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From the file

The Arms Race | We need to get the world vaccinated as fast as possible. We’re in an arms race: vaccines vs variants.

The Covid coup
Slow Views

The Covid coup

Thursday 16 September 2021

Tunisia’s leader used vaccine shortages to take power, and then vaccine supply to consolidate his new position


The gravediggers walked out of their hut in Jellaz cemetery, the largest in Tunis, up a winding asphalt road that quivered under the hot sun, all the way to a fresh burial ground. “The health ministry doesn’t let anyone near it,” one says. “It’s all people who died of Covid.”

It was just rocks and dust a few months ago, one of the last unused patches in this sprawling nine-century-old cemetery. There were more men there. One was digging a new grave, his head bobbing above the arid surface. Another was shovelling plaster into an occupied grave. “Health protocol,” he explains. “We must follow it.”

There was no protocol for the gravediggers themselves. The health ministry did not provide them with masks or gloves or any kind of protective personal equipment. They worked only with shovels, trowels, and wheelbarrows. Their days were long, punctuated by a distant call to prayer from a minaret below, but they were getting better.

“Today, only three,” another says. “In July, 30 to 40 a day.”

Tunisia’s Covid death rate had doubled during July, adding over 4,600 deaths to a toll of more than 15,000. By the end of the month, it had the highest Covid death rate in the world. It was a disaster, and it was man-made. 

The government was slow to procure vaccines, the international community slow to deliver them. The slowness accelerated a coup and the new ruler’s popularity grew when vaccines finally arrived. North Africa’s only democracy is now another loss to the virus. 

But the story matters beyond the tragedy of Tunisia. It opens a window onto corruption, inaction, and profiteering in the global response to the pandemic.

The story had an encouraging start.

“The first and second waves were soft,” Slah Soui, head of the intensive care unit at Ibn El Jazzar Hospital in the central city of Kairouan, says. “We didn’t have a lot of cases because of the lockdown.”

A national state of emergency followed the detection of the first case in March 2020. The virus was contained, with a low number of daily cases that mostly came from overseas. The government reopened the economy gradually over the following two months and in June began easing international travel.

Cases began rising again, but some restrictions remained and the virus was managed. Masks were mandatory in public spaces, public gatherings were prohibited, and a curfew was imposed. The government said it would increase the number of treatment beds to 1,200 by the end of October. Its ambition was far too limited.

Hospitals across the country, multiple doctors say, had long been under-resourced and in poor condition. They got through the first two waves thanks to severe restrictions, but the third wave was different. It was powered by the more transmissible Delta variant, which arrived in spring.

A shortage of beds was not the only problem. “There was a lack of oxygen,” Soui adds. “We had no generators to refill the tanks and we had insufficient tanks” – there were 250 in the whole region – “so I watched Covid patients go through litre after litre of limited oxygen, and then die. It was traumatic.”

COVID-19 patients receive first aid at the Charles Nicole hospital’s emergency room in the capital Tunis

Soui, the only intensive care specialist in the region, went from working 12 hours a day to 18 hours a day. “I suffered,” he says. “My family suffered; I forgot my daughter’s birthday. But you cannot leave the intensive care unit. With Covid, every five minutes you might have to change the strategy for a patient.”

He blamed the crisis on people failing to respect rules around social distancing and hygiene. But he says a deeper problem was a severe lack of vaccination. Only five per cent of Tunisia’s population was fully vaccinated when the third wave hit.

“The vaccine programme, in the beginning, was slow,” Soui says. “But now it’s better: it’s in the hands of the military.”

It was first in the hands of the government, which turned to international organisations for help.

‘“It was early in September [2020] that we were approached by the Ministry of Health, the division in charge of vaccination, to support the development of strategy,” Yves Souteyrand, the World Health Organisation’s representative in Tunisia, says. “In parallel, we were involved in all the discussions about Covax.”

The multilateral initiative – mainly run by WHO, Unicef, and Gavi, a public-private partnership to increase global immunisation rates – was to enable poor countries equitable access to Covid vaccines. Tunisia, with an average income a fifth of Britain’s, is officially a middle-income country, so it did not qualify.

“But through what is called the advanced market commitments,” Marilena Viviani, Unicef’s representative in Tunisia, explains, “it became included in the list of countries that could benefit from Covax donations. And that was huge news for us.”

The news was that Tunisia got free access to enough vaccines to cover 20 per cent of its population. At that point, the Pfizer and AstraZeneca vaccines looked like they would succeed in getting clearance, but Tunisia had to make a choice between them.

“It was not based on our advice,” Souteyrand says. “The country decided to consider Pfizer.”

The choice was not obvious. Pfizer’s was a new kind of vaccine, made using mRNA technology rather than a weakened or inactivated germ as in traditional vaccines like AstraZeneca’s. It needed to be shipped at ultra-low temperatures – -70°C – and then could only be stored in refrigerated units for a few days. 

“We were a little bit concerned by the capacity of the country to store all the quantity of vaccine,” Souteyrand adds. So was Covax. 

It asked the government, which worked closely with WHO and Unicef, for reassurances that it could handle a shipment of Pfizer, distribute it, and report back on quality control. There were multiple long meetings. There was a lot of paperwork. 

“There was also competition worldwide to be on track to request the doses,” Viviani explains. “I will never forget the intensity, the intensity of our own discussions and the passion that I saw also in colleagues.”

It was not until January 2021 that Covax finally told Tunisia that it could provide it with the Pfizer vaccine. The Tunisian government announced a vaccination campaign soon after, saying that it will cover half the adult population and would be free. But it did not have the vaccines for it.

Even Covax said that the Pfzier vaccine would only be available from mid-February. In fact, it would be longer still.

Pfizer would not accept indemnification liability, meaning it wanted to be absolved of any harm that could be caused by its vaccine. The country had to come to an agreement with Covax, which first required the government to pass a bill on liability specific to the vaccine through parliament. Many MPs resisted for weeks until government pressure became too much to bear. And then there were more delays.

“The delays were in the delivery of vaccines,” Viviani says, “even by the same manufacturers.”

At long last, on 17 March, the first Covax shipment arrived: 93,600 doses of the Pfizer vaccine, enough to fully vaccinate less than 0.5 per cent of the population. 

“To me,” Viviani recalls, “that day was really a great day.”

The day should have come earlier. Had the shipment arrived on time, had it been the full share of the promised doses, then Tunisia may have averted its third wave.

In the four weeks between mid-February, when Covax expected to send the doses to Tunisia, and mid-March, when they arrived, Tunisia’s daily number of Covid cases was in decline. In the last week of March, it rocketed. Those four weeks were a window to control the virus before it spread. The window opened and shut.

“It was four weeks, these weeks were long,” Souteyrand says, “but it is only four weeks.”

The benefits of Covax were clear to Hechmi Louzir, an immunology professor who directs the government’s vaccine programme and the Pasteur Institute of Tunis, which produces vaccines for tuberculosis. “We accept that there is not enough vaccine for everybody, so having this kind of organisation,” he says, “is something very important.”

But Louzir recalls “many, many, many meetings” about Covax. The government began to feel it was losing its time in discussions and paperwork. 

In some of the files he had to prepare, Louzir remembers being asked whether Tunisia was in discussions directly with vaccine manufacturers. “Gavi did not see it as too good,” he says. The Tunisian government pressed ahead anyway.

The delays with Covax had worried officials enough to begin making direct purchases. They approached Pfizer – for two million doses – and they approached the Gamaleya Institute in Moscow about its Sputnik vaccine, which is less effective in preventing severe illness and death than the Pfizer one. The decision not to have approached them earlier would prove fateful.

“So now the problem is, even with different pharmaceutical companies, the delay was very, very long,” Louzir says. “The first delivery, by two or three months. It’s very difficult.”

It was with Gamaleya that things were hardest. The Tunisian government paid half upfront for 500,000 doses of Sputnik. Until now, it has only received between 20 and 30 per cent of the quantity.

At least some Sputnik doses – 30,000 of them – had landed in Tunisia early: four days earlier than the first Covax delivery. They were used on frontline healthcare professionals who had been trained in various aspects of vaccination, and who had vaccine centres to staff and a national strategy to implement.

“But no vaccines,” Louzir says. “This time corresponds also to the evolution and the epidemiological dissemination of the disease in Tunisia.”

The Delta variant had arrived and, according to Louzir, would soon account for 96 per cent of all cases.

Senior government officials did not seem to notice or care.

They tried to get Pfizer, which has operated a drugs manufacturing unit as a joint venture with a state-owned pharmaceutical company in Tunisia since 1998, to produce its Covid vaccine in the country. Discussions were conducted by the prime minister’s office. 

They went nowhere. The rumours swirling around some cafes in Tunis are that the prime minister tried pushing Pfizer representatives to work with one of his preferred companies. (A Pfizer spokesperson says that “any discussions that occur with governments remain confidential”.) But a source with knowledge of the discussions said that the company had already contracted a vaccine manufacturing plant in another country to supply North Africa.

In any case, the establishment of a manufacturing line for a new vaccine would have taken months. The number of new cases was already running at 2,000 a day by the end of April and the proportion resulting in death was rising faster than ever before.

“This wave was different,” Zakaria Bouguira, an intensive care doctor at El Kassab Hospital in La Manouba, says. “It was Delta, and Tunisia was not vaccinated like the developed world. If it were, if it actually launched its vaccine campaign in January, then infections wouldn’t have been mirrored in deaths.”

The government, falling further and further behind the virus, grew increasingly hopeless. The prime minister invited Louzir, as a scientific advisor, to a meeting with people he was told were “serious” and able to supply the country with plentiful amounts of AstraZeneca or Sputnik vaccine doses.

“They were intermediaries,” Louzir recalls. “From Dubai, I think. I went to the meeting and found people who were very well-dressed.”

The intermediaries offered the Tunisian government a shipment of AstraZeneca or Sputnik doses at twice the normal price. Suspicious of them, Louzir went to Gamaleya and asked whether they were representatives of the institute.

“They said, ‘No, no. They are not’,” Louzir says. “They told us, ‘Please be careful.’”

A company based in the United Arab Emirates, run by Ukrainian national Natalya Muzaleva and her Hungarian husband Istvan Perger, who normally manage an art gallery, was approaching European governments with similar proposals. (Muzaleva did not respond to multiple requests for comment.)

She had written to the Czech ambassador to the UAE, offering him “the entire quantum of doses you require,” and warning that “vaccines are allocated on a first come first serve basis and demand is understandably large”. 

The discussions in Tunis were soon called off, and the government returned to doing nothing. By mid-July, Tunisia’s Covid death rate was the world’s highest. 

At that point, on 17-18 July, the prime minister was by a luxury pool in the seaside resort town of Hammamet. His ministers had cancelled other work meetings on the country’s Covid response to go on the trip, having used the excuse, Tunis-based journalist Fadil Aliriza says, “that Covid restrictions prevented them from meeting”.

Tunisians erupted in anger. They saw videos of doctors breaking down in tears, and of hospital wards overflowing with patients. They saw all this alongside their lounging prime minister.

On 25 July, a national holiday marking republic day, thousands of Tunisians took to the streets in a dozen cities. The heat was a sweltering 40°C, the police forces were often violent, and the government’s pandemic restrictions on travel were broken. Protestors called on the president to act.

Kais Saied, an uncompromising ideologue whose reputation for living modestly set him apart from the corrupt parliamentary elite, heeded their calls. It was a coup, but Tunisians welcomed it: Saied suspended parliament, lifted parliamentary immunity for its members, and fired the prime minister.

In the background, vaccine deliveries had been trickling in.

In July alone, over 85,000 doses of Pfizer came through the direct-purchase deal. Turkey donated 50,000 doses of Sinovac, the Chinese vaccine, and France donated 324,000 doses of Pfizer through Covax. (The country had contacted the Tunisian government directly to avoid delays with Covax, but decided against the direct route.) And then, on 30 July, five days after Saied’s coup, a delivery of one million doses of Moderna donated by the US came through Covax.

The country was suddenly awash with vaccines. Saied revived the vaccination roll-out. He had put the military in charge and now, with the help of the scouts and the International Red Cross and Red Crescent Movement, it distributed hundreds of vaccines at centres across the country. 

Over August, the percentage of Tunisians who received one dose went from 15 to 35 per cent. Many are now queueing outside vaccine centres for their second dose.

“We are open from 7.30am to 7pm,” Lina Ben Brahim, an International Red Cross and Red Crescent Movement volunteer at a vaccine centre in La Marsa, says. “Too many people had come on our first open day” – before Saied took power, and when one attendee recalls sweaty bodies climbing over sweaty bodies for a shot – “and we didn’t have enough volunteers or resources. But now Tunisia’s vaccine campaign is doing great.”

Outside the centre, one middle-aged woman waited for an hour and half with her young son for her second dose of AstraZeneca. “It was well-organised,” she says. “Everything has been good, especially with the new government.”

It is a sentiment that echoes across Tunisia: things are better now under Saied. 

And it could be heard even at Jellaz cemetery. 

A high-school teacher from Tunis stopped to take in the view of the gravediggers at the Covid burial ground. Talk, as usual, went from the virus to Saied.

“Before the 25 July, I had no idea whether I would ever get vaccinated,” he says. “Personally, I am very happy. Saied is an honest man. He will not be a dictator.” 

A few days later, Saied’s spokesman told journalists of a plan to change the political system in Tunisia through a referendum. He said the plan was at a final stage and that it would be unveiled soon, but provided no details. The expectation is that Saied will weaken the role of parliament.

The country’s hard-won democratic progress since the Arab Spring, when its last dictator was overthrown, is now falling apart.

Photographs by Fethi Belaid / AFP/Getty Images

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