Nobody is safe until everybody is safe.
Only .01 percent of COVID-19 vaccines have been administered in low-income countries. That needs to change, and fast.
As the United States is ramping up its daily vaccination rates to around 900 shots per 100,000 people, a large portion of the world has been utterly left behind. Data assembled by the New York Times shows not a single low-income country has been able to attain a vaccination rate of at least 10 doses per 100 people, and only a single lower-middle-income country — Morocco — has met that mark. There is a myriad of reasons why these countries are lagging. Like most of the world’s nations, none of them are home to pharmaceutical companies that developed the leading COVID-19 vaccinations, forcing them to go on the international market for doses. Many lower- and lower-middle-income countries do not have the financing or diplomatic clout to get to the “front of the line,” delaying their ability to purchase vaccines. Others have poor public health systems or are facing bureaucratic and logistical hurdles preventing them from getting shots into arms, even if there is a supply (a problem not exclusive to low-income countries).
Many organizations and activists pushing for more equitable vaccine distribution have rallied around a compelling and easy-to-understand idea: Nobody in the world is safe from the pandemic until everyone is vaccinated. In practice, this means a significant amount of the population needs to be vaccinated to achieve herd immunity, which is achieved when the remaining low percentage of unvaccinated individuals are protected due to the viruses’ inability to spread. Worryingly, vaccine uptake needed to achieve herd immunity is significant. While the exact numbers to achieve COVID-19 herd immunity are not yet clear and will likely vary from community to community, diseases like measles and polio require 80–95 percent of a population to be vaccinated. Achieving this goal is in sight in places like China and the United States, but much of the world is nowhere near these numbers. Kenya, for example, only expects to have 30 percent of its population vaccinated by the middle of 2023, despite the fact its gained access to Russia’s Sputnik V vaccine. And as we have seen over the past year, the more time we allow the COVID-19 virus to incubate and spread, the more likely new resilient mutations will arise.
At the outset of the pandemic, observers rightfully highlighted that COVID-19 exacerbated existing inequalities in society, from poverty and lack of access to healthcare to who is deemed “essential” and gets prioritized for vaccinations. If current global inequities in vaccinations continue, however, we risk not only a society where inequalities are heightened but where these dynamics become calcified within every system and institution. Decades of progress in combatting diseases, reducing poverty rates, and improving access to education and healthcare are at risk. The prospect of a world where lower-income countries must deal with years of COVID-19 while their vaccinated neighbors and allies fear they are the next hotspot for another wave of the disease is very real.
There is no single solution to this issue and any work to address the global inequity of vaccine distribution will need to work with and through international systems. What is clear, though, is that the world both needs more vaccines and more effective processes for getting those vaccines to people. Here are two considerations for making these things happen.
A public vaccine for the public
A significant debate that has been brewing over the last year is whether to wave intellectual property (IP) protections for COVID-19 vaccines. The argument in favor of temporarily suspending IP protections for vaccines is fairly simple. If the formula and methods for producing a COVID-19 vaccination are publically available for anyone to copy, pharmaceutical companies across the world — especially in lower- and middle-income countries — could start making vaccines and more quickly get them to their populations. Waving IP protection is not a new idea and, importantly, has significant support — 58 countries have endorsed a World Trade Organization proposal to temporarily suspend international patent protections. The United Nations’ COVAX facility is also supposed to help with this issue, providing a fair platform for countries unable to strike costly bilateral deals with manufacturers to bargain for and buy vaccines. But in practice, COVAX has struggled to do this, largely due to an $11.1 billion funding gap. And while the U.S. has committed another $2 billion to COVAX over the next two years, this pales in comparison to the $2.59 trillion in total Congress has appropriated to tackle the pandemic.
Opponents of waving IP protections for COVID vaccines — including most drug manufacturers — argue that waving patent protections for vaccinations risk alienating pharmaceutical companies from working with governments in the future, worried that their products could be up for grabs. Another more immediate argument is that, even if patents are suspended, many lower- and middle-income nations simply do not have the domestic capacity or facilities to produce the vaccines.
Both these arguments, however, fall flat in the face of the realities of an unprecedented and still ongoing global crisis. While it is true that many lower-income countries do not have the capacity to mass-produce vaccines, the benefits of globalization, multilateralism, and the slow but demonstrable gains in social and economic development have positioned many more countries to stand up domestic pharmaceuticals industries. Russia and Bangladesh are examples of this type of success, and the launch of the African Continental Free Trade Area (AfCFTA) in January of this year will help set industry standards and connect disparate national markets, issues that have historically dissuaded foreign investment in domestic pharmaceutical industries across the continent.
And even if the capacity of other countries to produce the COVID-19 vaccine remains low in the short term, isn’t it worth the risk? For decades, Western countries and international institutions like the World Bank, U.N., and International Monetary Fund (IMF) have preached the importance of private sector growth as the primary vehicle for development. While many contemporary development experts would admit this strategy is not the whole story at best, and woefully misguided at worst, why not take the reins off and see what the private sector around the world can do? Even one or two more nations able to produce the vaccine would be a game-changer for their citizens and regional neighbors and also likely spur the further development of domestic medical and pharmaceutical industries ready to take on the next pandemic.
The other issue on this front is public funding. At least $12 billion worth of funding from federal governments around the world has been put into the development of the leading COVID-19 vaccines. The U.S. government alone has provided Moderna with nearly $1 billion in public funding — paid for by taxpayers — for the research, development, and production of their coronavirus vaccine. While this public funding is being used by governments like the U.S. as a bargaining chip to secure favorable prices for the doses, this massive amount of money rightfully calls into question the very nature of who owns these vaccines and has the right to produce them. And a growing number of policymakers agree. Movements like “The Peoples’ Vaccine” are pushing for all publically-funded COVID-19 vaccinations to be free and available to everyone, and their campaign has attracted a number of high-profile supporters, including the leaders of Pakistan, Ghana, Nigeria, South Africa, and Senegal. All of this is not to say that concerns of private pharmaceutical manufacturers on waving IP protections are unwarranted. Indeed, major pharmaceutical companies unwilling to accept public funding could pose grave issues for curing rare diseases or preparing for the next pandemic. But in the face of this crisis, the time to discuss these concerns must be pushed to the future, and the people must have access to their vaccine.
It’s logistics, stupid
Along with challenges in producing an equitable supply, the other more complicated issue when it comes to vaccines is the nuts and bolts of inoculations. The problem stems from the fact that even if countries are able to purchase vaccines from the manufacturer or via COVAX, the responsibility to administer the shots falls to their governments. And similar to their lack of domestic capacity to produce vaccines, many lower- and middle-income countries lack the basic infrastructure to properly administer the doses. This includes everything from cold storage requirements to registration and data management and available healthcare personnel. The latter issue is especially troubling. According to the latest data from the World Bank, on average low-income countries have only .345 physicians per 1,000 people. Compare that to the U.S. — where getting shots into arms has similarly been a struggle — which has 2.62 physicians per 1,0000 people.
In practice, what this is means is that governments and domestic and international healthcare organizations working in lower- and middle-income nations will need to rely on community healthcare workers, volunteers, and NGOs traditionally not focused on public health to fill this void. While non-profits bolstering the social safety net is not a new phenomenon, the massive scale of this gap is worrying. In addition, over a year of quarantines and lockdowns have left many community organizations and NGOs on their own, with many of their international staff and partners unable to return due to travel restrictions and with their funding drying up. An op-ed by Gunjan Veda of the Movement for Community Led Development (MCLD) — an organization that hosts members from more than 70 prominent international NGOs and hundreds of local civil society organizations (CSOs) to advocate for locally-led governance and development — describes how many community organizations have been entirely left out of the planning and feedback process for vaccine rollout, instead supplemented by large-scale international aid and development organizations. In global calls hosted by MCLD with its members, some of its representatives from community organizations even expressed hesitancy in taking a COVID-19 vaccine themselves.
(Disclosure: The organization that I work for is a member of MCLD.)
This points to a troubling reality — the organizations best positioned and most trusted by communities to inform citizens about the pandemic and administer vaccines in the absence of robust public health services do not have a seat at the table. While to its credit, the ACT-Accelerator (which leads the COVAX facility), does has an engagement platform for CSOs, it is is woefully underutilized and under-resourced — it is just now putting together an unpaid council of “10–15 civil society and community representatives,” according to a recent call for applications. The burden is on the primary financial contributors to ACT-A and COVAX, such as the U.S., the U.K., Germany, and the E.U., to push its leadership to deepen its community engagement model and methods and earmark specific funds for partnerships with community health workers, not just as a matter of equity but also as a matter of effectiveness. The $578 million worth of funding from the “Quad Vaccine Partnership” of the U.S., Japan, Australia, and India for “last-mile” vaccination is a strong start, but it’s also vital that bolstering relations with community health workers and organization is a central party of this strategy.
From a larger perspective, the logistical challenge of administering vaccines in lower-income nations is a direct symptom of foreign aid systems that have superseded and replaced national government institutions. In many countries, the same international NGOs that ceased or rolled back operations during the pandemic were the de facto public health system for millions of citizens. As international donors and multilateral lending institutions have compelled aid-recipient states to outsource key public functions like finance, infrastructure, and healthcare to consultants and private firms, they inadvertently have left states to deal with the immense challenge of administering the largest vaccination campaign in history on their own. Just as international development organizations need to more deeply engage community organizations, a key lesson from the coronavirus pandemic should be that, in many respects, there is no substitute for government that works. While working toward a model of aid that builds states instead of replaces states will come with some risks — such as more money going directly to governments with less-than-stellar track records — the return on investment will be immense, especially if there is another pandemic on this scale.
A significant number of countries around the world have for a year been in stasis, waiting on when they will receive financial assistance and now waiting on vaccines. For the world to be safe, we need to make address this inequitable dynamic now and make sure it never happens again for future crises.
