The Indian government, however, wanted to ensure it had sufficient supply for its own domestic needs. On the same day India’s National Task Force for COVID-19 recommended hydroxychloroquine for treating high-risk cases. Two days later, India’s Ministry of Commerce and Industry prohibited the export of the drug and formulations made from it, with exceptions (such as where pre-existing commitments had been made, as well as on humanitarian grounds).

But then doubts about hydroxychloroquine’s effectiveness at treating COVID-19 began to emerge as the International Society of Antimicrobial Chemotherapy – which houses the journal where the Marseille-based research was published – criticised the study. Yet, on April 4, India banned the export of hydroxychloroquine without any exception.

President Trump didn’t take long to respond. At his White House press conference on April 6, he warned “there may be retaliation” if India didn’t supply hydroxychloroquine to the US. Just a day later, India’s complete export prohibition was lifted. Supply would be allowed to more than 20 countries on a commercial and humanitarian basis. World leaders including Trump, Benjamin Netanyahu and Jair Bolsonaro all thanked Narendra Modi, the Indian prime minister.

Searching for medicines and vaccines

While the effectiveness of hydroxychloroquine is still hotly contested, the tribulations over the drug are an insight into some of the challenges to be overcome in fighting the virus.

Efforts to develop a vaccine are well under way yet projected to take considerable time, so the search continues for repurposed drugs to treat and reduce deaths from the disease. Having China and India involved as manufacturing partners for any treatment or vaccine will be vital given their unparalleled ability to produce in high volumes and cost effective economies of scale.

Manufacturing capabilities are also present in China and India for two other potential treatments. Favipiravir, normally used to treat influenza, was approved in China and Italy for experimental use against COVID-19 in March 2020. By late April, it was reported that Mumbai-based Glenmark had developed the API in-house and was applying for regulatory approval for its use against COVID-19. And another Indian firm, Strides, also announced it had commercialised and begun exporting favipiravir to a number of countries in the Middle East.

Meanwhile remdesivir (owned by US firm Gilead Sciences) has been authorised by the FDA to treat COVID-19 in emergency cases.

As early as mid-February, Gilead partnered with the China-Japan Friendship Hospital and the Chinese Academy of Sciences for human trials of remdesivir in Wuhan. A Chinese company quickly manufactured the API for remdesivir and by the end of March a total of five Chinese companies and the Taiwanese National Health Institute announced they had the capacity to produce the drug.

Patent barriers?

Remdesivir is distinct from the other drugs which have attracted attention as COVID-19 treatments so far in that Gilead has a patent for it, raising serious concerns of intellectual property issues restricting access to medicines or vaccines. Since mid-April, various Indian pharmaceutical companies had already begun developing remdesevir, as has Bangladeshi company, Beximco.

Facing a public health emergency, global trade rules permit governments to issue a compulsory license. Such a provision allows a manufacturer to produce a medicine without the permission of the patent holder, who is paid a royalty fee instead. A variety of countries including Chile, Ecuador, Israel, Canada and Germany have all moved to make it easier to issue a compulsory license, if needed, for COVID-19.

Perhaps anticipating such a move, Gilead announced on May 12 that it had issued voluntary licensing agreements for remdesevir to one company in Pakistan (Ferozsons Laboratories) and four in India (Cipla, Hetero Labs, Jubilant Life Sciences and Mylan). The deal would involve transfer of technology and allow the five companies to make remdesevir for subsequent distribution in 127 countries, primarily in the global south.

Gilead has agreed a deal with these five generic companies to manufacture and supply this drug on which so much hope has been placed. Gilead has also entered discussions with the Medicines Patent Pool – a UN backed agency which tries to increase access to treatments for HIV/AIDS, hepatitis C, and tuberculosis. It has now expanded its remit to include “any health technology that could contribute to the global response to COVID-19”.

Global public good

Any prospective vaccine faces a challenge of not just being effective, but also requiring enormous manufacturing capacities to reach the majority of the world’s population.

As of late May, more than 200 COVID-19 vaccine candidates are in development around the world, according to the Coalition for Epidemic Preparedness Innovations. While 42% are in North America, six of the ten which have already progressed to human trials are being developed in China. Many hopes are riding on a vaccine candidate at the University of Oxford, which began human trials on April 24. AstraZeneca has been given the worldwide development, marketing and distribution licensing rights for the vaccine. The UK company has also received more than US$1 billion in support for the vaccine from the US Biomedical and Advanced Research Authority. And AstraZeneca is in discussions over increasing production and distribution with India’s Serum Institute, which has already been involved in collaborations with Oxford on the vaccine.

In addition to its involvement with the Oxford vaccine, Serum Institute is also working with the US-based Codagenix to develop a vaccine. Other manufacturers in India trying to develop vaccines include Bharat Biotech (with University of Wisconsin-Madison and FlyGen), Zydus Cadila, Biological E, Indian Immunologicals and Mynvax.

Given the chance of re-infection (unless billions of people are inoculated) any effective vaccine must be manufactured at considerable scale, a task which would benefit considerably from Chinese and Indian involvement. Ngozi Okonji-Iweala (Board Chair of Gavi, the Vaccine Alliance, and WHO Special Envoy on Global Collaboration to fight COVID-19) has warned:

It is the duty of every government to put its citizens first, but during a pandemic this duty also requires thinking and acting globally. If manufacturing agreements or export restrictions impede the deployment of vaccines and allow the virus to survive anywhere, nowhere can be safe from reinfection.

On May 4, a number of countries and global health organisations committed €7.4bn for a coordinated approach to COVID-19 through the development of vaccines, treatments and diagnostics. Notably, while China, the UK and several major European countries participated, the US, Russia and India were absent.

A lot depends, of course, on whether China and India share the products of their manufacturing with the rest of the world. India’s restrictions on exporting key drugs in March (albeit later rescinded) are a worrying sign of things that may be to come. Recent history from mitigating the impact of HIV-AIDS demonstrates the huge benefits for global access to medicines when India is involved. The all-time high for AIDS deaths in the USA was in 1995. But for the world as a whole, mortality from HIV only fell from the mid-2000s, when anti-retrovirals became more widely available in the global south.

In contrast to some of the doomsday fears of what might happen amid a global public health crisis, China has not yet issued any restriction or ban on export of medical goods. Although often framed in the US as an unhealthy dependency on China, what is often overlooked is that China also relies on the US and major European countries for some of its medicines. In 2019, Germany was the largest source of China’s medicine imports, followed by France, the US, Italy and Sweden. Much of China’s anti-cancer drugs are imported. This inter-dependence in pharmaceuticals, rather than dependence, means China may not be as quick to putting up a seal around its border as some thought.

Confounding fears of “vaccine nationalism”, China’s President Xi Jinping announced at the World Health Assembly on May 18 that “COVID-19 vaccine development and deployment in China, when available, will be made a global public good, which will be China’s contribution to ensuring vaccine accessibility and affordability in developing countries”.

The dependencies and inter-dependencies of globalisation have been exposed by the COVID-19 pandemic – and nowhere more so than in the pharmaceutical industry. We don’t yet know how the medicine and vaccine challenge will end. Whether it be hydroxychloroquine, favipiravir, remdesivir or something else, it is unclear which drug, if any, will work. It may be a vaccine. While it may be an American company or an Oxford lab that is hailed as a hero for a treatment or prevention, the task is not just about discovering a treatment or vaccine that works, but making it available to as many people as possible in as short a time as possible. Successful accomplishment of that task – especially in the global south – is difficult to envisage without Chinese and Indian involvement. COVID-19 ignores borders and the solutions to address it will need to overcome them too.

Rory Horner is a Senior Lecturer at the Global Development Institute, University of Manchester.

This article is republished from The Conversation under a Creative Commons license. Read the original article.