Since the outbreak of Covid-19 experts and commentators have often invoked the Spanish flu of 1918 as a useful precedent. But with various drug companies moving toward the advanced stages of vaccine testing, we should now shift our attention to the history of smallpox. Though smallpox is a different, and more deadly, pathogen than the coronavirus, the international politics that gripped the campaign for its global eradication during the 20th century offer valuable lessons for the coming struggle we will face distributing a coronavirus vaccine.
In 1958, the World Health Organization initiated a plan to rid the world of smallpox. The virus had long been stamped out in rich countries, but it still ravaged populations in Brazil, South Asia, Africa and Indonesia. At a World Health Assembly meeting that year, Dr Viktor Zhdanov, the deputy minister for health in the Soviet Union, urged delegates to consider the cost-to-benefit ratio of a global campaign to eliminate smallpox. Not only would working together to eradicate the virus help to keep all nations safe, it would also eliminate the costs of their annual vaccination programmes.
But the United States, the WHO’s biggest funding contributor, did not support the programme. Many other nations that thought smallpox vaccination was the responsibility of individual countries let it go unfunded as well. Eradicating smallpox would remain an idea on paper only until, seven years and two presidents later, Lyndon Johnson was moved to sign a renewed version of the campaign, pledging “American support for an international programme to eradicate smallpox completely from the earth within the next decade”. Thanks to this financial aid, and a donation of 1.7bn doses from the Soviet Union, smallpox was eventually extinguished from the planet in 1977.
As we await news of a successful vaccine for Covid-19, Zhdanov’s advice about the international cooperation needed to fight a deadly virus has never been more timely. Whether politicians will heed his words remains to be seen.
There have been some positive signs. In an interview with the activist Ady Barkan, Joe Biden said that if he were elected president of the US he would “absolutely” commit to widely sharing technology and access to an unpatented Covid-19 vaccine.
In a recent Washington Post op-ed, leaders from across the world, including Justin Trudeau, Sahle-Work Zewde and Cyril Ramaphosa, proclaimed “global solidarity” for vaccine development and distribution. These leaders are all signatories of Covax, an initiative of Gavi, a vaccine alliance run by the WHO, Unicef, the World Bank and the Bill & Melinda Gates Foundation. The alliance has initiated a vaccine pool, which allows participating countries to back a larger number of vaccine candidates while helping poorer nations secure shares.
But Covax lacks the support of some of the world’s richest countries, and Biden is still only a presidential candidate making promises that are not yet his to keep. Instead of multilateral cooperation, many of the most powerful countries have been seeking preferential access to promising vaccines through licensing agreements.
Last week, the US contracted with Pfizer for up to 600m doses of their vaccine, and the EU has made a deal with AstraZeneca for 400m doses. This bilateral bargaining will make it hard for the Covax plan to proceed: if rich countries buy up all the early stock, there will be little vaccine to be distributed elsewhere. Also, the Covax plan might allow rich countries to double-dip, buying vaccines for themselves through private deals while gaining vaccination for 20% of their population through the alliance.
Appeals to social justice and human rights, though important, are not likely to remedy these inequities. As the smallpox eradication programme demonstrated, self-interest has often proved to be the most compelling reason for nations to care about a global vaccination programme. Vaccination campaigns in poorer countries meant rich nations didn’t have to pay for the continued vaccination of their own population or for more surveillance of the virus at their borders.
But the fight against smallpox also saw loftier principles work in tandem with self-interest. Reeling from the international shame of the Vietnam war, Johnson was keen to support the campaign to show the US’s renewed commitment to the world. He signed on and, in the middle of the cold war, the USSR agreed to supply the 1.7bn doses. For this reason alone the WHO, and the planet at large, is right to celebrate smallpox eradication as a momentous victory for international cooperation.
Can coordination of this magnitude ever happen again? As in 1958, it is unlikely the US will lead the way. Donald Trump recently declared that the US would no longer fund the WHO, and America and China appear to be entering a new cold war. The recent accusation that China and Russia have been trying to steal vaccine formulations from American companies follows a string of xenophobic attacks on China that date back to when Trump labelled Covid-19 “a foreign virus” on 11 March.
Perhaps Biden, if elected, will see himself as the heir to Johnson in the midst of Vietnam. Facing a world that has soured on America and “America first”, and newly chastened from its own coronavirus crisis, Biden may look to repair the damaged reputation of the US by working to create global supply chains for a vaccine.
But at the moment our only hope for an equitable distribution plan lies with the countries that have partnered with Covax. Politicians, scientists, medical professionals and activists of all stripes must press governments around the world to close loopholes and address questions of how wealthy signatories and manufacturers will be held to account for their share. Through pooled resources, all nations, rich or poor, and all people, should have enough vaccine doses to at least protect their most vulnerable populations – and we cannot leave out the world’s growing refugee population.
If the history of smallpox eradication teaches us anything, it is that distribution equality is just as important as the vaccine itself, if not more important. Once a vaccine was available for smallpox, disease control in poorer countries took generations to achieve, and was only accomplished with unprecedented global collaboration. The smallpox vaccine was unpatented. Today, drug company profiteers and their stockholders have privatised access to a global good, making equitable distribution harder and more expensive. If we don’t learn these lessons, we will end up living with the threat of this pandemic for decades to come.
• Stephanie DeGooyer is ACLS Frederick Burkhardt fellow at UCLA and Srinivas Murthy is associate professor of infectious diseases and critical care at the University of British Columbia