Administering the AstraZeneca vaccine at a pharmacy in Paris on Friday, after European countries resumed distribution. Photo / Dmitry Kostyukov, The New York Times
While Washington went into business with the drug companies, Europe was more fiscally conservative and trusted the free market.
The calls began in December, as the United States prepared to administer its first batches of Covid-19 vaccine. Even then, it was clear that the European Union was a few weeks behind, and its leaders wanted to know what they could learn from their American counterparts.
The questions were the same, from President Emmanuel Macron of France, President Ursula von der Leyen of the European Commission, and Alexander De Croo, prime minister of Belgium.
"How did you do it?" Dr. Moncef Slaoui, the US vaccine czar, recalled being asked on the calls. "And what do you think we missed?"
Since then, the rollout gap between Europe and the United States has widened, and some of the countries hardest hit early in the pandemic are facing a deadly third wave of infections. France, large parts of Italy, and other regions are back in lockdown. Roughly 20,000 Europeans die of Covid-19 each week.
The continent was dealt a further setback when a scare over blood clots and brain bleeds led several countries this week to temporarily halt the distribution of the AstraZeneca vaccine. Most of them resumed using it Friday after Europe's top drug regulator vouched for its safety, but public confidence in the shot has been badly shaken.
Vaccine salvation remains, for now, tantalisingly out of reach. Only about 10 per cent of Europeans have received a first dose, compared with 23 per cent in the US and 39 per cent in Britain.
There is no single culprit. Rather, a cascade of small decisions have led to increasingly long delays. The bloc was comparatively slow to negotiate contracts with drugmakers. Its regulators were cautious and deliberative in approving some vaccines. Europe also bet on vaccines that did not pan out or had supply disruptions. And national governments snarled local efforts in red tape.
But the biggest explanation, one that has haunted the bloc for months, is as much philosophical as it was operational. European governments are often seen in the US as free-spending, liberal bastions. This time, though, it was Washington that threw billions at drugmakers and cosseted their business.
Brussels, by comparison, took a conservative, budget-conscious approach that left the open market largely untouched. And it has paid for it.
In short, the answer today is the same as it was in December, Slaoui said. The bloc shopped for vaccines like a customer. The United States basically went into business with the drugmakers, spending much more heavily to accelerate vaccine development, testing and production.
"They assumed that simply contracting to acquire doses would be enough," recalled Slaoui, whom President Donald Trump hired to speed the vaccine development. "In fact what was very important was to be a full, active partner in the development and the manufacturing of the vaccine. And to do so very early."
The result in Europe is a stumbling inoculation effort that has led to political fallout, with leaders pointing fingers over why some of the world's richest countries, home to factories that churn out vast quantities of vaccine, cannot keep pace with other wealthy nations in injecting its people.
Compared with nearly all the rest of the world, the European Union is in an admirable position. Its leaders say it remains feasible to vaccinate 70% of the continent by this summer. The bloc has ordered enough doses to fully vaccinate its population at least three times, to the consternation of countries that will wait years for full coverage.
But Europeans are stung, especially, to see Britain's rollout going so well after the country exited the bloc. Everyone wants to know why the EU has not triumphed.
The European Union trailed the US and Britain from the start.
Washington had already spent billions on clinical trials and manufacturing by the time Europe decided to pool its resources and negotiate as a bloc. In mid-June, the European Commission, the bloc's executive branch, announced a joint vaccine purchase with a US$3.2 billion pot.
In Washington, Operation Warp Speed, the Trump administration's vaccine programme, had a US$10 billion budget. European officials say it's unfair to compare the two figures because neither amount is a complete picture of all the money spent on vaccines. But there is no dispute that in Washington, officials had decided that money was no object if vaccines could avert the economic cost of a lockdown. Europe, on the other hand, was on a tight budget, so its negotiators chased cheaper doses.
"Pricing has been important since the beginning," Sandra Gallina, the EU's main vaccine negotiator, told lawmakers in February. "We are talking about taxpayers' money."
Europe's first deal, with AstraZeneca, came in August, months after the US And while Europe negotiated as a powerful buyer, it lacked the wartime procurement powers that the Trump administration had used to secure raw materials for companies.
That meant that the bloc was not first in line for the doses.
The United States made the negotiations easy — its critics say far too easy — by signing away any right to intellectual property and absolving the drug companies of any liability if the vaccines disappointed. Washington paid for the development and the trials; the companies had essentially nothing to lose.
Drugmakers expected the same concessions in Europe, but the back and forth over liability was the major stumbling block, Gallina said. European negotiators had to reconcile disparate liability laws across multiple countries, finding common ground among 27 leaders.
"In a crisis, it always becomes clear that the EU is not a country," said Jacob Kirkegaard, of the German Marshall Fund. He said the bloc approached vaccine procurement like a contract negotiation when in fact "it was a zero-sum game with limited supply."
"It was not equipped for a gunfight," Kirkegaard said.
Slaoui said Washington and London approached the crisis in lockstep. He recalled biweekly meetings with his British counterpart, Kate Bingham, but said Europe went its own way.
"If you're at the table from Day 1, and you paid to be the first to pick from the menu, you're going to eat first," he said.
European institutions are, by design, risk-averse. One of the founding tenets of the European Union is called the precautionary principle: The bloc errs on the side of caution when risks are unclear.
That, some analysts have said, hurt the bloc. German leaders argued for a heftier bet on vaccines from Pfizer-BioNTech and CureVac, but they were based on unproven messenger RNA technology and were more expensive. The bloc had just settled a thorny economic rescue package, and there was little appetite for more risk or spending.
It did not help that Europe backed the wrong horse in some cases. It spent billions on a vaccine candidate from French drugmaker Sanofi and Britain's GSK that was delayed more than a year after disappointing results.
So the bloc relied heavily on AstraZeneca for its early rollout plans, a bet that had repercussions from the beginning. Italy, for example, embraced Europe's bet on AstraZeneca doses because they were cheaper and did not require extreme storage temperatures. But then Italian regulators recommended against giving the vaccine to older adults until more data were available, leaving a country with the oldest population in Europe more vulnerable to the pandemic.
Britain bet heavily on AstraZeneca, too, but its close working relationship with the drugmaker and its early agreements gave it an advantage when the company hit supply problems in January. AstraZeneca has slashed its delivery plans, telling European leaders that it would hand over 100 million fewer doses by the middle of the year, according to the commission's president, von der Leyen.
That has pitted the bloc against AstraZeneca, and the dispute has spilled into public view. Leaders in Brussels have been all too happy to blame the company for the shortfalls, and the dispute could end up in a Belgian court.
Europe lost even more time because its medical authorities were slow to approve the AstraZeneca vaccine, seeking to assure the public that it was safe. That "cost us two to three weeks of delay," von der Leyen said this week.
The bloc fell further behind when national authorities in Germany, France, Italy and elsewhere raised concerns about dangerous clots and bleeding, and temporarily suspended use of the vaccine. Although the World Health Organization and European regulators reaffirmed its safety, the damage was done. Only 1 in 5 French people now trust the AstraZeneca vaccine, according to a poll by the Elabe Institute published Tuesday.
Now Europe is striking a more aggressive tone about protecting its interests. Italy blocked a small shipment of AstraZeneca vaccines to Australia this month. Von der Leyen upped the ante this week, threatening to use an emergency mechanism, last used during the 1970s oil crisis, that would allow the bloc to seize production of vaccines.
"It is hard to explain to our citizens why vaccines produced in the EU are going to other countries," von der Leyen said.
Early this month, Toon Vanagt, a Belgian tech entrepreneur, accompanied his 77-year-old father to a vaccination centre north of Brussels. Vanagt, 47, was not eligible for the vaccine, but a worker offered him a leftover shot, which he gladly accepted.
Millions of Americans have been vaccinated this way, and software companies have rushed to link patients with doses that would otherwise expire. But in Belgium, when Vanagt tweeted that he had been vaccinated, it became a mini-scandal. Health officials rebuked the vaccine centre, which quickly apologised: "A minor communication problem, very quickly rectified."
Belgium's rollout is one example of the continent's rigid approach to following vaccination guidelines. In a country where nursing home infections led to one of the highest per capita death tolls, the policy was intended to strictly prioritise the neediest residents.
Many European countries are also stockpiling doses to guarantee that everyone who receives a first injection will receive the second dose on time. The United States and Britain have been more flexible, erring on the side of giving more first injections.
"In the US, there is a much more flexible, liberal system and you just vaccinate people who come along. Same in the UK. And it can go quicker. Here it is quite regulated,'' said Steven Van Gucht, the Belgian government's top virologist, who said it was too soon to know which system is better.
Administrative hiccups have exacerbated the problems. In Frankfurt, Elke Morgenstern was escorted out of a vaccine centre because she enrolled using the wrong online application. "It was embarrassing," said Morgenstern, adding that she qualified for a vaccine because of a pre existing condition.
Because of the AstraZeneca shortages, she cannot book another appointment before May.
"It is a catastrophe how they are handling things here," she said.
In the Lombardy region of Italy, once the centre of the pandemic, the vaccination campaign got off to a slow start in part because the top health care official refused to marshal medical workers over the Christmas holidays. Technical difficulties worsened the problems at the region's vaccination centres.
"Some sessions were empty," said Paola Pedrini, the regional secretary-general for Italy's family doctors federation. "For some others, they called 900 people when they could only vaccinate 600."
For all of the problems, Slaoui said Europeans were in an admirable position. By the numbers, the continent is about five weeks behind the United States, with vaccine supply expected to increase steadily. "It's too late to have taken the first bite," he said. "But they're in a good place."
Van Gucht, of Belgium, agreed. But he said European leaders would probably take nationalistic lessons from the past months.
"I think we relied a little bit too much on the free markets," he said. "What you really need to do from the beginning is really make sure you produce the vaccines on your territory and that they're destined for your own population."
Written by: Matt Apuzzo, Selam Gebrekidan and Monika Pronczuk
Photographs by: Andrew Testa, Laetit Vancon, Dmitry Kostyukov, Alessandro Grassani and Hiroko Masuike
© 2021 THE NEW YORK TIMES
Simone White, 28, is the fifth tourist to have died after becoming ill last week.