Biden pressed on global vaccine strategy

"History is going to measure whether we're up to the task. I believe we are," Biden said on Jan. 21, announcing a seven-goal, 200-page plan that he vowed would curb the virus here and abroad while preparing for future pandemics.

Almost four months later, the last of those seven goals - a vow to "restore U.S. leadership globally" detailed in 11 pages of that nascent plan - remains the subject of intense debate within the administration and of growing concern overseas, with officials still wrestling over how to fill in the many blanks in Biden's plan as cities in India run out of space to cremate their dead.

Global allies want more clarity on how the United States plans to share its resources, know-how and, especially, its growing vaccine stockpile. Advocates say there's no time to waste, pointing to virus surges hurting India and other countries that collectively reported more than 5 million cases in the past week.

Even some administration officials concede that Biden's recent decision to support the developing world's petition for a vaccine-patent waiver, which led to a disagreement with drug companies that sped hundreds of millions of doses to inoculate America and probably will boost supply this year, shows the risk of dribbling out tactics, rather than setting out a comprehensive strategy to help vaccinate the world.

"Where is the plan?" asked one Department of Health and Human Services (HHS) official involved in the coronavirus response who spoke on the condition of anonymity to discuss private deliberations. "The waiver is not a plan."

Diplomatic experts say the growing outbreak offers Biden his greatest immediate opportunity to help the United States regain the global stature lost under his direct predecessor. China and Russia have pursued "vaccine diplomacy" - leveraging their homegrown vaccine supplies in donations and deals - in bids to boost global public health and to win favor with dozens of countries.

"We have to acknowledge that the Trump administration was a disaster for America's image in the world, and for our soft power in the world," said Bruce Stokes, a senior fellow at the German Marshall Fund. He said the United States should become "the foundry of vaccines" for the globe, riffing off a similar goal laid out by Biden. "If we can do that, it seems to me we can rewin people's confidence in America, which will redound to the benefit of America across a whole spectrum of issues," such as climate change and competing with China, he said.

But inside the Biden administration, there is confusion over which agency is leading the effort to craft the country's global vaccination strategy, which has led to a fragmented rather than strategic approach. While Jeff Zients, the covid-19 coordinator at the White House, has been the person in charge of setting and executing the domestic fight against the virus, five administration officials say there are too many players addressing the worldwide challenge, with not enough direction.

The actors involved in the global response include officials from the White House's coronavirus response team, the National Security Council (NSC), the Office of the U.S. Trade Representative, the State Department, the U.S. Agency for International Development and HHS.

Several of those officials conceded that the United States does not appear to have an overarching strategy but rather is taking a piecemeal approach. Speaking on the condition of anonymity because they were not authorized to discuss the issue publicly, some framed the government's recent actions - including sharing 4 million AstraZeneca doses with Canada and Mexico, pledging an additional 60 million doses later this year, and supporting the patent waiver - as incremental steps.

The White House defended its process and said Zients and national security adviser Jake Sullivan were co-leading the global response, with support from NSC senior director Beth Cameron, who oversaw the Obama administration's pandemic playbook, the State Department's Gayle Smith, who is coordinating global diplomatic outreach, and USAID's Jeremy Konyndyk, among others.

"Part of the strength of our response to date is our whole of government, interagency response," said Natalie Quillian, deputy coordinator of the White House's coronavirus response. "We've roped in almost every agency to help us respond. And we'll have a similar interagency process, with some additional players and some players that domestically, play internationally in this response."

Asked about the best tactic to vaccinate the world, Quillian noted the ongoing production push. "We've got to produce more vaccine," Quillian said, touting the "power of American manufacturing" to help scale up the response.

And unlike other governments, the Biden White House is not making commitments it cannot fulfill, deputy national security adviser Jon Finer said.

"There are countries that are overpromising and underdelivering on their global covid-19 response for various reasons, including challenges with their vaccines or underestimating their own domestic needs," he said. "And we really expect the opposite - to meet and exceed what we've pledged to do."

But with about half of American adults having received at least one vaccine dose and domestic virus cases at their lowest levels in seven months, public health officials say the United States needs to increase its focus abroad.

"It's time for a more systematic approach," said Mark McClellan, who served as Food and Drug Administration commissioner during the George W. Bush administration and co-authored a recent report that said the United States could have 300 million or more excess vaccine doses by the end of July, if another vaccine made by Novavax receives emergency-use authorization.

"We have to have a 'both/and' strategy at this point - especially since we're doing so well in terms of vaccine availability in the U.S.," McClellan said.

The raging outbreak in India, which has vaccinated less than 10% of its residents and where lifesaving oxygen treatments remain in short supply, has exacerbated the contrast with the United States as deaths plunge and U.S. officials move to vaccinate younger and healthier populations.

"It's not India's crisis. It's the world's crisis," said Priya Sampathkumar, a Mayo Clinic infectious-disease physician who has been trying to rally support for India through a volunteer organization called INDIA COVID SOS. "If India falls, the world is in danger."

White House officials insisted that they have made a significant down payment fighting the coronavirus abroad, such as committing supplies to India and pledging millions of doses to Asia as part of the loose four-country "Quad" coalition. Officials also noted steps such as rejoining the World Health Organization and donating $4 billion to the Covax partnership to buy vaccines for developing countries, which were telegraphed in the president's January strategy. Additional moves are in the works, they said.

"I do think the last week or two has been an inflection point in our global response," Finer said. "The president's announcement about the significant vaccine-sharing to come, coupled with the waiver, suggests that we are increasing our engagement globally on these issues from what was already a strong position."

Players on the international stage acknowledge those contributions but say the world needs more help from wealthy countries.

Biden's team has "ticked so many of the big boxes," said the WHO's Bruce Aylward, crediting the United States for helping boost the global response by pledging billions to Covax, vowing to share as many as 60 million doses internationally, pushing for the patent waiver and coordinating manufacturing partnerships.

"That's the kind of leadership you need on this thing - but you have a window, and it's narrow, and [we've] got to move fast," said Aylward, a Canadian physician and epidemiologist who is a senior WHO adviser.

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The coronavirus response is emerging as an early test of Biden's global priorities after he leaned heavily on his foreign policy credentials to draw a contrast with President Donald Trump during last year's campaign.

As Trump withdrew from the global fight against the coronavirus - particularly through his decision to leave the WHO - Biden promised a different approach.

"Diseases do not stop at borders. They cannot be thwarted by building a wall," Biden wrote in USA Today in January 2020. "And here's the truth - the United States must step forward to lead these efforts, because no other nation has the resources, the reach or the relationships to marshal an effective international response."

In private, Biden often pressed his advisers for more information about the global state of the pandemic, particularly for Africa, according to one adviser involved in the briefings.

The Biden administration's decision to back an easing of patent protections for coronavirus vaccines to help speed vaccines to the developing world also fulfills a pledge made by candidate Biden.

"Absolutely, positively," Biden told liberal activist Ady Barkan in July, saying he supported sharing vaccine technology. "This is the only humane thing in the world to do."

But the decision to support the waiver petition has angered pharmaceutical companies and their allies, who argue that it will do nothing to boost vaccine supply in the short run, while sparking competition for already-scarce raw materials.

"It will unleash a scramble for the critical inputs we require in order to make a safe and effective vaccine," Albert Bourla, the CEO of Pfizer, wrote in a letter to employees on Friday, predicting that untested manufacturers would struggle to produce high-quality shots.

Officials in the pharmaceutical industry say they were particularly frustrated by the decision because they say the companies pushed the United States to play a more aggressive role in global distribution of vaccines for months. Opponents of the decision are now resting their hopes on Germany and other European Union countries to nix the patent waiver.

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In addition to calls for sharing surplus doses, global health and development experts urge the United States to take other steps to help vaccinate the world.

Rachel Silverman, a policy analyst with the Center for Global Development, a nonprofit think tank, called for "orders of magnitude" in more U.S. funding, such as committing tens of billions of dollars more to vaccine manufacturers now to build up global production capacity.

"I think we are still in the mode of penny-pinching on the international response, talking in hundreds of millions, maybe single billions, when the globe is continuing to lose tens of billions of dollars a day in value as this pandemic goes on," she said.

Pharmaceutical companies say their contracts with the U.S. government have, at times, impeded their efforts to sell doses abroad. The U.S. government assisted in the companies' acquisition of the raw materials to make the vaccines, officials familiar with the matter say, and that has complicated their efforts to ship doses overseas.

A Biden official involved in the coronavirus response disputed that notion, saying that once companies fulfill their contracts with the United States, they are free to send doses abroad, pointing to the Pfizer shipment of vaccines to Canada and Mexico. The official said there are no export bans or other restrictions on the companies' vaccines.

One official said the White House's Framework for International Access, which was begun during the Trump administration, could be released soon with further details on global vaccination plans. Another official said the document probably would not lay out specific steps to significantly increase international supply.

Some said more drastic action is needed now, with Mayo Clinic's Sampathkumar warning that India was a flashing red light.

"Increasing vaccinations further in the United States, even getting to 100%, will not help you if India fails and the virus spreads across the world," she said, adding that virus variants could pose new challenges. "Anything the world can do to get more vaccine to India would be in the world's best interest."

The WHO's Aylward credited Sweden's decision last week to donate 1 million of its vaccine doses - roughly one-fifth of its current supply. He added that a senior Swedish official told him that it was "a tough political decision" but that global health was a priority.

"People keep talking about 'donate surplus doses,' " Aylward said. "What Sweden is trying to say is, 'No, donate doses in real time . . . we cannot have more Indias.' "

"Political decisions are always tough in wartime," the physician added. "There's no easy decisions, and it's out of these kind of environments that the great leaders emerge."