Various UK media reports have blamed lower than expected supply of the AstraZeneca vaccine from India for a slowing of the UK’s vaccination programme, especially delaying immunisation of the under-50s. Although five million doses of vaccines produced by the Serum Institute of India were dispatched from India to the UK on 5th March, another five million that were due later this month are reportedly being held back at the Indian government’s request to direct these instead to India’s domestic vaccination programme. A quick look at these 10 million doses sheds light on the inequalities faced by low and middle-income countries (LMICs) in current COVID-19 vaccine distribution efforts, and the contradictory role of the UK.
The Serum Institute and Global Vaccines
Let’s start by underscoring the key role played by the Serum Institute in global vaccine supply. India has one of the largest pharmaceutical industries in the world. In fact, many pharmaceutical products consumed in the UK are made in India, and India is also the largest vaccine manufacturer in the world. The Serum Institute in Pune is the world’s largest single vaccine producer (by volume), annually providing more than 1.5 billion doses around the globe, and it plays a central role in AstraZeneca’s global network for manufacturing and distributing the Oxford vaccine.
The agreement between AstraZeneca and Serum Institute authorizes the latter to produce doses to supply India, to supply LMICs around the globe directly (Serum Institute has even branded its version of the vaccine, “Covishield”), and also to supply the global joint procurement scheme COVAX (established by the WHO to assure vaccines reach the poorest countries). Indian supply, predominantly from the Serum Institute, is central to COVAX’s supply forecasts, which set a goal of supplying 2 billion doses by the end of 2021.
In addition to supporting India’s own domestic vaccination programme, vaccines produced by the Serum Institute (and other Indian producers, too), are being distributed globally. India dispatched its first vaccines abroad to the Maldives on 20th January, just four days after the country’s domestic vaccination programme began. The first COVAX-supplied vaccines, made in India by Serum Institute, arrived in Ghana in late February. In total, as of March 24th, India has supplied 60.4 million doses (10 million more than have been administered domestically) to a total of 76 countries, directly through donations and bilateral sales from Indian producers to countries, indirectly via COVAX.
Indian-made Doses for the UK
The decision to use vaccines from the Serum Institute to supply the UK (and the EU) seems to be rooted in controversies that followed production shortfalls at AstraZeneca’s manufacturing sites in Europe. Foreign Minister Dominic Raab announced a UK-India collaboration on vaccines to prevent future pandemics on a visit to India in December 2020, and in February Liz Truss, UK Secretary of State for International Trade, visited the Serum Institute. Reports then emerged that the UK’s pharmaceutical regulator, the MHRA, was inspecting Serum Institute’s production facilities, linked to potential supply to the UK. (This was followed by reports of similar steps being taken by the European Medicines Agency, to enable the use of Serum Institute-produced COVID-19 vaccines in the EU.)
And this brings us to where we are. The UK secured 10m doses from Serum Institute, of which 5m doses were received and are already being administered, and 5m doses have been delayed – for now. The UK government has reportedly responded to the delay with a diplomatic visit to Serum Institute. The Pune-based company has requested permission from the Indian government to export the second batch of 5 million doses to the UK, indicating that its original contract includes an obligation to treat AstraZeneca as a “priority customer.”
Even without the doses that weren’t received, the 5m doses supplied by the Serum Institute earlier in March make the UK the third biggest foreign recipient of Indian-made Covid-19 vaccines so far – after Bangladesh (9 million) and Morocco (7 million).
The fact the UK is procuring vaccines from India at all demonstrates the country’s fundamentally contradictory role in global COVID-19 vaccine allocation. The UK is among the largest funders of COVAX, and government officials have proclaimed the country’s global leadership and interest in ensuring people in low and middle-income countries get timely access to COVID-19 vaccines. However, resorting to procurement from India to help meet its stated domestic goal of offering a COVID-19 vaccine to all UK adults by the end of July 2021 runs directly counter to improving access to vaccines in LMICs.
The UK, one of the most vaccinated countries in the world, faces much less immediate deprivation regarding COVID-19 vaccines compared to India or other lower-income countries. Although India has surpassed the UK in terms of total number of COVID-19 doses administered, as of 22nd March 3.2 vaccine doses had been administered per 100 people in India, compared to 45.2 in the UK.
Dismissing concerns about the UK’s demand contributing to unequal access, the UK government insists that it “sought assurances from AstraZeneca and from Serum that our doses will not impact their commitment” to supply LMICs. Yet in the current context of extremely constrained supply, it is undeniable – it is a mathematical fact – that allocation of vaccine to the UK reduces potential access in other countries.
Vaccines are in scarce supply and, in the short-term, allocation to one country removes potential access in another. COVAX already faces a huge struggle, as do low and middle-income countries more generally, in accessing vaccines. Adar Poonawalla, CEO of Serum Institute has already indicated that COVAX will likely fall well-short of its forecast 2.3 billion doses in 2021, which depends on over 1 billion from his company. For COVAX, he has suggested, “if we’re lucky, we’ll have produced 400m by the end of the year.” Reflecting such a challenge, India will reportedly now suspend all vaccine exports for one month so as to ensure uninterrupted supply domestically. If the 5 million doses received by the UK had gone to COVAX instead, they could have increased its distribution of vaccines to LMICs (30 million so far) by over 15%.
The reality of 5 million India-made doses (and potential still of another 5 million doses) that could be used to vaccinate high-risk groups in LMICs being directed instead to lower-risk groups in the UK brings home the structural contradiction underlying the UK’s approach. At home, the UK’s approach to vaccination has proudly prioritised more vulnerable population groups, but globally it is taking vaccines away from vulnerable people in LMICs. Such actions are the epitome of the vaccine injustice and lack of global prioritisation which the WHO has so passionately and eloquently critiqued. To be sure, the UK has pledged to donate its surplus COVID-19 vaccine doses to help vaccinate the world, but if and when it does so, that action will come only after directly undermining such efforts.
Let’s be clear. That there is massive inequality in global vaccine allocation, or a long wait forecast for widespread vaccination in many LMICs, is hardly a secret. The redirection of 5 million (or 10 million doses) to the UK hardly creates this problem, nor would keeping these doses as part of the Serum Institute’s supply for India and LMICs resolve the problem. But the case is certainly illustrative.
Countries that, at best, are aiming to vaccinate the most at-risk 20% of their populations by the end of 2021, are losing some of their precious stock of vaccines so that the UK can help achieve its goal of vaccinating all adults by July 2021.
Here’s the WHO’s Dr Mike Ryan, passionately summing up the hypocrisy of low priority people in high-income countries being vaccinated before vulnerable people in lower-income countries.