Until everyone is safe

COVAX is the international effort for sharing Covid vaccines with the world’s poorer countries. But could more be done by rich nations to ensure that recovery from the pandemic is more equitable? Natalie Healey investigates

Until everyone is safe

COVAX is the international effort for sharing Covid vaccines with the world’s poorer countries. But could more be done by rich nations to ensure that recovery from the pandemic is more equitable? Natalie Healey investigates

When Pfizer and BioNTech announced successful results for their Covid-19 vaccine in November last year, the collective relief was palpable. Experts had warned that immunisations were likely the only way out of the crisis, but nobody had expected a working jab to arrive so quickly. We now have several other vaccines that have been shown to stop people contracting moderate or severe disease with Covid-19. And in some nations, vaccination programmes are well underway – half of Israeli citizens had received two doses of a Covid jab by mid-February. But it’s a different story in many other parts of the world. Research suggests some low-income countries may not receive sufficient supplies of coronavirus vaccines until as late as 2024.

Everyone should care about equitable recovery from the pandemic. An International Chamber of Commerce Research Foundation study found that if Covid-19 vaccines aren’t distributed equally, the economy could contract by up to $9.2trillion this year – around 7% of global GDP. “Science has given us the exit strategy, but it will only work if its benefits can reach the maximum number of people around the world,” said Jeremy Farrar, director of global research charity Wellcome Trust in a statement for the Science Media Centre in mid-March. He was talking about the emergence of new strains of the virus, like ones first discovered in countries such as South Africa and Brazil that may have evolved ways to evade immunity gained from previous infection or vaccines. If a vaccine-resistant strain arrives in a country that has successfully inoculated its population, all that hard work could be for nothing. Health systems may be at risk of being overwhelmed all over again. The best way to reduce the opportunity for Covid to mutate and potentially produce new variants of concern is to reduce virus spreading as much as possible. Vaccination is the best tool we have to do that. But only if everyone can access it.

Moral argument

As well as preventing mutant super strains of coronavirus, there is also a strong moral argument for ensuring equal distribution of Covid-19 jabs around the world. Vaccinating all of one country before anyone from another receive a jab puts millions of people at unnecessary risk. “It really doesn’t make sense for a healthy individual in his 30s to get vaccinated before a much higher risk individual elsewhere,” sums up Olivier Wouters, Assistant Professor of Health Policy at London School of Economics and Political Science (LSE). But rich nations will always have more leverage in this situation. In December, The People’s Vaccine Alliance, a coalition of global health organisations and charities such as Oxfam and Amnesty International, found rich nations representing 14% of the world’s population had bought up more than half of all the most promising vaccines.

“If rich countries continue to monopolise the world’s supply of vaccines, leaving low and middle-income countries behind, there will be a huge number of avoidable deaths in countries that can’t receive widespread vaccination coverage,” says Deborah Gleeson, public health policy researcher at La Trobe University in Melbourne, Australia. “This is why the Director-General of the World Health Organization (WHO) refers to the current inequitable distribution of vaccines as a ‘catastrophic moral failure’.” Without a collaborative effort to manage access and distribution for everyone, there could be hoarding in some places and shortages in others. That’s why a vaccine-sharing scheme called Covid-19 Vaccines Global Access Facility (COVAX) hopes to deliver more than two billion doses to people in 190 countries in less than a year.

Although the world has not faced a health challenge as severe as Covid-19 before, we can learn lessons about vaccine equity from previous epidemics, says Wouters. In 2009, swine flu killed nearly 285,000 globally. Scientists quickly developed a vaccine. But high-income countries were able to secure contracts with pharmaceutical companies to receive the jabs, and low-income nations were pushed to back of the queue. Many countries did not receive the vaccinations until the epidemic was already over. Luckily swine flu was not as deadly as first feared, but a similar issue with HIV treatment was a more sombre story for low-income countries. When effective drugs for the virus were first developed in the 1990s, many developing nations couldn’t buy them because of the prohibitive costs. It was only several years later when generic versions of the drugs were available at a much lower price that everyone gained access to the life-saving treatments.

Source: Official data collected by Our World in Data


The nations who have developed vaccines domestically, and those rich enough to afford to buy up stocks from manufacturers were already beginning to pull ahead in the race to vaccinate their populations by April. Despite slow rollouts in some rich countries, such as the EU, poorer nations could still be waiting much longer, even until 2024, before they get access to the vaccines they need to safely protect their citizens.

Vaccine nationalism

COVAX, which launched at the start of the pandemic in April 2020, is intended to ensure such medical inequity is not repeated during the coronavirus crisis. The scheme was set up by WHO, the GAVI vaccine alliance and the Coalition for Epidemic Preparedness Innovations (CEPI). Richer countries buying vaccines agree to help finance access for poorer nations. The idea is that all participating countries will initially receive sufficient vaccine supplies to inoculate 20% of their populations. And that no country should vaccinate more than a fifth of its residents until all countries have done the same. “For lower-income funded nations, who would otherwise be unable to afford these vaccines, as well as a number of higher-income self-financing countries that have no bilateral deals with manufacturers, COVAX is quite literally a lifeline and the only viable way in which their citizens will get access to Covid-19 vaccines,” says GAVI. COVAX saw its first success story on 24 February, when 600,000 doses of the AstraZeneca/Oxford coronavirus vaccine arrived in Ghana.

Not everyone is convinced that COVAX will succeed, however. There are several challenges that need to be overcome with the scheme. One hurdle is vaccine nationalism. “COVAX cannot fulfil its mission if rich countries continue to buy up the very limited stock that’s available this year,” says Wouters. But many high-income nations have opted not to purchase their jabs via COVAX and have instead struck advance purchase agreements with pharmaceutical companies to ensure there is sufficient supply to vaccinate their entire adult populations by the end of this year. Perhaps unsurprisingly, many countries have put widespread inoculation their own populations ahead of protecting the vulnerable in poorer parts of the world.

“Developed and wealthy countries, out of either personal survival or fear of backlash from their citizens if they do not effectively control the outbreak, have decided to essentially hoard vaccines before they left the vaccine production lines,” says Mosoka Fallah, a public health consultant and lecturer at the University of Liberia. “Hence, there is limited access for other countries.” This approach becomes a vicious circle as more countries procure vaccine doses directly, concerns about the COVAX supply increase and more nations panic buy doses for themselves. Fallah believes COVAX is the best platform we have for equitable access to Covid-19 vaccines, but he questions whether the 20% figure will be enough. “Experts in Africa are saying we need to vaccinate at least 60% of people on the continent to achieve herd immunity,” he says.

Share the know-how

COVAX might have greater impact if it used its purchasing power to push corporations to share the science, knowledge, and technology behind the vaccines which could lead to scaled up production, says the People’s Vaccine Alliance. “As injections of hope are being administered at a rate of one a second in rich nations, people in poorer countries are dying from Covid-19 because they lack the basics like oxygen and have little hope of a vaccine,” says Anna Marriott, Oxfam’s Health Policy Manager. “Rich nations have a chance to stand on the right side of history and support, not block, calls made by developing countries for a temporary waiver of pharmaceutical intellectual property rights to unlock more manufacturing capacity around the world.”

In October, South Africa and India asked the World Trade Organization (WTO) to waive IP rights related to Covid jabs until most of the world has been vaccinated. Not surprisingly, the pharmaceutical industry was unconvinced. “At a time, when the focus should be on science and innovation, undoing the very system that supports it is dangerous and counterintuitive,” said Thomas Cueni, Director General of the International Federation of Pharmaceutical Manufacturers and Associations (IFPMA) in a statement at the end of last year.

But intellectual property is not the only problem. Vaccine supply chains are fragile. Several regions, such as India and the European Union have announced restrictions on vaccine exports this year. And unlike some medicines that are relatively easy to copy if you have the right equipment, many of Covid-19 jabs are difficult to replicate because they are made of biological material. Making them is a complex process requiring hard-to-source ingredients and multiple quality control steps. Some pharmaceutical companies have been more forthcoming than others though. AstraZeneca has licensed production of its vaccine, developed at Oxford University, to companies in India, Brazil and Argentina. And WHO’s Covid-19 Technology Access Pool (C-TAP) promotes ‘technology transfer’ (where companies license their IP rights to third parties) so other institutions are able to manufacture the vaccines. “I think we need to work on both in parallel,” says Wouters. “We need to make sure that COVAX is able to get its hands on doses and deliver them where needed. And in the meanwhile, governments need to figure how to get companies to license their products more widely to manufacturers across the globe to expand supply.”

Even if the goal of getting Covid vaccine doses to every country is reached, another hurdle that must be urgently addressed is vaccine hesitancy. “It’s not enough to have vaccines developed and produced at scale, priced affordably and allocated globally so that they’re available where needed,” says Wouters. “If people don’t take them, it’s all for nothing.” Vaccine hesitancy occurs in all countries – rich and poor. But a report from the World Bank found that only around a quarter (27%) of low- and middle-income countries are planning public information campaigns to encourage people to get the Covid jab. Failing to invest in this area could undermine efforts to get the pandemic under control.

Effective vaccines offer the world a glimpse at the light at the end of the tunnel. But to truly expunge the pandemic, the coronavirus must be eradicated in every country.

Since the beginning of the crisis, WHO has stressed that a global pandemic requires the whole world to end it, frequently quoting the mantra that “no one is safe until everyone is safe”. International solidarity may be forged yet. Several world leaders have called for a new global settlement to help the world prepare for future pandemics. But whether unity will form in time to stop the current crisis remains to be seen. Fallah says: “We need to find the means and the will to ensure that poor countries are not left poorer and the rich do not become richer after Covid-19 comes to an end.”