FIRST EDITIONVOL THREE
Prioritizing Wealth over Health: The Covid-19 Vaccine Strategy
This article demonstrates the link between inadequate international cooperation and global health inequalities in COVID-19 vaccine distribution within the context of neoliberal globalization. This is accomplished using Immanuel Wallerstein’s World Systems Approach as a framework to critique unequal vaccine distribution between the periphery and core states of historical capitalism as the units of analysis. The paper claims that the embedded market interests within globalization have furthered inequality within the already vulnerable states of the Global South by hindering cooperative international governance on vaccine strategy. First, neoliberal globalization is defined in relation to the vulnerabilities it has created in the Global South, both within and above the level of the state. Next, the examples of intellectual property rights (TRIPS) and public-private partnerships (COVAX) are highlighted as examples of institutional barriers to global cooperation on vaccine strategy. Instead of globalization providing a means for international cooperation, the pandemic facilitated opportunities for megacorporations, marketization, and high-income countries (HICs) to economically exploit the disadvantaged populations in the underdeveloped world by withholding essential biotechnology through international policies that prioritize wealth over health. Finally, the paper explores how these barriers have instead upheld the polarizing processes of vaccine nationalism in the developed Western societies.
Keywords: COVID-19, World-Systems Approach, vaccine strategy, TRIPS, COVAX, vaccine nationalism
The COVID-19 pandemic highlighted and exacerbated global inequalities, especially regarding global health governance. The forces of neoliberal marketisation within global governance structures have left the Global South vulnerable to health crises and enshrined the nationalistic methods of the Global North, hindering equitable cooperation methods. Rather, the pandemic provided increased opportunity for mega-corporations and high-income countries (HICs) to economically exploit the poor by withholding necessary technology through international policies that prioritize wealth over health. This paper draws on the works of Immanuel Wallerstein and deploys a World Systems approach to critique the unequal distribution of vaccines between periphery and core countries (Shen, 2021). It posits, by means of a neo-Marxist theoretical lens, that the embedded market-interests within neoliberal globalization have furthered inequality within the already vulnerable states of the Global South by hindering international cooperative governance on vaccine strategy during the COVID-19 pandemic. It then explores how these barriers have upheld the polarizing processes of vaccine nationalism. This central thesis is illustrated through the examples of intellectual property rights (TRIPS) and public-private-partnerships (COVAX) as barriers to global cooperation.
The Goals of Neoliberalism Achieved Through Economic Globalization
Globalization is the process of the increase and deepening of human connection across time and space (Al-Rodhan and Stoudmann, 2006: 3). Globalization is at its core an economic process, through which increased connection seeks to reduce market barriers and expand the socio-political influence of integration globally (Al-Rodhan and Stoudmann, 2006: 3).The current form of economic globalization is inherently linked to neoliberalism as it is the process by which the tenets of neoliberal ideology are spread within state and society (Rapley, 2004: 8). There are two core values that influence this process of economic globalization: market fundamentalism and anti-statism (Chorev, 2013). These are supported and disseminated within the state and society through neoliberal policymaking; thus neoliberalism has played a significant role in shaping the process of economic globalization over the past five decades. The core belief of neoliberalism is that the market is the most efficient means of economic allocation, and thus narrow government oversight is necessary so as to not distort this process (Chorev, 2013). Its principles and policies have been influential in guiding the liberalization of trade and investment, the removal of barriers to cross-border flows of goods, services, and capital, and the expansion of the global supply chain. This is advanced through policies that support privatization, marketization, deregulation and the entrenchment of private property rights (Chorev, 2013). This aligns closely with the anti-state sentiments mechanisms of economic globalization. Therefore, the current form of economic globalization and neoliberalism are interconnected concepts, with neoliberal policies and ideologies providing the framework and rationale for promoting and shaping the process of economic globalization.
In addition, according to neoliberalism, collective wellbeing is guaranteed through economic growth, achieved through market expansion. In this way, the goal of neoliberalism is to liberate and strengthen the international economy, by reaching new markets and deregulating existing markets to create the most wealth possible. High income countries (HICs), particularly the United States and major Western European nations, have exerted significant influence in international institutions such as the International Monetary Fund (IMF), World Bank, and World Trade Organization (WTO)(Chorev, 2013: 628-631). These institutions have been instrumental in spreading neoliberal policies and practices globally. HICs have used their economic and political power to shape the policies and conditions attached to loans, aid, and trade agreements, often requiring recipient countries to adopt neoliberal reforms (Chorev, 2013: 628-631). Through international institutions, HICs have promoted trade liberalization, financial deregulation, and structural adjustment programs in many countries (Chorev, 2013). Often this was achieved by coercive means, orchestrating a global project of neoliberalism which disproportionately benefits HICs (Chorev, 2013). This interconnection between states and the increasingly free market is a goal of neoliberalism achieved through economic globalization. The neoliberal project is all encompassing, hegemonic and united in achieving its goals of market superiority and thus entrenches its values throughout organizations and governments above and below the level of the state (Chorev, 2013). The polarized benefits of neoliberalism however, are reflected in the great disparity in the global division of wealth and resources.
Economic Globalization Makes the Global South Vulnerable
Despite its claims of providing universal benefits, economic globalization has created vulnerabilities for the Global South (Zhou, 2023). This has become more apparent than ever during the COVID-19 pandemic, by weakening resilient non-marketized methods within and between societies; such as socialized healthcare and community-led reciprocity. This was done through various policy methods. First, neoliberalism has created health vulnerabilities for LICs by forcing open markets through structural adjustment policies (SAPs). This effect was two-fold. For one, market expansion has increased movement within and between states, making them more vulnerable to diseases, such as COVID-19 (Zhou, 2016: 286). Another important area of SAP restructuring has been health governance within the state, which has been especially destabilizing in the Global South. By hollowing out the state and marketizing healthcare through privatization and deregulation, neoliberal institutions have weakened state healthcare capacity. Specifically, roll-back neoliberalism, namely via privatization of state health facilities and tax cuts, has empowered the highly marketized roll-out form of neoliberalism, which encourages competition, incentivizes investment and individualizes the responsibility of healthcare (Zhou, 2022: 18). These have destabilized state response capacities, specifically in LICs. According to Zhou (2022), the resulting funding gap in the crisis response mechanisms of LICs has evolved alongside the charity model of addressing global health insecurity. By utilizing market-mediated health delivery as a quick-fix for the systemic damage caused by the failure of market oriented health systems, HICs need not turn their attention to the failures of the current model (Zhou, 2022: 19). This, coupled with the systemic underdevelopment of LICs, already suffering from poverty and limited access to resources, has created vulnerable states with restricted response capacities (Godwell and al, 2021; Sparke and Williams, 2022; Peters and al, 2022: 709). The exploitation of economic inequality by globalization forces in the name of private profit has created extreme precarity in the developing world, and this was magnified in the pandemic. Marketized health services that commodify necessary technology and healthcare are found to be systematically inadequate in providing health at a public level, ultimately incapacitating health systems in the developing world when faced with a crisis like COVID-19 (Sparke and Williams, 2022: 22-25).
Similarly, global health governance has been impacted by the neoliberal project as well. For example, supra-national organizations such as the World Health Organization (WHO) and the World Trade Organization (WTO) have undergone neoliberal restructuring. Specifically, the WHO’s mandate of equitable access to healthcare has been watered down by market superiority, which has destroyed cooperative methods between states to tackle common goals (Chorev, 2013; Sparke and Williams, 2022). Consequently, due to the co-opting of global health governance structures by neoliberal policies, these organizations have not been able to provide adequate support to LICs. Instead, HICs and the pharmaceutical industry have been allowed to exploit poor states through these very institutions (Spake and Williams, 2022: 24). Ultimately, Global North states and multinational corporations (MNCs) have pursued their own interests of capital accumulation and the protection of market interest. In this way, neoliberal market interests have magnified existing vulnerabilities in the healthcare systems of the Global South allowing private interests, such as pharmaceutical companies to capitalize on a global health crisis.
World Systems Theory and Vaccine Distribution
Immanuel Wallerstein’s World Systems Theory, outlined in his book Historical Capitalism (1983), lends a useful lens through which to contextualize this complex system of inter-state exploitation. This theory dictates that within the whole of global capitalism, the historic core states have instilled a system of exploitation on the periphery by which the core is able to profit (Wallerstein, 1983). This is made possible through the embedded political economic systems and norms created by the cores of historical capitalism; which has allowed for the economic and social dominance of the core over the periphery. This form of domination encourages the exploitation and unequal distribution of resources between regions. As in the case of neoliberal globalization, exploitation has been entrenched in the economic processes exported by the core through intra-governmental organizations, such as the WTO and WHO, to the Global South (Peters et al., 2022: 707-710). This immiseration and exploitation is exhibited in the global governance responses to the COVID-19 pandemic, organized by these very institutions, notably through the complex barriers created by intellectual property law (TRIPS) and public-private partnerships (COVAX). It is apparent through these examples, that the coordinated vaccine response to the pandemic benefitted wealthy multinational corporations rather than promoted global wellbeing during a worldwide health crisis: it ultimately prioritized wealth over health. This is further exemplified in the economically domineering behaviour of HICs during the pandemic. Utilizing the globalized market-oriented system they have orchestrated, HICs ensured the unequal distribution of biotechnology to their benefit.
Vaccine Nationalism as a Result of Neoliberalization
Vaccine nationalism is the process of states hindering global cooperation in pursuit of access to newly developed vaccines for themselves (Zhou, 2022: 451). This was commonplace during the COVID-19 pandemic. Early on in vaccine development, before vaccines had even been approved, the world’s richest countries had already secured more than half of projected early supply (Zhou, 2022). This amounted to enough to vaccinate their entire populations with multiple doses, while LICs were left scrambling due to limited manufacturing and economic capacities (Zhou, 2022). Instead of creating broad mechanisms that sought to fix this unequal division of resources in a global health crisis, many states refused to cooperate. The United States even pulled out of the World Health Organization under President Trump (Zhou, 2022). This individualist state behaviour is apparent in the actions of the cores within the frameworks of the TRIPS agreement and COVAX. States did not cooperate because they were pursuing a strategy of vaccine nationalism. But, at the same time, vaccine nationalism is a result of the failure of global structures that should have protected cooperative mechanisms between the developing world and HICs. In this way, recent globalization forces have affected structures within and above the state, thus destroying resilient and broad mechanisms of cooperation in the name of an ideology of market superiority. The prioritizing of wealth over health has directly translated into the issue of vaccine nationalism. It begs the question, have we learned anything about global governance strategies from COVID-19?
To pursue equitable cooperation, states must create a framework outside of the neoliberal market system that values social determinants of health and empowers local and national strategies. For example, Remco utilizes ‘shortfall equality’ to examine the equality of global COVID vaccination, namely how vaccines are allocated within and between states, and vulnerable populations utilizing a ‘standard years of life lost’ averted per dose (2022; 27). To effectively tackle a global issue such as a pandemic, it is futile to pursue nationalist policies, as these do not address the spreading and mutating of the virus in the developing world (Zhou, 2022). New systems of governance must be established to provide broad and equitable frameworks for global cooperation on vaccine research and development, distribution and inoculation that benefit all affected individuals and communities. This must happen outside of profit-maximizing private interests to be sustainable.
TRIPS as a Market-Oriented Barrier to Global Health Governance
There are many examples of limited cooperation in global vaccine strategy. One such mechanism of the limited cooperation through neoliberal framework was the failure of the TRIPS agreement. Here, the core prioritized wealth over health during the pandemic by upholding the intellectual property rights (IPR), entrenched by the WTO, in the Trade Related Aspects of Intellectual Property Rights (TRIPS) agreement. This agreement was a hindrance to global governance as it was a barrier to a multifaceted and equitable vaccine strategy. The TRIPS agreement inhibited the equitable distribution of pandemic ressources, further entrenching global inequalities. TRIPS kept countries in the Global South from accessing COVID-19 vaccine technology protected by intellectual property rights laws (Sparke and Williams, 2022; Zhou, 2022; Godwell and al, 2021). The TRIPS agreement, to which all WTO member states are bound, blocks access to LICs by limiting access to needed technology transfer and health capacities hindering research and manufacturing of COVID vaccines, particularly for low and middle income countries (Remco, 2022: 26-28). The TRIPS agreement kept much needed vaccine research and development (R&D) patents behind the paywall of big pharmaceutical companies, creating an artificial barrier to vaccine availability and affordability in the developing world. The market-oriented nature of the intellectual property regime disincentivizes equitable R&D in innovative medicines and vaccinations for LICs (Remco, 2022: 28). This was an unsurpassable barrier to accessing freely available generic vaccines through an equitable process that valued the superiority of public health and recognized the vulnerabilities of the developing world as a reason for increased vaccine aid. This has deepened existing disparities between countries and exacerbated global health inequalities.
According to research, the most vulnerable populations are overwhelmingly located in the developing world (Zhou, 2022). The developing world is more densely populated, racialized, and poor, making the region more vulnerable to the spread of COVID and the likelihood of severe cases higher (Zhou, 2022: 453-457). This population is more likely to reside in close quarters, have employment outside of the home and have limited access to sanitation and necessary precautions such as PPE; all of which increase risk of infection (Zhou, 2022: 453-457). In addition, the Global South has weak health systems as a result of neoliberal restructuring, such as the privatization of state healthcare facilities and the underfunding of public health programming (Zhou, 2022: 453-457). These disparities are clear indications of the link between economic power and vulnerability to public health crises. Yet, TRIPS and the Organisation for Economic Co-operation and Development (OECD) countries disregarded this fact. The WTO and OECD countries instead protected vaccine monopolies and their bilateral ties to pharmaceutical firms by upholding the TRIPS agreement. TRIPS created inaccessible paywalls for LIC through patent protected monopoly pricing (Sparke and Williams, 2022: 26). This created a two tier-system wherein the Global South could not compete for vaccines at such high prices and could not access the technology to create their own. Ultimately, these actors have chosen to pursue their own interest in capital accumulation, despite the obvious immiseration caused by this barrier. This is proof of the pervasive disparity in economic barriers between the core and periphery in accessing necessary biotechnology during the pandemic. In this way, existing inequalities in global governance structures, such as the WTO, have been beneficial to the multi-billion dollar pharmaceutical companies of the core, as wealthier nations drove prices up while keeping the monopoly intact.
This point is further proven by the failure of collaboration on a TRIPS waiver. To address the issue of global governance during times of crisis there is a mechanism built into TRIPS called a TRIPS waiver. This allows states to waive the agreement and force firms to provide pharmaceutical patents during times of crisis to protect public health (Chorev, 2013). In October 2020, key countries of the Global South, India and South Africa, presented a request for a TRIPS waiver to the WTO. This was a request to temporarily suspend intellectual property law pertaining to vaccine technology so that it could be accessible to low-income countries during the course of the pandemic (Zhou, 2022). This was not well received, as key counties in the OECD, such as the EU, Switzerland and the UK refused to commit to technology transfers (Sparke and Williams, 2022: 24-27). High-income countries claimed that intellectual property rights (IPRs) are necessary incentives for vaccine research and development, and that equitable vaccine access should be pursued through other means such as COVID-19 Vaccines Global Access (COVAX) (Zhou, 2022: 455-59). This is a blatant example of market-interests creating barriers to cooperation within the pandemic response. According to Sparke and Williams (2022), by shooting down the TRIPS waiver HICs chose to empower the IPR model and support the pharmaceutical industry’s capital interests. Technology transfer during this crucial second wave of the pandemic could have saved thousands of lives, but instead these multinational corporations have heavier pockets.
Public-Private Partnerships as a Failed Means of Vaccine Strategy
Another method of cooperation that failed to produce equitable results is the donor-funded public-private partnerships system. With the rise of austerity policy, public-private partnerships (PPPs) have become a common tool in global health governance. Used as a mechanism of cooperation between donors, states and NGOs, PPPs are created to achieve a common goal. According to the article Public–private partnerships in global health: the good, the bad and the ugly, private interests play a disproportionate role in the decision making and the policy development process of PPPs, making them unreliable forms of cooperation (Ruckert and Labonte, 2014: 1606). PPPs erase the barriers between private and public interest, often co-opting resources for their own agendas. This is because market oriented agendas often appeal to both public and private actors but tend to benefit corporate private interests over those of less powerful public actors, such as LICs (Ruckert and Labonte, 2014: 1606). This is apparent in global health governance, as private partners rely on the assumptions of neoliberalism in their policy making. Neoliberalism assumes that a small state presence and the superiority of market mechanisms creates the most efficient environment for effective crisis responses. But by entrenching systems that do not adequately address existing inequalities within the interstate system, PPPs cannot adequately address their mandates as a whole. Additionally, PPPs also favour technical approaches and marketized programs, another assumption of neoliberalism. These methods often omit more equitable approaches from being even considered during decision-making processes. Instead of tackling mandates as an interconnected whole, PPPs often work from within the capitalist system based on allegedly ‘objective’ empirical determinants such as GDP and deaths per capita (Ruckert and Labonte, 2014: 1609). Vaccine strategy is one such mandate with complex and interconnected issues. Due to the narrow and market based perspective of PPPs, vaccine equity could not be achieved through this framework. This rings true for the public-private partnership, COVAX, set up by the WHO to address vaccine strategy during the COVID-19 pandemic.
COVAX was established to ensure equitable access to vaccines for poor countries; though this did not happen due to its market oriented nature and rather enshrined inequalities and hindered cooperation. COVAX is administered by the Global Alliance for Vaccine and Immunizations on behalf of a variety of private donors, corporations, states and non-governmental organizations (Sparke and Williams, 2022: 26). The COVAX partnership sought to pool resources thereby offering larger orders to pharmaceutical companies in hope of securing lower prices on behalf of LICs (Zhou, 2022: 457). Despite this diversity of financial backers, COVAX faced a 19 billion USD funding gap in 2021 alone (Zhou, 2022: 457). This is largely due to the voluntary nature of its funding,resulting in a fragmented approach, wherein some members sought bilateral agreements with vaccine producers. As a result, vaccine distribution has been influenced by individual states’ economic power and willingness to participate, rather than strictly focusing on equitable allocation based on social need (Zhou, 2022: 457). Therefore, rather than resulting in the optimal goal of vaccine equality through fair and equitable access to pandemic technology, COVAX sustained and deepened pre-existed inequalities.
COVAX also undermined the case for technology transfers, a TRIPS waiver and compulsory licensing, by presenting the illusion that equity could be achieved through the existing polarized system if a corporate-private-coalition was formed (Sparke and Williams, 2022: 26). This is because COVAX was designed to work within the market-oriented constraints of neoliberalism. By establishing a larger purchasing body, using funds from all partners, COVAX was able to compete with HICs to secure vaccines from manufacturers. But by working within this model rather than empowering a multi-level challenge to the inequalities of this method of allocation, COVAX undermined the struggle for a more equitable process (Sparke and Williams, 2022: 26). According to the article, Neoliberal disease: COVID-19, co-pathogenesis and global health insecurities, COVAX was constructed to work within the framework of the current pharmaceutical market, where firms hold monopolies on patents to negotiate high profit margins, making the sector heavily profit motivated (Sparke and Williams, 2022: 26). Therefore, COVAX drastically underperformed. Using a World Systems analysis, COVAX is an example of the interconnected nature of economic, political and social motivations, as the social and political response to vaccine allocation is deeply rooted in the framework of global capitalism, despite its obvious and inherent inequalities. This was demonstrated by the creation of COVAX as a PPP race horse to compete on the global market for finite resources in a global health crisis. Ultimately, it is clear that the market interests embedded in PPPs as a result of transnational neoliberalism have hindered cooperation by failing to challenge the pharmaceutical industry and by failing to facilitate equitable cooperation as to not ‘rock the boat’.
Furthermore, COVAX’s system offers more opportunities to HICs for accessing vaccines and does not require that they donate extra vaccines, while maintaining strict protocol for LICs within COVAX (Zhou, 2022: 457). According to Zhou (2022), the separation between states based on economic purchasing power suggests the unfair influence of monetary metrics over public-good considerations and risks further polarizing LICs and HICs -thus further hindering the global vaccine distribution framework. In this way, cores and peripheries are unequal players on a neoliberal global market due to the frameworks created by the interstate system.
The examples of TRIPS and COVAX as barriers to equitable and effective global health governance exemplify the embedded inequalities of neoliberal globalization. Both mechanisms were created by and for the interests of major Global North public and private actors and systemically disempower the developing world. The interests of these Global North actors are inseparable from this system of exploitation and can be summarized as the pursuit of capital accumulation and economic growth in the Global North. This comes at the expense and immiseration of the developing world. During the pandemic these interests took the form of increased wealth for the pharmaceutical mega-firms involved in vaccine research and development; and the acquisition of as many vaccines as possible so that Western economies could open swiftly (Shen, 2021). The pursuit of these interests came at the cost of the Global South. The pursuit of these interests was not compatible with equitable international cooperation; instead HICs resorted to vaccine nationalism to maintain control of pandemic resources and ensure the accumulation of capital in their hands.
In conclusion, embedded market interests within neoliberal globalization networks have systematically rendered the developing world vulnerable to global health crises such as the COVID-19 pandemic. States in the developing world were weakened by the increase in movement enabled by the opening of markets and the hollowing out of state and supranational organizations. Therefore low income countries were already more vulnerable to the pandemic. This paper argues that the mechanisms put in place in the name of international cooperation by neoliberal globalization forces have in fact hindered cooperative governance efforts between states. Using the examples of TRIPS and COVAX, this paper has demonstrated that market interests have created barriers to global cooperation on vaccine strategy. Vaccine research, development and rollout processes were extremely unequal and polarized throughout the pandemic as a result of corporate greed. Instead of pursuing a strategy of inclusive development and cooperation at a time of crisis, states in the Global North used the strategy of vaccine nationalism to pursue their own goals of wealth accumulation and vaccine contacts. This paper has compared the drastically unequal relationship between the core and periphery of historical capitalism through the example of the COVID-19 pandemic and specifically vaccine distribution.
Although this paper has analyzed the failures of market-oriented responses and barriers to equitable vaccine allocation and the nationalist domestic policy of HICs and international institutions based on market incentives, there has been little discussion of alternative non-market-based models of pandemic response. New studies are needed investigating possible alternatives to the current hegemonic model promoted by the cores of historical capitalism. Academic researchers will find fruitful avenues of expanding our field of understanding of how to effectively limit the effects of a pandemic by compiling and analysing both quantitative and qualitative data regarding successful COVID-19 responses originating in the developing world – such as, for example, the Cuban state’s centrally coordinated strategic approach to healthcare provision, which achieved its core aim of protecting Cuba’s population from the pandemic’s effects by adopting solutions rejecting the free market principles of the Washington Consensus model (Wylie, 2020).
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