Editorial

Without any doubt, it is a success for South Africa, India and other co-sponsors of the TRIPS Waiver proposal, along with progressive political, professional and civil society voices, that the United States of America changed its position on the TRIPS Waiver. The waiver proposes a time-limited waive of patents and other rights related to essential health products for COVID-19 in the World Trade Organisation (WTO) TRIPS agreement.

The TRIPS Waiver proposals are now moving to text-based negotiations. If historical experience on access to medicines and the current power relations are anything to go by, the waiver proposers have grabbed the tail of the proverbial tiger in pushing for more distributed production of vaccines, diagnostics and therapeutics. What is to be done now that the US has agreed to talks?

It is important to understand that this stage does not represent agreement on the waiver. It has now merely advanced as an agenda item for discussion. The terms of the waiver have yet to be worked out. Even once agreed, implementation demands rapid support to increase production capacities for the range of products and systems that are able to distribute them, particularly in resource constrained settings. For all products covered, and particularly for vaccines and therapeutics, the waiver time frame and production capacities would need to be able to deal with current and emergent viral mutations and the updates required for a potentially endemic situation of an evolving virus.

Much remains to be done and the convergence of progressive forces that have pushed the waiver to this point need to robustly take on these remaining challenges to realise equitable access to vaccines, diagnostics and therapeutics.

The text-based negotiations and counter-lobbying by big pharma and others pose a risk of the proposals being diluted. As faced by HIV treatment activists in struggles over access to medicines, the proposals will face an incremental detraction from the largely wealthy countries seeking to preserve economic interests. Germany, the influential European power, remains opposed to the waiver, notwithstanding the US change in position. The tables seem to have turned on this. In the HIV-related Doha negotiations in 2001, the US played the ‘bad cop’ and the Europeans the ‘good cop’. While the European Parliament is largely supportive of the waiver it has limited legislative power, as intellectual property is in the European Commission’s domain. Further, the US trade representative to the WTO has said these negotiations will take time, as if they and not they virus are setting the timeline.

Already, the revisions that South Africa and India have made point to some of the areas that may be weakened: The duration of the waiver, with proposals for 3 years subject to renewal, must be adequate for the distributed transfer of capacities in an evolving situation. The necessary scope of technologies -vaccines, diagnostics, medical devices and therapeutics – is in the revised text and should not be whittled down. It is unclear if it will apply to patents only, or as in the current waiver proposal, to other key elements of intellectual property such as trade secrets, industrial designs and copyright.

The struggle for access to HIV-related medicines has much to teach. Two agreements were reached at the WTO, the 2001 Doha Declaration on Public Health, and the 2003 ‘August 30th Decision’. Both were victories to build on, but proved to fall short in meaningfully addressing access. They allowed rich countries that could not be seen to deny access to HIV treatments to virtue signal, but sustained hurdles for countries in applying the flexibilities they provided. This largely sustained dependency on imports for the lower income countries most affected by HIV.

The Doha declaration did establish the important principle of trade agreements being “interpreted and implemented in a manner supportive of WTO members' right to protect public health”, and levered improved, albeit not universal, access to HIV-related medicines. But, as the current pandemic has shown, they do not provide adequate measures for vaccines, diagnostics and other technologies essential for a public health response, and did not adequately shift priorities, power or production capacities to address unfair barriers in global trade rules to meeting public health challenges.

While the World Health Organisation (WHO) Director General has stood fast in articulating support for the waiver and called the inequity in vaccine access ‘vaccine apartheid’, WHO has less power in this debate and lacks the enforcement mechanism that the WTO has for its rules. WHO was out-manoeuvred by the Gates Foundation and rich countries’ preference for the ACT-Accelerator and COVAX at a time when the deeper proposals for patent pooling and technology transfer were made through the COVID-19 Technology Access Pool (C-TAP). The delay in enabling distributed production and weakness of COVAX is already evident in the shortfalls in supplies reaching low and middle income countries through COVAX, more sharply now with the pandemic demand in India restricting vaccine exports. The African Union recently warned African countries that delays in supplies may mean that they will need to restart their two dose vaccine programmes, or complete them with one dose vaccines that may not be distributed until late 2021. This global failure to meet health need makes virtue signalling on solidarity at the same time as self-protecting a profitable system reliant on patents and other monopoly rights particularly hollow. This is especially so in the context of the massive amounts of public funding that enabled innovations and the public support in opposing high income western countries for the waiver.

It can of course be argued that diplomacy involves compromise and that radical change demands sustained struggle. But the process is itself taking place in a space that is biased towards existing wealth. Negotiations at the WTO run on arcane principles and are largely not transparent. The rich countries hold much sway, including through supportive WTO officials. Important negotiations take place in so-called ‘green rooms,’ where experience indicates that consensus is achieved largely by excluding dissenters from the table. A current proposal by some high income countries to prioritise voluntary licensing arrangements as a solution is a symptomatic treatment, still under the control of big pharma, fails to address the causes of import dependency in Africa and other low and middle income countries and should not be used as a lever to delay or focus attention away from the waiver.

Proposers and supporters of the Waiver have grabbed the tail of the tiger. If the proposals are to avoid a death by a thousand cuts, this is the time to intensify focus. The transparency of these negotiations at the WTO and active vigilance, support and sustained activism will be essential to ensure that the outcomes achieved protect the public health rights and aspirations that have been behind the TRIPS Waiver to date.

There is no doubt that the COVID-19 pandemic has affected working people. In September 2020, the International Labour Organisation (ILO) reported that beyond workers exposure to COVID-19 infection in their living and working conditions and experience of COVID-19-related disease, workplace closures and job losses have significantly reduced workers’ incomes.

An EQUINET information sheet included in this newsletter, produced jointly with the Southern African Trade Union Co-ordination Council (SATUCC), outlines how COVID-19 has affected working people in the East and Southern Africa region, and the responses to these impacts.

Publicly reported data on COVID-19 is not disaggregated by economic activity or occupation. It is thus difficult to know how the pandemic has differently affected different categories of workers. Health workers (HWs) are, however, widely understood to be at greater risk of infection due to the nature of their work, especially when they work without adequate personal protective equipment (PPE) or in conditions that lack adequate infection control measures.

However other workers are also at risk, such as those who work in crowded, poorly ventilated workplaces. The Minerals Council of South Africa reported in June 2020, for example, that mineworkers had twice the rates of infection than the general population. Carers, vendors or service providers who are in common contact with the public may also have higher risk of exposure. There is a gender dimension to this, as many of these workers are women. Most HWs are female and African countries that disaggregate their data found that 72% of all HWs testing positive for COVID-19 were women.

Migrant labour is common in the region. Migrant workers have faced challenges in accessing services or been trapped when lockdowns close borders on them. Border closures and costs of testing can lead to crowding at borders and an increase in use of irregular travel routes across frontiers, as was reported when migrants returned home at the end of 2020.

While remote work is indicated as an option to prevent transmission, only about 10% of workers are estimated to be able to do this in the region, largely those at higher incomes who can afford data charges to the internet. This is not possible for most workers. While workers are increasingly aware of what raises their risk of infection, the precarious nature of many jobs and incomes in the region mean that many continue to work in environments that they know put them at risk. As a union official from the metal workers union in South Africa (NUMSA) noted: “The workers are aware that these are extremely dangerous spaces, but decide to risk it simply because they don’t have the means to stay in isolation, feed their children, or care for themselves without due pay.”

Beyond the risks of infection, the response to COVID-19 has raised its own stresses for working people. Lockdowns and blocks in supply chains have disrupted jobs, livelihoods and mental health.

A SATUCC study found that by mid-2020 over 42 000 labour contracts had been suspended in Mozambique; 680 000 employees had lost jobs in Malawi, and 70 000 in Zambia. An East African Confederation of Trade Unions (EATUC) assessment found that already by mid-May 2020, one million informal jobs and over 200 000 formal jobs had been lost in Kenya in the wake of the pandemic. The pandemic meant that 68% of people with disabilities in Kenya were not able to work and perceived their jobs to be insecure due to their disability. Where COVID-19-related messages have induced fear of outsiders, migrant workers may be stigmatized. Migrant job losses are reported to have reduced remittances that many families in the region rely on.

There is now guidance, including from the ILO and World Health Organisation, on the public health, workplace infection control and personal protective equipment measures required for different employment settings. Some ESA governments have also reduced income tax and VAT, provided wage subsidies and distributed food and other basic goods, as important areas of support for working people.

However, there has often been a gap between guidance and practice, and schemes have not always reached the most insecure workers who need them the most. HWs in Zimbabwe, Kenya and South Africa have protested over lack of PPE, and the ILO reports that migrant workers often do not access the testing, treatment, wage subsidy and other social protection measures that are provided to other workers. Informal sector workers have difficulties with the formal documentation that social protection systems ask for. Vital information does not effectively reach workers with disabilities if it is not made available in sign languages, video captioning, or other forms that they can access.

Trade unions have engaged on these issues, even though the pandemic has undermined union communication and operations. Beyond their contribution to national task forces on COVID-19 in some countries, unions have engaged when employers have taken wage subsidies but still imposed unpaid leave on or retrenched workers, or failed to provide PPE. Unions have also flagged wider concerns, such as how the conditions accompanying with international funding of rescheduled debt repayments may further undermine employment and the funding of public services.

While there is now a significant focus on access to vaccines and technologies, a comprehensive public health response to the pandemic, including to distribute vaccines, depends on formal and informal, male and female workers from many sectors, and the full involvement and protection of communities.

This link between workers and communities is fundamental. As a union shop-steward noted in the recent Alternative Mining Indaba, “in the day I am a mineworker, but when I go home to my family I am the community.”

Working people of different types fill the gaps in the social protection systems in the region so that vulnerable people in communities are not further impoverished by the pandemic. The economic recovery that is now critical in our region will not be possible without workers and communities. It will also not be meaningful unless it is a recovery of the productive opportunities, jobs, incomes, capacities and protection of all working people in the region.

The COVID-19 pandemic and its socioeconomic consequences have affected all Eastern and Southern African (ESA) countries. The long-term impacts still remain to be seen. While COVID-19 affects everyone, it does not affect everyone equally. It has entrenched and exacerbated the extreme inequalities and injustices that existed before the pandemic.

The collective insecurity generated by the pandemic requires a decisive public health response. This response has, however, tended to apply centralised, top-down and undemocratic decision-making, often using ‘war’ narratives that prompt or reinforce fear, and that promote individual self-protection. Reactive interventions have not adequately taken local conditions and rights into account, prevented longer-term harms to health, including from gender violence, nor protected income, food security or social trust.

However, the pandemic also offers an important opportunity to demonstrate that alternative, people-centred, democratic and collective responses are possible. Indeed they are essential, not just to prevent and contain infection and mitigate the impact of the pandemic, but also to ‘build back’ using a stronger, more compassionate and equity-driven form of public health.

In October, EQUINET published 42 case studies of community action on COVID-19 that collectively demonstrate examples of this (see https://tinyurl.com/yxrekzre). The case studies come from different settings, income levels and dimensions of the response. They show innovative and solidarity-based approaches to prevent and care for COVID-19, to address social needs and hold states accountable. They provide a powerful argument for public participation and collective action in health.

One of the case studies, the Cape Town Together Community Action Network (CAN), tells the story of a self-organising network that emerged in March 2020 in South Africa as a community-led response to COVID-19.

In early March, it was clear from other countries that formal responses would struggle to keep up with the pace of the virus. As a network of autonomous, neighbourhood-level groups working together to respond to local challenges as and when they emerge, Cape Town Together felt that bottom-up community organising could spread faster than the virus and could rapidly identify and respond to its emerging health, social and economic impacts.

The Community Action Networks (CANs) actively work against a tendency to centralise planning, decision-making and management. They reject hierarchies of knowledge, resources and power. Each neighbourhood CAN operates independently and autonomously, while drawing on the collective energy and wisdom of the network as a whole. The hyper-local nature of the CANs allows for street-level organising, reminiscent of anti-apartheid activism. Generosity, trust and solidarity are important foundational principles. The CANs prioritise relationships over bureaucracy. They are enabled by inter-personal connections built during lockdown conditions largely through online co-learning, WhatsApp groups and Zoom meetings.

At the peak of the pandemic this decentralised, self-governing structure provided vital support where formal social safety nets failed, including public health guidance, mask-making clubs, community gardens, community care centres for COVID-positive people who could not safely self-isolate at home, and food and medicine deliveries to elderly people.

A few weeks after South Africa initiated its hard lockdown, 47% of households were suffering from extreme food insecurity. Across Cape Town, CANs distributed food parcels and established community kitchens. With rapid communication across the network, CANs shared experience and resources, learned from each other and worked with public health services to follow COVID-19 safety protocols in the community kitchens. Beyond the hot meals provided, the community kitchens became safe, organic spaces, enabling protective behaviours and information sharing. They responded to local social needs in a way that was inclusive, welcoming and free of stigma and shame.

The CANs generated community-level intelligence. In their inclusion of community members, researchers and local public servants, they enabled informal communication. They built trust between communities and health system actors, through dialogue and co-learning forums between CANs and health sector decision-makers. They made input into educational materials developed by the health department. With the lived local realities of those most affected by the pandemic often very different to that of health department officials, these connections proved invaluable in framing appropriate measures.

The CANs aim to support and not substitute state efforts, and this was initially possible. However, the shortcomings within state efforts became a subject of an increasingly politicised debate. For example, some CANs and local civil society organisations formed a coalition that protested the unlawful eviction of residents in informal settlements. Political actors reacted by asserting that the CANs were acting unlawfully and presented a political threat. When another CAN renovated a badly vandalised and unused public community hall, the local ward councillor accused them of unlawfully occupying the space.

Such tensions may be inevitable where community initiatives highlight deficits in state responses and provide different approaches. Bottom-up initiatives such as the CANs call for and contribute to alternative forms of governance that celebrate, enable and invest in community-led public health responses.

The case studies in the EQUINET report show that community-engaged and -led responses and relationships are more likely when they build on prior histories of social networking and organisation around social justice. The relationships, the citizen scientist and activist leadership, the connections with public, professional and civil society organisations and prior activities on different dimensions of wellbeing enabled a relatively rapid, collectively-organised range of health responses to the pandemic. Information technology was used to organise collective understanding and action. The case studies also show the importance of investing in comprehensive primary health care systems for an effective and equitable response to pandemics. If we continue to frame our health systems only in terms of efficiency-led measures to treat particular diseases and top-down responses to emergencies, we weaken the ability mobilise the relationships, capacities and creativity within communities, networks and service personnel, or the multi-sectoral responses needed to prevent and address the many health challenges we face from such crises.

We hear many negative stories about COVID-19. Yet these compassionate stories of equity, rights-driven and holistic responses also need to be documented and told. They show a solidarity-driven response to COVID-19, and that people are subjects not objects in health.

Please send feedback or queries on the issues raised to the EQUINET secretariat: admin@equinetafrica.org. For more information on the CANs please visit the https://capetowntogether.net/ and https://www.facebook.com/groups/CapeTownTogether

Equity issues infuse our experience of COVID-19 in the region and globally. It should also infuse the response.

It is not well measured in the aggregate data commonly reported, nor in the media profile given to individual cases in elite groups, but COVID-19 spreads through and worsens social inequality. While the first spread of the pandemic may have come through richer, more mobile people and while all social classes have been affected by COVID-19, it would appear that the spread of the coronavirus exploits and exacerbates the social inequalities in the way we live, work, trade and travel in the region.

People living in lower income areas are often crowded in smaller, poorly ventilated homes, with many generations living in the same crowded home, without safe water supplies to wash hands and immune systems are already battered by undernutrition, infectious and chronic diseases. Crowded transport systems, dusty, poorly ventilated working environments and pollution from cooking fuels and houses sited near landfills and industries raise the risk of respiratory diseases, asthma and occupational lung diseases, making people more susceptible to severe effects of the virus. If resilience refers to the ability to restore the ‘normal’ that we had before COVID-19 and all the inequalities that put people at risk, then we should not aim for resilience. We should aim for change.

There are also social inequalities in a response to COVID-19 that provides less access to and continuity of care for COVID-19 and other health problems. It raises burdens on those who are already more vulnerable. As is happening in all countries affected by austerity, the chronic underfunding of and weaknesses in our public health services undermine care for poorer communities and protection of the health workers who work in them, notwithstanding the efforts being made by health ministries and other stakeholders. Private providers have expanded their role, but often without adequate public co-ordination and leadership and generally unaffordable for low income communities and enterprises. As noted by UNFPA, women represent a large share of health and social sector workers who are more at risk, while increased household tensions during lockdowns are increasing domestic and gender violence.

We are learning that a well-funded public health infrastructure is essential to keep all healthy and safe, that investing in prevention is primary and that transparency on resource flows is critical. Globally, with protectionist responses from high income countries, patent barriers and past policies of importing rather than locally producing medicines and other health technologies in the region, ESA countries, like poor households, are last in the purchase queue. ESA countries are often dependent on charitable contributions or rising debt to obtain health technologies that should be regarded as a right and as public goods. Global mechanisms that depend on charity and two tier systems risk aggravating inequality in access across countries.

Without a vaccine, the response has largely been one of command and control, sometimes militarised, putting whole sectors, areas and communities into lockdown. Many households in the region already live hand-to-mouth and do not have the social security to stop work, or the means to work remotely, so lockdowns increase income inequality. Restrictions on public transport without safe alternatives leave poor households trying to reach essential services stranded. Macro-economic concerns have motivated formal sectors like mining to restart, but do not address these socio-economic insecurities in more marginalised communities. Migrants returning home or located away from home are sometimes stigmatised and treated more as a public health risk than a vulnerable community.

These inequities call for local, national and regional responses. Social isolation measures have proved critical for the technical response to COVID-19. Yet for people who are compelled to work to secure daily incomes for their families, dialogue to find the best ways to protect both public health and livelihoods would seem to be more effective and sustainable than criminalising their actions. A biosecurity, top-down, secretive and militarised response to COVID-19 in the name of public health damages the trust, participation and collective solidarity that are essential for effective public health. In part this reflects whose knowledge and experience counts. Importing modelled concerns from high income countries on the adequacy of hospital resources can focus attention away from areas that the specific epidemiological and health system conditions in the region demand. While journal articles and scientific advisors compete for political attention, the experience, ideas and agency of those directly affected by the epidemic is often marginalised.

Yet there are many positive experiences in the region to report. Public officials, health workers, volunteers, including community health workers and health facility committees, have worked overtime to reach households, trace contacts and organise responses. Communities have formed solidarity networks to support vulnerable households with food and care and have held the state accountable for interventions. Parents have schooled children and teachers have found alternative ways to teach students during lockdowns. Small enterprises and local universities have produced affordable face masks and other technologies; local producers have switched lines to produce ventilators and local artists have produced music and murals to promote social awareness. Communities have provided support for returning migrants; diaspora and local people have crowd funded for support initiatives and local enterprises have contributed to solidarity funding of health technologies. COVID-19 has provoked social attention on health worker and gender rights. It has shown that ignoring social inequalities in health and their determinants and under-investing in comprehensive primary health care and public health threaten our society and economies as a whole.

We need to measure, publicly report on and visibly address these dimensions of inequality and to integrate the experience and ideas of all those affected. Not doing so undermines the effectiveness of our current and future responses. As Anand Giridharadas has said: “Your health is as safe as that of the worst-insured, worst-cared-for person in your society. It will be decided by the height of the floor, not the ceiling”. Even while African political leaderships are calling for global leaders to stop the debt outflow and patent and procurement barriers that are undermining responses within the region, we need to also confront the inequality that COVID-19 is intensifying within our countries.

So we are reaching out to you! Are you working on or concerned by any of these dimensions of inequality? Are there others that you want to raise? If so, please share your concerns, ideas and work! As a community that promotes equity values, EQUINET would like to learn more, share more, inform and voice more on these issues. If you have blogs, webinars, poems, art, stories, case studies, published work or videos on these issues or other equity concerns in the region that you want to share, please let us know so we can provide a platform to share them. Let us know if there are interesting case studies that we can support, or if you have ideas for joint work with EQUINET. Send feedback to us by email or on the feedback form on the EQUINET website and we will follow up with you.

The pandemic is a threat. It must also be an opportunity in our region to confront conditions and mantras that have generated the worsening inequality, rights violations, precarious labour, capital outflows, underfunded and commercialised systems and ecological decline that make us vulnerable to epidemics and that undermine capacities to respond in our collective interest.

We welcome your feedback on the issues and invitation in this oped – please send them to the EQUINET secretariat: admin@equinetafrica.org. Please visit our website for information sheets produced by EQUINET.