirus vaccines, using those same low-cost approaches and methods. Because all we know how to do is make low-cost, straightforward technologies for people who live in poverty and resource-poor settings, we did it for the Covid-19 vaccine. And now we've developed it and licensed it.

We're helping the co-development in India, Indonesia, Bangladesh and Botswana. All have differing capacities for developing recombinant protein vaccines. The most advanced is Biological E based in Hyderabad, which has been making vaccines for global use for many years. They have 150 million doses ready to go and have the capacity to produce a billion doses this year. No patents, no strings attached — [the goal] is simply to get people vaccinated as quickly and as efficiently as possible, with a high-quality vaccine that looks like it could protect about as well as mRNA vaccines at a cost of around $2 a dose, with simple refrigeration [requirements]. When you go down the checklist, this looks like a pretty good vaccine for global health. We hope this will make a fundamental contribution to vaccinating the world.

CFM: Can this technology work effectively against new variants of Covid-19, like omicron?

PH: In the lab, it works as well as any vaccine against delta and beta, which are two variants of concern. We're not on a priority list for getting the omicron pseudovirus and the virus isolate — but that's coming and we'll hopefully have that data soon. Based on how it's performing against delta and beta, we have some reasonable expectation that it should hold up pretty well against omicron as well.

CFM:  That would be good news, given most of the world is still not getting access to sufficient doses, in part because of the failures of vaccine diplomacy. Why, decades after Albert Sabin managed to work on the oral polio vaccine with Soviet scientists at the height of the Cold War, have 21st century efforts fallen short?

PH: We've seen two very ominous trends. The first one is the exclusive reliance on the multinational pharma companies. Not that the multinational pharma companies are bad; when you look at the Gavi Alliance pre-pandemic, the big pharma companies supplied quite a number of those vaccines. The problem was the way the incentivizing structure worked for Covid-19, through Operation Warp Speed in the US and the G7 countries. It was all about speed, innovation and rapid immunization of smaller populations.

They wound up making interesting vaccines. I got the Pfizer-BioNTech vaccine, and I'm grateful that it may have saved my life, but it should have been expected that those vaccines were not going to filter to low- and middle-income countries. You can't scale them at the level you need. A billion people in Africa, a billion people in Latin America and the Caribbean, a billion people in the smaller, low income countries of Southeast Asia — multiply that by three and that's nine billion doses. With a new technology, as any engineer will tell you, you can't go from zero to nine billion. So I think that was a terrible policy failure.

Then you had the fact that countries like China and Russia were making vaccines that are not holding up well against the variants, certainly in the case of the whole inactivated virus vaccines out of China. They conducted their business in a very transactional way that initially bypassed the World Health Organization.

CFM: In your latest book, "Preventing the Next Pandemic", you also talk about the need for new vaccine technologies and surveillance in vaccine diplomacy. Could that be the next phase? Can we right the wrongs of the first two years of the pandemic?

PH: I think so. In our case, not only are we transferring the technology, but we help to build vaccine development capacity. I think there's a lot of misunderstanding about the vaccine ecosystem. It's not as simple as building a factory. I mean, you could build an mRNA factory tomorrow, but it's the human capital — knowing how to make vaccines at scale. It takes years to build the human capital, to do this with quality assurance, quality control, to work with national regulatory authorities. That's one of the things we do. You can't walk into Merck or GlaxoSmithKline and say, "Show me how to make a vaccine." But you can walk into our facility and we'll teach you. We do a lot of capacity building and we've been doing so for years.

CFM: What more can we do when it comes to surveillance? That will be crucial to ending the pandemic, and to managing whatever comes next.

PH: We're not even ready for the next variant. There's all this happy talk that somehow omicron represents some kind of attenuated vaccine, that it's going to give everyone immunity and this is how it's going to end, which is utter nonsense. The omicron variant will probably behave more like upper respiratory coronaviruses in terms of immune response. It will not provide very durable protection. We're going to be vulnerable again, and because we've refused as a society to vaccinate the world's low- and middle-income countries, we know what's coming. We will have another terrible variant of concern that will, like the last two summers, sweep across the southern United States and cause a lot of devastation.

Mother Nature is not being coy — she's told us what she's going to do. She gave us delta out of an unvaccinated population in India, and omicron out of an unvaccinated population in southern Africa towards the end of last year. She's going to do it again. I just can't tell you whether it's gonna be from Africa or Laos, or somewhere else in Southeast Asia or Paraguay. And that's going to continue to happen until we resolve that we are going to vaccinate the world. Hopefully our vaccine will make a difference.

CFM: One of the issues you touch on in the book is the anti-science movement, a great impediment when it comes to preparing for the next variant, never mind the next pandemic. You've been very involved personally in combatting that. How can public-health authorities deal with disinformation and inoculate people against it?

PH: At least in the US, we've not been willing to take on the anti-vaccine movement in a big way. It's taken a political spin in aligning itself to political extremism on the right, and now it's a full-on component of the far right. You're hearing it from members of the US Congress.

The consequences are devastating. When you add up the numbers, since the middle of last year, 250,000 unvaccinated Americans have lost their lives to Covid-19, despite the widespread availability of vaccines. I don't even know what words to use: it's not even misinformation or disinformation, it's a form of self-immolation out of allegiance to political extremism on the right. Anti-science is a killing force and now it's starting to globalize, it's in Canada, and we're seeing in Western Europe. I'm very concerned that we are not taking this seriously enough. 

CFM: What concrete actions can be taken? Is this about policing the internet, or can we help people talk through their questions and doubts?

PH: Well, the problem is that the health sector has more or less abdicated any interest in doing something about it. They can't deal with the fact that it's taken on a political dimension — it's impolite to talk about it, so they'd rather let people die. I hate to say that in such blunt terms, but that is the reality. On the US side, we need to bring in the Department of Homeland Security, the Department of Justice. We've got [President Vladimir] Putin and his Russia propaganda machine using this as a wedge issue, filling our internet with anti-vaccine messages. We have to bring in the State Department and people who know how to combat these global forces. And we need to do this the international level too, to bring in all the UN agencies.

CFM:  Covid-19 has also caused significant economic hardship and impeded regular healthcare, causing the resurgence of diseases that we had thought eradicated or contained. Can the world deal with both Covid-19 and these long-standing problems?

PH:  Most of my 40-year career has been devoted to neglected tropical diseases. These are poverty-promoting diseases because of the social stigma they cause, especially among girls and women. For example, female genital schistosomiasis, a disease of 40 million girls and women that no one has heard of, is one of the major causes of gynecological problems on the African continent, affecting worker productivity, child development, pregnancy outcomes. These diseases trap in poverty.

CFM: And we're now seeing some of these diseases in areas they have never been before.

PH: So much of the dialogue around global health is about poor versus wealthy countries. Well, the world's not quite that way anymore. At least pre-pandemic, most economies were growing, but leaving behind a bottom segment of society. When you add up where most of the world's poverty-related diseases are, sure, they're in fragile states in Africa and elsewhere, but overwhelmingly they're found among the poor living in G20 countries as well as Nigeria, which is not a G20 country but has an economy bigger than those at the bottom end of that group. For instance, we've identified around 12 million Americans living with a poverty-related neglected disease.

CFM: And on top of that, there are the illnesses triggered by a changing climate, including zoonotic diseases that spread from animals.

PH: For the first time, as of a few years ago, more people live in an urban than rural environment. These are often mega cities that outstrip their public infrastructure — things like sewers, high quality water and food safety. That's become a problem. Climate change doesn't act on its own, it interacts with other social forces like urbanization or conflict. 

In the Middle East, we've seen the return of measles, polio and cutaneous leishmaniasis, accelerating in areas [of conflict]. But at the same time, you have unprecedented temperatures of 50 degrees Celsius, forcing people to abandon agricultural lands and pour into cities, and that itself is a destabilizing factor. Whether zoonotic or non-zoonotic, infectious diseases are being buffeted by new forces.