When a new pathogen breaks out, usually in a low- or middle-income country, sharing the pathogen’s genetic data with the world allows others, mostly in high-income countries, to develop vaccines more quickly.

But even as COVID brought new urgency to the need for an international agreement on pathogen access and vaccine sharing, negotiations within the World Health Organization (WHO) have stalled — even before the U.S. withdrawal from the WHO.

In an op-ed, Professor David McAdams of Duke University’s Fuqua School of Business and Professor Gavin Yamey of Duke’s Global Health Institute explained the stakes:

• Without an agreement on pathogen access, vaccine makers may not be able to develop new pandemic vaccines nearly as quickly during the next pandemic;
   
• Without an agreement on vaccine sharing, many low- and middle-income countries (LMICs) may remain unprotected from the virus for far longer than high-income countries (HICs), as they were during COVID.

The current impasse at the WHO is due to LMIC’s insistence that vaccine makers should be required to sharing a portion of their future production, while vaccine-producing countries insist that their vaccine makers should only be “urged” to donate doses, the authors wrote.

But there is a win-win solution, McAdams said.

Vaccine manufacturers who commit ahead of time to sharing some of their production could be rewarded with enhanced access to pathogen data and opportunities to accelerate vaccine testing in the countries with the earliest outbreaks.

The pandemic agreement should not directly compel vaccine-producing nations to give away doses, McAdams argues, but should instead establish a “pandemic-prevention club” that vaccine-producing nations may join if they commit to sharing a portion of their vaccine production with LMICs. Vaccine-producing nations and LMICs each benefit from such an arrangement, McAdams said. LMICs benefit by getting some of the earliest doses produced, while vaccine-producing countries benefit by being able to begin protecting their own people much earlier than otherwise.

In a Q&A, McAdams explains how his research on “game theory” led to the idea of a “club” for vaccine-producing nations that agree to share the benefits of their vaccines.

Why is it so important for vaccine-producing countries and low-income countries to work together when it comes to developing a pandemic vaccine? 

The Coalition for Epidemic Preparedness Innovations (CEPI) has laid out a vision, called the “100 days mission,” for how we can develop, test, and be ready to begin producing vaccines for a novel pandemic within 100 days of pathogen identification. But that only works if we are able to test these new vaccines in the “frontline countries” where the virus has first emerged. During the COVID pandemic, many people in vaccine-producing countries were already infected with SARS-CoV-2 virus by the time vaccine makers were ready to test their vaccine candidates.  Consequently, it was easy for an American vaccine-maker like Moderna to run vaccine trials here in the United States. But wouldn’t it be far better to begin testing a new vaccine before many Americans have become sick? The only way to do that is to partner with other countries, often low-income countries, where the first outbreaks have occurred.

The problem is that low-income countries currently have little incentive to help vaccine makers accelerate the vaccine-development process. Indeed, many of these countries feel burned by their experience during the COVID pandemic. They shared pathogen data without demanding anything in return, allowing us to develop vaccines in record time, but then got pushed to the end of the line for access to those vaccines.  If we don’t find a way to assure LMICs that they will be treated more fairly during the next pandemic, we could find ourselves in an even worse situation in which frontline LMICs refuse to share pathogen genetic data, as Indonesia did in 2007 at the start of the H5N1 avian influenza outbreak.

You wrote the book, Game-Changer: Game Theory and the Art of Transforming Strategic Situations. What is “game-theory” and how does it apply to the problem of protecting the world from pandemics? 

A game is a situation where multiple parties are making choices that impact each other. In our setting, we have a low- income country where a new pandemic is emerging. They have to decide whether to share pathogen genetic data. And then we have wealthy countries that are deciding whether to share some of the doses that they will produce. Game theory predicts no one's going to help. High income countries, once they have the vaccine, have no incentive to just give doses away. Their political leaders will want to keep their doses for their citizens, since otherwise they will likely face a public outcry. On the other hand, low-income countries know that if they just give away the genetic data, no one's going to come to their rescue. They're going to be suffering the pandemic all on their own. If you put yourself in their shoes, it makes sense for them to demand something in exchange for the pathogen genetic data, to hold off on giving this vital data until they get credible assurances — or maybe some money, so that they can buy vaccine doses for themselves later, once they're available. That's the game-theory prediction. Which is exactly what's happening: they're having a really hard time reaching a pandemic agreement. 

Fortunately, there are ways to change this game for the better — the first step being to recognize that what we have here is a “public good problem.”

What is a public-good problem? 

A public good is something that everyone gets to enjoy, regardless of whether they contributed to make it happen. In this case, when a high-income country gives doses to a low- or middle-income country, they allow the pandemic to be better controlled. Helping LMICs brings the pandemic to a faster ending and reduces opportunities for dangerous viral mutations — this is a public good for the whole world. However, high-income countries all benefit when other high-income countries give doses to LMICs. They have little incentive to do so themselves. Consequently, we should expect many high-income countries to refuse to help the rest of the world, resulting in a less-controlled, longer, and more harmful pandemic. Fortunately, game theory points to several ways to solve the public-good problem, one being to bundle the public good with another “club good” that can be restricted to those who contribute to the public good.

What is a “club good” and how does this concept apply to preventing pandemics?

A club good is a benefit that only goes to those who are in the club. The key difference between a public good and a club good is that a club good is excludable from those who are not in the club. This creates an incentive for people to want to join the club, in order to gain access to the club good. 

Now imagine that we design a club whose purpose is to support the provision of a public good. Such clubs are quite familiar in American life. For instance, the Kiwanis Club is “open [only] to men and women who are interested in helping the community and other people.” Commit to help other people and you get to enjoy the benefits of being a Kiwanis Club member. In the same way, imagine a club for vaccine-producing nations that is open only to those willing to commit to give a portion (say 10%) of their vaccine production with LMICs. 

Vaccine-producing nations will want to join this club so long as the benefit they get from being in the club is more valuable than the doses being donated. Of course, giving away vaccine doses during a pandemic is costly and could have negative political consequences for the leader of a vaccine-producing country. So, we need the “club good” not only to be beneficial to the nation but sufficiently salient to voters that political leaders look good and gain support as a result of joining the club. This is where we need to get creative and think, “Okay, what is a club good that would be more valuable (for the country and for the political leader) than, say, 10% of their doses?” 

The answer Gavin Yamey and I propose is much faster access to vaccines, down from a year to just a few months. Any politician who can take credit for his people getting access to vaccines before the rest of the world will be lionized as a hero! Moreover, as a vaccine-producing country accelerates testing and begins vaccine production earlier than otherwise, that country will naturally end up with more overall doses even as it gives away 10% to LMICs. To see why, say that we start producing doses nine months earlier than otherwise. All doses produced in those nine months are essentially “extra” doses. Even after giving away 10% of them, we end up with about 8 months’ worth of extra production, compared with what would have happened if we had not joined the club. Putting it in a different way, imagine being the one world leader who, out of stubbornness, refused to help others and hence kept his country out of the club. When the next pandemic hits, that one country would be uniquely disadvantaged and everyone would know why—because of its inept political leader! 

What does this mean for the United States? We have amazing scientists and amazing vaccine developers. When the next pandemic strikes, there is no doubt that we will have several vaccine candidates ready very quickly. But we won’t be alone. Suppose that China has a vaccine candidate and that they are partnering with poorer countries as I’ve discussed here, allowing China to get their vaccines tested for safety and effectiveness before us. Now, imagine that one of those Chinese vaccines is proven to be highly safe and effective — maybe they test several vaccines and figure out which one is the best. Other high-income countries will then naturally have an incentive to buy up the Chinese vaccine, leaving our own vaccine makers in the dust and our citizens less protected for a longer time.  

If you were advising the government of a wealthy nation, what would you tell them?

Should United Nations negotiators agree to create a pandemic-prevention club as I have outlined, then you should join it. In game-theory terms, joining such a club is a dominant strategy. But what if they are unable to reach a meaningful agreement and nothing really changes? Even then, there is much to gain for your country by taking a leadership role and building relationships with low- and middle-income countries to be prepared for the next pandemic. The more you help them, the more instrumental you will be in building up the infrastructure for detecting viruses and ultimately partnering with them to rapidly test and deploy pandemic vaccines that can also be used to protect your own people. 

A club of nations working together would be best for all of us but, if the world cannot get its act together, there is still room for “win-win” outcomes for your country and for low-income countries partnering in a more bilateral way.