Episode Transcripts

Presenter: Dr Shane Bergin
Guests: Achal Prabhala, Prof Maya Goldenberg, Dr Tiffany Green, Dr Jahnavi Phalkey

Shane 0:04

This is The Trust Race, the series of scandals and controversies that have impacted our trust in science. We began The Trust Race by talking about mask use and COVID-19. We saw how establishing trust in science is complex when the science is changing, and recognize the importance of proxies like journalists for creating trust. In this episode, we returned to COVID, specifically to COVID vaccines will ask why is global access to vaccines aren’t equal? And why are so many people reluctant to take vaccines when offered one. As a scientist, I’m motivated by the idea of science as a common good, that it benefits everyone no matter who you are or where you’re from. It’s a quality of science that makes it trustworthy, I think. The reality therefore, that science is not always done for the common good majority impact the trust placed in it by many. I spoke about this with Achal Prabhala who works on access to medicines and vaccines.

Achal 1:12

At this time, we’re in July 2022. And there are two ways to think about this – the past and then the future. The pandemic was declared a little over two years ago. When the pandemic was declared in 2020, we didn’t have vaccines. We had a range of treatments that turned out to be not very good at what they did. But we have had vaccines now for at least a year and a half. And in the year and a half that’s passed with vaccines, what happened is a travesty. The vaccines went to people who could buy them rather than people who needed them. And so for all of the vaccines that were produced last year, almost without exception, especially if they were from the West – and so these are vaccines, like the ones from BioNTech and Pfizer, from Moderna, from AstraZeneca, from Johnson and Johnson – they overwhelmingly went to Western countries, they went in very small quantities to non-Western countries.

Archive News Audio 2:18

According to the World Health body, the Coronavirus pandemic will go on for a year longer than it needs to because poorer countries are not getting enough vaccines.

Archive News Audio 2:29

The last two years have demonstrated a simple but brutal truth. If you leave anyone behind, in the end, we leave everyone behind. Vaccination rates in high income countries are shamefully seven times higher than in African countries. And we need vaccine equity now.

Archive News Audio 2:49

Inequality is just you know, it’s a human rights issue. It’s immensely, you know, unfair. And what you’ve seen is that even efforts by COVAX from W.H.O., the reason that they’ve sort of fallen behind is because rich countries are getting ahead in the line and buying up the doses as manufacturers are producing them.

Archive News Audio 3:07

While other African nations have struggled to obtain sufficient vaccine supplies, officials blamed production difficulties and vaccine hoarding by high income countries but logistical problems also mean jabs often don’t reach less populated areas.

Archive News Audio 3:22

Today, the capital is well stocked, but the government doesn’t have a plan to get the vaccines to remote parts of the country.

Archive News Audio 3:33

Begging for vaccines in Caracas with no idea of who was listening. And help is not coming fast. Venezuela rejected offers of AstraZeneca vaccines from COVAX. The United States has excluded Venezuela from its vaccination donations for now, citing a lack of transparency about how the country has handled COVID. The black market though is surging for those with means, paying up to hundreds of dollars for a shot.

Archive News Audio 4:01

Amnesty International activist Diana Gichengo finds it scandalous that the most vulnerable people are being neglected. The few people in the middle class who understood why we needed the vaccine took all measures to jump the queue. And that left us falling very very far behind in terms of focusing on the priority population.

Achal 4:26

The poorest countries in the world received vaccines for less than 20% of their population to date. While in countries, some countries in the west where vaccine hesitancy is low, they have near universal rates of coverage of not just the initial vaccination but also multiple repeated booster shots. So the past of the pandemic has been extreme vaccine inequity as well as extreme inequity in terms of anything else that we need to deal with the pandemic, starting with masks and tests, to treatments – pills like Paxlovid which are recommended in Europe and the United States, but are largely unavailable anywhere else. The future of inequitable access, and it sounds terrible to say, is something that is not even a prediction but more a fact at the moment is that, partly as a result of the vaccine inequity in the past in the pandemic, we had an astonishing rate of mutation of the original wild strain of the Coronavirus, which means that we had variants that rendered existing vaccines less and less effective as the pandemic progressed. The last variant that came to us is the Omicron variant, which has now mutated into various subvariants, almost all of which are causing panic in one part of the world or another. And our existing vaccines even the very best mRNA vaccines from Pfizer, BioNTech and Moderna work very badly to prevent transmission of this Omicron subvariant. A lot of vaccines protect against hospitalization and death, which is a good thing. However, just having millions of cases again, flaring up is not a good thing. It invariably leads to some degree of hospitalization and death, and certainly a large amount of social and economic panic. And our vaccines are not good enough to control them. And so very soon, in October, we will have next generation updated reformulated COVID vaccines, which will also be on the mRNA platform, which are Pfizer, BioNTech, and Moderna. And the truth of these vaccines is if their past record is anything to go by, 93% of all vaccine supplies from these two companies, the two mRNA vaccine manufacturers went to rich countries. So half the world, which would be classified as non-poor or rich, got 93% of these vaccines, the other half of the world got 7%. That ridiculous situation, unfortunately, is likely to repeat itself, not just with the vaccines that come out now in October, but every further progression on the mRNA technology platform, which is the most radical, easiest to use, and certainly the most brilliant technological development in the pandemic. Brilliant, except for the fact that it’s available to so few.

Shane 7:26

But I wanted first to step back and explore inequality in public health more broadly. So I spoke with Tiffany Green for a US perspective on this. Tiffany is an assistant professor in the departments of population health sciences, and obstetrics and gynecology at the University of Wisconsin Madison. I wanted to understand from her how COVID and public health systems fraught with inequality interacted.

Tiffany 7:53

My work really has focused for the last decade plus on the causes and consequences of racial disparities in health in general and reproductive health in particular. So I’m very interested in going beyond just individual level factors to understand how environments and structures influence health. This took a tiny bit of a turn, when the COVID-19 pandemic came into being. Very early on, I saw that people were really reverting to this, this individual level blame, when it was very clear to me from my own research, that the larger structural factors, including systemic and structural racism, we’re at we’re at blame. And essentially, in the US, in particular, the racialized nature of our occupational structures, class, all of that really came together in a perfect storm, to really disadvantage people of color in general, Black people in particular. And also people from other groups, including LGBT folks, Disabled folks, the list goes on and on. It really has been a pandemic that has just disadvantaged so many already marginalized groups. And now we’re seeing we saw it again, with the vaccines which we could have predicted was going to happen. It is happening with people trying to tell us to get back to normal when these groups that I’m talking about had never had a normal that was really acceptable or adequate. And it is because of structural inequality, including structural racism.

Shane 9:33

I guess, a kind of continuation of that is ‘fix the inequality and it would fix the issue’. Maybe that’s too simplistic, you know.

Tiffany 9:44

I’m not laughing at you. I mean, of course, that is absolutely true. You may have heard about a recent study from some social psychologists that showed that when the white Americans in their sample learned about racial disparities in COVID, they became less supportive of public health mitigations and measures. And to be quite frank, this is not surprising to any Black people, a lot of Black people who are not researchers said yeah, we knew that. That as soon as the conversation turned towards ‘oh, well, there are some racialized differences in how COVID is showing up’, then the support for these these measures started to decline. And this gives us empirical proof as to why.

Shane 10:27

Maybe you might be able to tell us some examples of what that systemic racism looks like for an issue like COVID-19. How might people see yes or notice it in the world around them?

Tiffany 10:38

Oh man, do you have all day? I guess we can, we’ll show we’ll go back to that whole big dinner debacle in DC. On a lot of the conversation, we saw this, the DC power players, brokers, government officials, all getting COVID. But how many of those articles talk about the people that were serving them? How many people talked about the people working in the back – the waiters, the staff – and these folks tend to be disproportionately people of color in the United States. Why is that? We know in the United States that access to education is classed, very much classed in contrast to other places. The quality of schools is often dependent on parents property taxes, so if you are in a place where your parents aren’t paying high property taxes, if you’re in poor areas, more likely than not your schools don’t have the resources. And of course, what is racialized in the United States? Class. So people of color, including Black people are less likely to have the same kinds of educational attainment. And importantly, even when we have the same educational attainment, we still don’t have the same incomes there. You know, it just really shows up in where we live, where we work, where we play, where we get health care, it’s just it’s constant.

Archive News Audio 12:00

Race, and income really determine your access to resources, and that’s no different with COVID. Studies show more than 30% of Black adults don’t have broadband internet, leaving many without information online about where and how to get vaccinated. You don’t have great high speed internet, you don’t have a computer. How can you jump in line to make an appointment?

Archive News Audio 12:22

Black residents are significantly more likely than white residents to live more than a mile from the closest vaccination facility. Researchers also found black people are less likely than whites to live near a pharmacy, clinic, hospital, or health center that can administer COVID-19 vaccines.

Archive News Audio 12:37

Data from the Kaiser Family Foundation suggests that LGBT populations may be disproportionately impacted by COVID-19. Historically, there has been a long distrust of the healthcare system by LGBTQ communities. LGBTQ folks have been vilified and mistreated in many ways by the healthcare system. And so folks are reluctant to engage in having a routine primary care relationship or seeing medical providers or healthcare professionals of any kind. And people are afraid sometimes of going to the emergency department because of ways they’ve been treated before or the fear that they’re going to be mistreated because of their identities and what they look like. And so that’s pretty significant in terms of getting folks to seek care when they’re having COVID-19 symptoms, for example.

Archive News Audio 12:38

COVID vaccination numbers among children are drastically different depending on where the child lives in America. Black and Latino and Native American children about three times as likely to be hospitalised.

Archive News Audio 13:31

Information from 23 states that report COVID vaccinations by race and ethnicity shows a stark difference in the role out

Archive News Audio 13:37

Black Americans are hospitalized for COVID at almost triple the rate and are at least 1.5 times more likely to die from this virus than white Americans.

Tiffany 13:53

Another example, showed up in Brown County here in Wisconsin towards the beginning of the pandemic, and there was an outbreak and I remember one of the Wisconsin Supreme Court justices said something like, oh, well, basically those people are getting, you know, COVID as if they were some other sorts of people. Well, they were primarily Hispanic Latinx immigrants. Why? Because Hispanic and Latinx immigrants are more likely to be working in meatpacking plants. And these plants do not have the oversight that they should have when it comes to providing good working conditions. I mean, we could go on and on and on. The reality is people of color in general, Black people in particular – much less likely to be able to stay at home. And if you’re less likely to stay at home, you’re more exposed. If you’re more likely to take public transportation, you’re more exposed. This is not difficult. But I think in the United States we are very willful in our ability to ignore what structural inequality It looks like including racism.

Shane 15:03

And so when you talk about the unequal nature of the front line, as you said, people who are unable to stay at home, people working in various service industries. If one was being logical about it do you think, well, perhaps people in those communities would be first to sign up for a vaccine. Right? Because they might feel protected by it. But I think it might be fair to say your your work has suggested that there are issues around structural racism affecting vaccine take up – what would you say about that?

Tiffany 15:33

Here’s a couple of things that I’m seeing. One is it’s complicated. So there are people that are hardcore, anti-vax, as I’m sure you know, even better than I do. And it’s gonna be really hard to reach them. But I think there are also people in the middle who may not be anti-vax, but they may have questions. Why did this vaccine take so little time to get to market? Well, those of us in the science community know that we now see where there’s a will, there’s a way. Right? And we know that it was based on on prior vaccines, prior work that we had done before on vaccines, but trying to explain that – it has been a failure of science communication, I would argue. We have not done a good job of explaining why these vaccines were able to get to market so quickly. And you combine that with the fact that these historically excluded communities have been historically exploited and exploited in the now, and you can see why there may be some hesitancy to vaccines. The other part is that there is there is an unfortunate conflation, even among so called liberal minded public health people about vaccine hesitancy and vaccine access, and they can look really similar sometimes. First of all, we know that, in the United States at least, people of color are less likely to have access to a primary care physician. Now you shouldn’t have to have one to get a vaccine, but – well you should have one anyway – but that plays a large role. If people don’t have a usual primary physician, a usual site of care, who do they have talking to them about vaccines? Are their community health workers showing up to have conversations about hesitancy? And then going back to structural racism, which is what you asked me about Shane in the first place. We both know, we all know that with the vaccine, especially that second one, at least for me, it hit me hard. I was certainly willing to take one for the team, happy to do so. But guess what I can do as a professor, I don’t have to necessarily show up to class the next day if I’m not teaching. I can take time off. If you’re an essential worker, you’re saying, well, not only do you not have sick leave, but you expect me to go take time off to get the vaccine, and then take more time off that is unpaid to recover from these effects. And we see data that reflects that, that part of the reason that some people were not getting vaccines was because they did not have paid sick leave to recover. And again, who are the people that are more likely not to have paid sick leave in the US or job with benefits? People of color, Black people, and/or Hispanic or Latinx people. Right? So it’s so it’s so pervasive? It’s so unbelievably pervasive in the United States that I think people just take this for granted, without realizing how grossly unequal it is, and that it doesn’t have to be this way.

Shane 18:44

So in terms of getting there, how do we build a community of trusts to move forward together? How do we relate to one another? How do we communicate with each other in a way that builds trust as opposed to things that are, as you said, intentionally polarizing?

Tiffany 19:01

That’s a hard question, and I think it depends on the place and the time and the context. I definitely would not have advice for Ireland, which is a completely different social, political and racial context than the United States. I would say a couple of things. One is that I think it’s very difficult given the way our media is structured for these evidence based ideas to rise to the top so I think it will take organic grassroots efforts to reach communities. We have some beautiful success stories about people who have gone from door to door in their communities, to talk to people, to educate them to listen importantly to their concerns. And that is long, hard, messy work, but It is vital to gain people’s trust. And there have been people and Black women in particular in the United States that have done this work. And it just fills me with so much pride and so much hope. I think for me, the second thing is to not give up hope. Sometimes it feels very, very hard. When I saw that article that I mentioned to you earlier, that essentially talks about a racial empathy gap with COVID, it’s so hard. But I think about it like this. I’m not a professional science communicator, although I feel like I’ve fallen into that role. I think there are people that I am not interested in reaching. I’ll just be frank. That’s other people’s job. I think some people are really good with going with the hardcore, anti-vaxxers, hardcore anti-mitigation folks. That’s not me. But I think if we can speak to the people in the middle, the people that might disagree with us, but are willing to listen, I think that’s who we go for. It doesn’t make as much sense for me to speak to the crowd or speak to the crowd that agrees with me. But there are people who are reasonable, that are people that are really reasonable and willing to listen, I think that’s who we try to find common ground with. Because frankly, there are people – and maybe this is me being cynical – but there are people that have a vested interest in seeing COVID go unchecked. And seeing any efforts towards mitigation, any efforts towards equity squashed, and we can’t reach them, at least I can’t. I’m not interested in doing that. But I think we can speak to folks in the middle. And then the third thing I would say is that I, as a former RWJ Health and Society scholar, that’s Robert Wood Johnson Health and Society scholar, unfortunately, that program is kaput now. But it was this beautiful postdoctoral interdisciplinary fellowship program. And one of the things that taught me is that there is health in all policies. And if anything, we have learned that none of this is siloed. We can’t just focus on public health. You know, although that’s drastically underfunded in the United States, we have to focus on social services, we have to focus on universal job guarantees, because all of those things are related to who’s getting vaccinated, all those things are related to who can protect themselves, right. And so what I would love to see is more people coming together across disciplines, across government agencies in the United States to understand that health is all policies and we cannot solve COVID just going through public health. We have to bring in social support programs, we have to bring in people that have nothing to do with public health in general, to make sure that people can protect themselves, we can protect our communities, protect our babies, and so that everyone can reach their highest potential. I know I said I’m very cynical, but I think I’m an optimist in that way, that I think if people have health care, if they have their basic needs met, then there’s so much we can do. There’s no limit to what we can do. And I think it bothers me that we have structural racism from a justice perspective, of course, but you know, as well, I like to say I’m an 80s, baby. And I used to watch the Jetsons and I saw those flying cars, and I have a flying car yet. I’m bitter about that. And I don’t have a flying car because there are so many people who have so much potential, that haven’t had opportunities because we have structured society that way. It is a policy choice. It’s a policy choice. All of this is a policy choice or a set of historical and contemporary policy choices.

Archive News Audio 24:14

If you accept what Tiffany Green is saying, it wouldn’t be too hard to imagine why some people in our societies may not trust that health care, or the associated science is for them. Why would any of us trust a system that’s unfair to us? I spoke about this with Maya Goldenberg, associate professor of philosophy at the University of Guelph in Canada.

Maya 24:37

Vaccine hesitancy is a surprisingly complex concept. It brings in a lot of misgivings and lack of trust around healthcare, government. It draws on past experiences with healthcare and government. And it also is, as a technology, it is always broader than the technology itself. That’s a little bit of a vague statement. There’s something about vaccines that elicits these kinds of responses that we don’t see in other healthcare technologies like pharmaceuticals. And so what that means is that vaccines represent a lot of things. On the one hand, it is a preventive measure that, at least historically has been somewhat dangerous. We don’t feel that way about vaccines anymore. They’re actually remarkably safe. They’ve always been tied to government mandates.

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Maya 26:49

And until COVID, most of the recent vaccine mandates have been targeted at children. And that is expected – that should be expected to elicit a lot of emotional response from parents. Parents, who I see as often well intended, trying to do what’s right for their children. So because of that, to describe why people are vaccine hesitant, the answer is, it’s for a lot of reasons. One, they care about their children. Two, they’re concerned about themselves. Three, they’re concerned about how their government is, is caring for them and their community during times of crisis like COVID. And of course, as if that’s not enough, there’s a lot of misinformation about vaccines, precisely because it is such a hot flash issue. It makes it a good point of fracture for people that are trying to sow discord and trouble in society, and the vaccines end up being a good way to do that.

Shane 27:57

No doubt given your role, you’ve come across interesting stories of public interactions with vaccines, what have you picked up on as an expert in this area with the COVID vaccines?

Maya 28:10

I’ve picked up on the extent to which people’s trust in the social framework that supports them. So I’m thinking of government, healthcare, and the sort is a very good predictor of whether they are accepting of vaccines. And I should say that the research already showed this prior to COVID. I think everything that we kind of knew before about vaccine acceptance and vaccine hesitancy has been amplified just because of the scale. So it had been the case prior to COVID, that people trusted vaccines to the extent that they trust the infrastructure that brings the vaccines to them. And this is true during times of calm, like whether you would vaccinate your kids in order to go to school. But it’s also been the case during times of crisis, like during H1N1, during ebola. If people thought the government was doing a good job responding to the crisis, they were more likely to get the vaccine. And that’s not just true in Canada, where I live, it’s been a global phenomena, worked through by there’s a vaccine confidence project that has done global surveying of vaccine confidence. And that is one thing that they find from country to country. If you trust the system, you’re more likely to take the vaccine. If you don’t trust the system. That’s probably a good reason not to take the vaccine because you might think the safety checks weren’t done properly, the regulatory checks are too weak. There are parts of the world where people suspect government of trying to maliciously kill or harm parts of the public.

Archive News Audio 29:57

Another problem is that many Kenyans don’t want to be vaccinated at all. Conspiracy theories about rich countries wanting to halt population growth in Africa through vaccinations are going viral on social media. Fact Checker Alphonse Cheongdo tries to counter online fake news. He’s shocked that even politicians are promoting rumors. One especially controversial video features the Minister of Health in neighboring Tanzania. So she’s addressing on why this is very important to for them to use alternative medicines, why we should not trust Western medicine and stuff like that. That was very, very potentially dangerous, and very, very misleading in the way it was typed, because he’s saying no vaccines in Tanzania, we don’t have COVID, take this and you will be safe from any viral infection.

Shane 30:50

So you talk about that the importance of the of establishing trust in in the system, and I’m doing air quotes there. But like, maybe you might tell us a little bit about who you might perceive that this system to be? Is it just government actors? Is it more complex than that? Might involve the scientists, the companies that produce the vaccines, etc?

Maya 31:11

I think it is broader, though government probably plays a very central role. And of course, health care systems do also, people who have had bad experiences in health care are less likely to engage in more health care, including engaging in vaccination. And government, of course. It’s been governments that have been promoting vaccines to the public. And governments are the – they’re in charge of the regulatory process. So I need to put a lot of attention to government, and to health care. But of course, the scientists play a part. The pharmaceutical companies that produce vaccines play a part too. And we’ve had so much attention during COVID, we’ve been many of us have been home, and spending a lot of time online, and we have so much attention to how these vaccines were being developed and processed and regulated. We’re watching scientists and medical professionals on social media giving us their hot takes. So if ever it was just healthcare and government, it doesn’t need to be any more because right now people are, you know, more informed about what epidemiologists at Stanford are saying then than ever before. So it seems that our view has broadened.

Shane 32:37

And does it help? Like does does that window on the process help to build the trust that’s necessary to improve wider uptake in vaccines?

Maya 32:46

It seems that it has for some and not for others. So there was this interesting phenomena at at the start of COVID. That trust – this is in many countries – trust in scientific experts actually went up. After years of slow decline, the survey suddenly showed an uptick. I think it was a moment of panic for a lot of members of the public. And they wanted to hear what the scientists had to say. That’s when politicians started putting their chief medical health officers – they’re called different things in different countries – but they’re putting their public health officers in front of the camera and then stepping back and saying, we’re going to follow the science. That had obviously polled well, people wanted to hear what the scientists had to say. And there was a little bit of a honeymoon for trust in science that hasn’t weathered all the way. There’s a number of reasons for that. One is nothing has worked out the way we thought it would it was easy to trust the scientists when we thought we just had to hunker down for a few weeks and flatten the curve, and maybe that would be the end of it. But we’ve seen many – remember that? – many unexpected turns along the way. The publics are getting a full view of what site how science and politics interact. And we don’t always like what we see. So it can breed cynicism, which of course is going to lower the trust, at the same time that it is also breeding familiarity, which is actually good for endearing the public to science. So I think both have happened.

Shane 34:28

Where might it go, do you think? As in, you know, would the the legacy of this global vaccination effort positively or negatively, or maybe a bit of both, affect public trust in science and particular vaccination science?

Maya 34:46

I’m still waiting to see where we’re going to land on this. The vaccines were billed as the thing that was going to get us out of this pandemic and that has not materialised. The vaccines were not as good as first promised. And of course, that promise came largely from press releases from Pfizer and Moderna. And that should have never been allowed, we should have had independently vetted information and clear analysis of what to expect right from the beginning. So that was a mistake that governments, and I wouldn’t say the media to sort of stepped back and let the press releases drive the story. Of course, we needed a good news story. But it created expectations that didn’t materialize. The vaccines are very good at keeping people out of hospital, but they did not end the pandemic. Even among those of us who live in high income countries and are now double vaxxed, triple vaxxed, now they’re doing a fourth in the US. And I assume they’ll follow in other high income countries too. And, of course, the global aspect is part of it. We’ve got large swaths of the world that cannot access these vaccines, even though they are literally dying to get access to it. I’m glad you’ll be pursuing this on on the podcast, there’s much to say about that. And, and that kind of global inequality is not helping anyone, it is not projecting a view of science as working in the public interest. Instead, it is demonstrating the limits of corporate science when you know, it’s it’s Pfizer and Maderna that are not giving up their information and getting the world vaccinated, even though there’s lots of compelling reasons to do it, even business reasons to do it. So we’re seeing the way the capitalist model and the need for public health don’t fit. And that’s not good for overall trust in science. If anything, this would have been the COVID by itself would have been a great time for a serious rethink about how science is positioned in society, and what we expect from our, from our scientific creators and our corporations. And it seemed like none of that happened. Instead, the capitalist model held, held strong, and we were relying more on, you know, philanthropic billionaires, then strengthening the public health infrastructure at the global scale, which is clearly what we need to get out of this. So that’s all to say, I’m not feeling good about the future of public trust in science, but it’s not too late. We could still enact some of those changes, but it’s going to take strong political will, that we’re just not seeing right now.

Archive News Audio 37:36

Speaking to you from Ireland, I’ve had the privilege of being COVID vaccinated and boosted several times. I clearly remember the day I had my first vaccine, it was a little over a year after the pandemic began the relief, I remember the relief to have knowing that my parents were safe after they had their jabs. And I figured that given the amount of public money that had been invested in the vaccine that I and many of you received, that they would be globally available to everyone around the world in no time. But as Achal mentioned at the beginning of this episode, that’s not what happened. So I wanted to know how vaccination worked in other countries. I spoke to historian of science, Jahnavi Phalkey, who’s currently leading Science Gallery Bengaluru in India,

Jahnavi 38:23

the pandemic experience in India, in many ways, laid open or laid bare the fault lines of, you know, what are otherwise social and political problems, you know, so the fault lines along which India is socially, politically, geographically, etc, divided, became stronger, became exacerbated in cases. So migrant labor, as you know, it’s a term I find very, very hard to understand, because you know, it, but nonetheless, people who, who move places for work within India found themselves displaced with not only short notice, but also access to pretty much not even public transport in you know, very, very immediately to be able to make the move and then and, you know, forget even bigger questions like, where would they eat along the way? And where would they stay along the way? And what would they do if they fell ill along the way? And, you know, we had incredibly, incredibly tragic stories unfolding around us through the pandemic. Access to healthcare and no access to health care, that divide becoming exaggerated during a pandemic is something we expect. But what we saw was the interconnections between that and everything else, as we of course always know. But here it was right in front of you, right? There were people you know, who worked for daily wages no longer had work and therefore no longer had food and therefore no longer could stay in places they were living in and therefore were thrown out of their homes, and many such things. And of course, we’ve seen this happen in the United States and also unfortunately, in the United Kingdom, for example, where child poverty, I think rose shockingly high during the pandemic. And so to come back to what I’m saying, you know, so we saw this, we saw the pandemic, in a way, unravel the very tenuous sutures, that ties Indian society and politics together. And I think we saw that happen. And it was very, very tough for many people. What was incredibly sobering during the second wave, which was in April last year, is that then these fault lines no longer sort of, you know, stayed true only sociologically, but actually, the pandemic began to hit even those who had access to health care in ways in which they had not anticipated, right. So I think the story that in many ways, shook people was a former Indian Foreign Services person, an ambassador, a retired ambassador, died in the parking lot of a hospital because he could not get a bed in the hospital. And this is someone with incredibly, you know, high number of privileges, and access to things, you know, simply because of the kind of, you know, profession they’ve learned, and even their family could not help them. I mean, it’s, I do not wish to present this as an isolated incident. But those kinds of incidents brought it home to everyone that that, you know, essentially this is a problem that needs to be resolved across society. And that infection, the infection was not going to know boundaries.

Shane 41:36

I know where I’m based here in Dublin, the perception of scientists and science has, I think, evolved through COVID. How has that experience been for you? How have you perceived and how do you think people around you have perceived scientists and science during the pandemic?

Jahnavi 41:55

It is hard to say, I think, for me, and for people around me to say that this has significantly transformed trust in science or trust in truth claims made by scientists, for example. Right. And I think there are many, well, there are a few reasons behind that not becoming possible. And I think, I mean, thinking about a few of them. And you know, the first one, I would go back again, to geopolitics, which is that if vaccines made in your country are not recognized abroad, then you don’t know whether you should trust people who are making vaccines in your country or not. Because you can’t be expected in a situation where you’ve lost a family member, to sit down and tell yourself, you know, there might be other reasons why this vaccine is not recognized. You’re not in a position to take risk on yourself or on your family members and your loved ones. And so in a sense, placing trust in work that is being done in your country, becomes a becomes a much bigger burden, when you’re in India, or Brazil, or China, or parts of Africa, and parts of Latin America. Because you are asked to assess the truth claim made by a scientist, and its assessment made in Europe and America. And who, you know, in a tragic, who even under normal circumstances would have – would have the wherewithal, the energy to actually go through go through the entire sort of, you know, process, accumulating knowledge, accumulating perspectives, discussions, and you know, even more so during a pandemic situation, you know, you’re not simply not going to have the emotional energy to be able to do all of that work. And so I think there is, we, we always I think, and, you know, I mean, you know, as a historian of science, I mean, you know, and I mean, I’ve worked outside India for a considerable number of years. And at that point of time, would well always tell myself that, you know, as a historian, for me, there is no, there is no ‘we’, which I can take as a natural ‘we’, right. And it was a position I could very comfortably occupy when I was not living in India, but when I live in India, I’m not only the historian that I am, and, you know, trying to have the critical perspective that I need to have, but I’m also a citizen, that is acted upon by the various agencies and the political forces, both from within and outside. And so it becomes that much harder to mediate my responses or to think through my responses and work through them. Right. And so that’s how I find myself saying ‘we’ now you know, with awareness of how I say it, but still, you know, I’m able to say that and what I can say is that we find ourselves in such difficult situations pretty much all the time, because you you, you know, you you’re denied in many ways comfort of, you know, yeah, accepting what’s what’s given to you. Because you know, you then ask yourself, Okay, you know, we have less resources in our labs. But of course, we have very good people, because clearly when Indians go abroad, they not only win Nobel prizes, but they also become sort of, you know, entrepreneurs, and who knows what all else. And so clearly, we have the talent pool, like every other country does, you know, that we have the the people who are able to do that kind of work, but then our institutions don’t quite work as efficiently. So how does one assess this? Right? And I think and, and there is, of course, public opinion and public opinion that is, especially in the time of pandemic, divided. And then you get news from elsewhere, and then you get news from it in India, and then you have to compute it. Right. And so I think it’s, it’s tough, actually, it’s tough to so to come back to a short answer to your question, I think it’s very hard for anyone sitting in a country like India to have confidence in their assessment of a claim given the number of ways in which it is contested, both within and outside.

Shane 46:22

Is science then – you know, science with a capital S, like the the institution of science – is it just perceived differently, you know, by virtue of like, historical influences or socioeconomic contexts? It’s not dawned on me before that science as a as a global enterprise, is perceived differently based on where you are, but because of who does it.

Jahnavi 46:51

And who is seen to be doing it, who is seen not to be doing it, who’s seen legitimately to be doing it, who is to be trusted, who is not to be trusted? You know, our tools of assessment are not symmetrical. And there’s no doubt about that. I mean, as a historian of science, I can say that with a reasonable degree of confidence. So here’s the thing, right? At the end of the day, science is cultural, it’s a cultural enterprise, right? And that includes the medical sciences. And this is what I say all the time about our work at science gallery Bengaluru, which is that we need to create a cultural conversation around science because we don’t have that. What we have is a professional conversation around science. We talk about grades, we talk about, you know, institutional rankings, we talk about professions we talk about upward social mobility. So even when we study professions or science scientists sociologically, we look at upward social mobility. We look at science as ideology, we do not engage with it culturally,

Shane 47:59

I find it so interesting that science is an academic pursuit or industry could be perceived so differently depending on where you are in the world. As someone in a country with a plentiful supply of vaccines and treatments, was I less exposed to discussions about inequalities and global distribution of vaccines? For the rest of this episode, I’m returning to my conversation with Achal Prabhala to investigate some of the reasons for such stark inequalities.

Achal 48:27

So broadly speaking, what I work against are pharmaceutical monopolies. And let’s just go back to that word monopoly. In general, I think people instinctively understand it as something that’s bad, bad for society, bad for the economy, bad for humanity. And so literally at every level that you can get to that word monopoly, it has a negative connotation. And yet, in the pharmaceutical industry, we have legal monopolies. These are actually sanctioned by the state rather than policed by it. The logic behind them is that pharmaceutical manufacturers need these sort of unfettered total control market incentives in order to invest in the research and development and the money behind that that’s required to produce these new vaccines. And it sounds logical and reasonable except for the fact that in the pandemic, as before, a large amount of the money that went into the research and development came from American and European taxpayers. And so in fact, the risk in this process was actually removed because no one could afford to have that risk. Many of these countries who funded companies like BioNTech, which received over $500 million in federal funding from the government of Germany, or American taxpayers who sent several billion dollars purely in just research and development funding to Moderna did so – these companies got this kind of money from their governments because the governments understood clearly that this was not a time to play. This was not a time where they could afford to take the kinds of risks we could in non-COVID times. So if for instance, there is no risk at all, not to mention the fact that the future of humanity is at stake. The logic of these state sanctioned and protected monopolies in the pharmaceutical industry does become a little absurd. But because of these monopolies and their unshakeable hold over the imaginations of governments and lawmakers certainly helped with aggressive lobbying and financial spends on campaign contributions to politicians. It’s very difficult to change that system from within the eye of the storm. And so the system needs a rethink. If we believe in healthcare as a universally essential good, which I think we do, and certainly many societies, not just believe in it, but actually have put pen to paper on it and have delivered it like in the United Kingdom, for instance, or in many parts of Europe, where there is a socialized healthcare system that takes care of you entirely from birth til death. The same, the same courtesy I think, should be extended to the medicines that are such an integral part of delivering that healthcare that the state already promises its people. And that commitment isn’t there. Because even though if you live in Europe, or Canada, or Switzerland or the United Kingdom, and you receive the socialized health care, and you’re not actually directly paying for the expensive cancer medicine, or the expensive COVID vaccine, your state is paying for it with your money, and so you are paying for it. In the United States and other countries where you have to buy these things yourself, it can be more stark in terms of what these things cost, but they do cost. And those monopolies are being paid for by you. And there isn’t any reason for this to be happening. It cuts into not just how accessible these things are in rich countries, but certainly cuts into how available they are in poor countries. And if we rethought this – if we rethought the idea of private corporate monopolies in favor of more public oriented research incentives, like prize funds, for instance, where you still create excellent financial incentives for companies, right. But you create them in a competitive manner, where the fruits of excellent brilliant scientific research is then not confined to the black box of a monopoly. But is not only rewarded, but it’s actually also allowed to be used by anybody who wants to manufacture them.

Shane 52:56

How does the so-called TRIPS Waiver fit into this story?

Achal 53:01

In the years leading up to 1996, pharmaceutical companies and technology companies in the United States noticed a funny thing and seized upon a perverse opportunity. What they had been doing through the late 70s and the 80s especially, was increasing monopoly control over this intangible idea that we call intellectual property that’s expressed through patents and copyright and trademarks. But they had increasingly understood in the two decades prior to the 1990s, that there was a lot of money that they could earn from these monopolies in rich countries. And then, when the world trading system was looking at an overhaul in the early 90s, they seized upon the opportunity to export their opportunities and collect rent from everywhere in the world rather than just the richest countries in the world. And they did that by inserting a trade rule, which is sort of obligatory and has to become law in member countries at the then nascent World Trade Organization while it was being created, at a time when very few people other than them understood the value and the consequence of these commitments. And what they put in was a binding commitment for all countries who are members of the WTO, the World Trade Organization, to respect and enforce their monopolies. So IBM and Pfizer, which led the lobbying on this round, essentially put in laws that said, well, prior to this, if you were India or Somalia or Taiwan or whatever else, you could just choose what you wish to do in terms of these intellectual property protections. But now you can’t because should you choose to do whatever you want to do then you will be effectively outside the world trading system. And obviously, that’s not an option for any country because, you know, trade is economy and economy is increasingly your basis for existence and simply not possible to exit the world trading system. But that is the bargain that they signed up for, which they didn’t understand. So they said, Yes, well I guess we can respect these monopolies. And then they very quickly found out towards the end of the 1990s, as HIV and AIDS spread, primarily in Sub Saharan Africa, threatening significant percentages of the population that lived in these countries, that these monopolies were going to kill them, literally kill them. So meaning millions of lives were lost at the turn of the century, as a result of $10,000 a year AIDS treatments, being technically available and on the market. So there is a cure for this deadly condition that you have, which no one can afford. And that situation then led to intense scrutiny on this previously obscure trade rule called TRIPS, which stands for the agreement on trade related aspects of intellectual property. Essentially, it’s a rule that binds all countries working in the world trade system, which is effectively every country in the world, to commit to doing what Pfizer and IBM want you to do. And that’s what we still do today, which is why we’re still doing what Pfizer wants us to do, which is, at this moment, if you’re in India, like me with parents in the late 70s and late 80s, not get the Pfizer vaccine despite about 50 companies – like by my own account and my own research that’s been put out and discussed widely – being able to produce those vaccines, right. So despite the fact that there are 50 companies in this country, nearly 50 companies who could make the mRNA vaccines which you receive, we have none.

Shane 56:59

There are companies ready to go so that they could just start producing the mRNA vaccines in the morning if this rule were changed?

Achal 57:08

Absolutely. A couple of months ago, colleague of mine Alain Alsalhani, who is a vaccines expert at Médecins Sans Frontières, and I worked on a substantial piece of research that surveyed pharmaceutical firms across Asia, Africa and Latin America. And what we found was that there were over 100 companies who could start making mRNA vaccines tomorrow, and by tomorrow, I mean, you know, sure three months, four months, right? But very, very, very quickly, if they were given the authorization by companies like BioNTech, Pfizer and Moderna to do so. But they’re not.

Shane 57:43

Gosh, the impact on people’s lives is profound, it must be incredibly frustrating to have done that research and know that reality. To sit with that must be so frustrating.

Achal 57:56

You know, it’s frustrating, it’s personally enraging, however, yes, because it’s not just a question of what’s happening now. So when you look at – so but it is important to underscore what’s happening now – the standard of treatment for somebody who is alive in the United States, or Europe or Japan, is that you have had two doses of an mRNA vaccine, you’ve possibly had two or three boosters of an mRNA vaccine by now. And if you still happen to catch whatever horrendously mutated form of Omicron is raging at the moment, you then have the option to be tested and treated, which is to say you have the option of getting Paxlovid, which is, at the moment, the best performing drug in lieu of vaccine protection to take, right, so you have potentially five doses of an mRNA vaccine in you plus a week’s course of Paxlovid. And this is incredible protection. It’s really the best we have in an evolving situation. And then let’s get to my father who’s 89. In India, he has zero doses of an mRNA vaccine and no Paxlovid, right. So this is it’s not, you know, it’s not frustrating. It’s enraging.

Shane 59:10

How has that affected people’s trust in science and in the scientific system?

Achal 59:17

This is a more complex question. One of the things that’s happening around mRNA vaccines for instance, which is very much the standard of treatment, that should be globally available, but isn’t is that there are several countries, about 50% of the world that has no access to them is doing very little about talking about them or creating ways to have access to them. In India, the reason this is not happening is because to admit to it would be to admit to political failure. So for the Indian government or any government authorities in India to say that we should have mRNA vaccines actually, and why don’t we, would be an admission of failure to the fact that they have not had any access to it the last one and a half years. It’s not like there is a popular rebellion in the country out to have access to mRNA vaccines. But that’s because the state is colluding with, in a perverse way in this case, the pharmaceutical industry, to not admit to its failure in asking for something that it can’t have and doesn’t have yet, because it sees that as a sign of weakness. So, in many ways, I think states like India have tried to create a sort of nationalist narrative around the things that are available in the country as being the very best things that you could have. That nothing more is necessary, and have been successful in doing so. Then, in other parts of the world, where there are different narratives unfolding, I had a surreal experience, which I have to relate in some detail because it’s complex, but in March of last year, with a colleague of mine called Chee Yoke Ling in Malaysia, I wrote an article in The New York Times around Chinese and Russian vaccines. We focused on two Chinese vaccines, Sinopharm’s Beijing vaccine, and Sinovac-CoronaVac vaccine. These were at the time and still remain the world’s most used vaccines. These are the vaccines that have gone into the largest number of bodies on earth. And they’re a remarkable success story in many ways. The Russian vaccine was a remarkable success in terms of its model. It was an open source vaccine. It’s just that they didn’t fully work out how to produce it, and so it was ultimately a huge failure. But at the time that we wrote this piece in March, there was far more promise attached to it. We wrote the facts of this vaccine in a respectable American newspaper, and were fact checked multiple times over the course of a month before we were published. What it turned into in multiple different Asian and Middle Eastern languages – so from Arabic to Khmer, to a range of other languages – was that we had somehow ranked vaccines around the world in terms of safety. And we had said that the Chinese vaccines were the safest, which is, which we didn’t even touch on. I mean, there was no mention of it whatsoever in the article, but because it was translated into languages and read by people who didn’t understand English well enough to go to the original article and see it, it was believed. I mean, I’ve received personal requests from cabinet ministers in Cambodia, for instance, to talk a little more about my research on why Chinese vaccines are the best, or the safest or something like that. I mean, it was just, you know, the head spun, and still does. What I think it was, it was a delusion, combined with hope and a way to be able to justify the circumstances people found themselves in. So I think that people who are in countries who started off getting Chinese vaccines and then started getting other Western vaccines seemed to need something. I think both the states of these countries as well as people within these countries needed something from Western media to tell them that what they were doing was fine, right. And maybe our article did that to some extent. But what they did was they took that and turned it into something saying that not only are they fine, but they’re doing the best of all, you know, what they’re getting is the best, and so on. So the whole thing was absurd. I mean, I just have to say it was the most unnerving thing that has ever happened to me, because I had absolutely no idea how to react to something like this. No, I mean, let alone even, you know, any fantasy of controlling it.

Shane 1:03:44

Is there any action even under the radar to seek access to mRNA technology?

Achal 1:03:51

As far as mRNA technology goes, I can assure you that countries that don’t have it, which are half the world, including mine, India, which is a sixth of the world, on its own, really don’t want to deal with this. They just don’t want to deal with it for multiple reasons. And unfortunately, not all of those reasons are the fault of Western imperialism alone. You can have two things be true at the same time. I think that during the course of this pandemic, a lot of what has happened – what I see before me is this narrative of poor good countries and then rich bad countries. And that’s just not true. You know, you can have two things be true at the same time. You can have Western countries, rich countries behaving badly. And at the same time, you can have poor countries behaving lazily and callously as they mostly have, you know, through the course of my lifetime. And that’s something – that is something like what’s happening right now, which is that either for a fear in India’s case, which I can definitively say, of being seen as having inadequately responded to the pandemic, having committed political failure essentially. This idea, there is no discussion of mRNA vaccines because to do that would be in their minds, I think, to open up this Pandora’s box of what they did wrong. In terms of the TRIPS Waiver itself, you know, vaccines are complex. And so the TRIPS Waiver and the TRIPS Agreement and so on deals with the kind of tangible monopoly in the pharmaceutical industry, which are patents, which are these instruments of the law. Vaccines, you know, require that monopoly to be overcome, but also another monopoly, which is the actual technology, the way that you make something, which has to not only be transferred, but you have to also licence others to do it, which is the kind of fly in the ointment there. So the TRIPS Waiver was always going to be a partial solution for vaccines, but a complete solution for something like Paxlovid or a complete solution for something like a diagnostic test. And at the TRIPS Waiver discussions at the WTO, I think as well, a lot of poor countries have played a double game, which is that they’ve done nothing to strengthen some of these laws themselves in the countries that they have sovereign control over, while then engaging in this much more convenient fight where everything can be blamed on the West, right. So again, I’m not letting any Western countries have the hope. But the truth is that all of the things that South Africa and India were asking permission from Europe and the United States to do are things that they could have done themselves by simply being bold and taking decisive action.

Shane 1:06:29

Science as an academic pursuit for knowledge and science as a for-profit industry are quite different. I have no problem with companies working to make money, but I do find it challenging when those profits are based on publicly funded research. It strikes me too, that public trust in science can be a victim of the complex relationships between publicly funded and privately funded science.

Achal 1:06:56

There are monopolies in the pharmaceutical industry that we can legally overturn. And these are the patent monopolies, which are the most simply identifiable forms of total control. So for instance, if India wanted to have access to Paxlovid like you do today, if we wanted access to that tomorrow, we could do that. We haven’t done it either way, which is a separate matter, but we could do it. So there are legal remedies available for some of these monopolies. But the somewhat sobering truth of this moment is that there are no legal remedies available to sharing vaccine technology to getting companies that have been funded by taxpayers to cooperate and license other companies in India or somewhere else, which is to say that we have created a system that is so foolproof in terms of the way that it protects corporations, that we don’t even have the emergency power to undo it. And I think the the sobering point here is that what this system requires to fix itself for the future is not just a set of tweets or a set of different decisions. But you know, in some cases, when it comes to things like vaccines, which are so essential to our lives, it requires tearing up the system and starting again. There is no other way to do it.

Shane 1:08:20

We began this episode talking about science being for the common good, and how that was associated with public trust in science. It seems, however, that the common good is not necessarily that universal. Implications of this for trust and science are obvious, and the implications for our collective capacity to respond to global healthcare emergencies is consequently diminished. We cannot meaningfully address socioscientific issues like pandemics without first acknowledging the impacts of inequality and working to address them. Trust will follow.

Shane 1:09:11

The Trust Race is supported by PERITIA, an EU funded project investigating public trust in expertise. Grant number 870883. This series is produced by Shaun and Maurice and you can find me on Twitter @shanedbergin.

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Produced by Shaun and Maurice

The Trust Race is an output of the Horizon 2020 project PERITIA.

This project has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No 870883. The information and opinions are those of the authors and do not necessarily reflect the opinion of the European Commission.

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