Lesson 7 — Who Does What? Why? Who Pays?

Understanding the Complex: How Do Vaccines Actually Work?

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Vaccines do not emerge from laboratories spontaneously. They require decades of basic research, clinical trials costing hundreds of millions of dollars, manufacturing infrastructure capable of producing billions of doses, and distribution networks that span the globe. Understanding who funds what — and why — reveals a great deal about why vaccine development has historically been slow, why COVID was different, and why global access remains deeply unequal.

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The long game: basic research

Most of the foundational science underlying modern vaccines was funded by governments and philanthropic organizations, not industry. The immune system research that allows us to understand antigen presentation, T-cell activation, and memory cell formation was funded primarily by national institutes — the NIH in the United States, the MRC in the UK, the DFG in Germany — across decades and sometimes generations.

Karikó's mRNA research, as we saw in the last lesson, struggled for funding precisely because it was basic research with uncertain commercial application. Her eventual breakthrough was serendipitous in timing — she was still working on it when COVID arrived. Much foundational science never reaches commercial application at all; it becomes part of the scientific commons from which future breakthroughs are drawn.

DARPA — the US Defense Advanced Research Projects Agency, best known for funding the precursors to the internet — has played an unusual role in vaccine science. DARPA funded early research into pandemic preparedness technologies, including some foundational mRNA delivery work, motivated by concerns about biological weapons and pandemic risk. The line between defense research and public health research is, in this domain, unusually blurry.

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Industry: the commercial calculus

The pharmaceutical industry funds the development and clinical trials of vaccines — but the business incentives have historically been poor. Vaccines are typically given once or a few times, not taken daily for decades like blood pressure medication or antidepressants. They work by preventing disease rather than treating it — meaning the benefit is diffuse and socially distributed rather than personally felt. They are subject to intense scrutiny and occasional liability; in the United States, a 1986 law created a special vaccine injury compensation program partly because manufacturers were leaving the market due to liability concerns.

For most of the twentieth century, vaccine development was concentrated in a small number of companies willing to accept thin margins for public health reasons, often with significant government support. The market was not seen as attractive enough for major pharmaceutical players to invest heavily.

COVID changed that calculation decisively — not just because governments provided billions in advance purchase commitments (making the commercial risk manageable), but because mRNA technology demonstrated that a vaccine platform could be genuinely profitable and broadly applicable.

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CEPI and the coalition model

Between the failures of the 2009 H1N1 response and the COVID pandemic, a coalition model emerged. CEPI — the Coalition for Epidemic Preparedness Innovations — was launched in 2017 at the World Economic Forum in Davos, funded by the Bill & Melinda Gates Foundation, the Wellcome Trust, and several governments. Its mandate was to fund vaccine development against emerging infectious disease threats before outbreaks became pandemics.

CEPI funded early COVID vaccine candidates, including the Oxford-AstraZeneca vaccine, which was then scaled up through an unusual partnership with a major pharmaceutical company that agreed to provide it at cost for low-income countries during the pandemic. The results were mixed — the cost model proved difficult to sustain, and manufacturing problems created delays — but the structural approach (pre-pandemic investment, coalition funding, tiered pricing commitments) pointed toward a possible model for the future.

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COVAX and the equity problem

COVAX — the COVID-19 Vaccines Global Access initiative — was established in 2020 with the goal of ensuring equitable global access to COVID vaccines. It aimed to provide vaccines to 92 lower-income countries, funded by wealthier countries and international organizations.

The results were disappointing. High-income countries purchased vaccines bilaterally before COVAX could secure supply. Deliveries were delayed. By mid-2021, many wealthy countries were offering third doses while billions of people in lower-income countries had not received a first. The ethical dimensions of this failure generated significant debate — about intellectual property waivers, technology transfer, and whether the principles of pandemic preparedness can coexist with the normal operation of pharmaceutical markets.

Those debates are ongoing. They are part of what we will examine in the next lesson.

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Next lesson: What's contested? What don't we know? — Vaccine hesitancy, authorization speed, mandatory vaccination, and global equity.

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Reading time: approx. 9–10 minutes