The idea was to tackle a problem that had been worrying public health experts for months: the widening gulf between vaccinations in the rich world and poor world, which had turned the covid-19 scourge into a two-lane pandemic. In one — call it the fast lane — the fully vaccinated and boosted; in the other, moving at a snail’s pace, those with no shots at all. The central concern: that large unvaccinated populations would give the virus space to spread and then mutate into new and dangerous strains.
For nearly a year, global organizations have tried to merge the two lanes. A World Trade Organization (WTO) meeting in November was meant to help by addressing a critical question: whether to waive patent rules that have kept production of vaccines in the hands of established manufacturers.
Waiving the rules could be a vaccine-supply game changer. Smaller, less-established drug makers would have the opportunity to boost local and regional production in the developing world. Everyone, the WTO said, was “committed” to the goal of delivering vaccines to all, though the organization added — deploying the sanitized language of international diplomacy — “Differences remain on significant questions.” This would be a chance to resolve them.
And then the WTO meeting was postponed. Why? Because a new variant of the virus had just been detected in southern Africa, one of many parts of the world that have struggled to vaccinate their populations.
It made the omicron variant’s discovery not just a “we told you so” moment, but also a moment of high irony. The latest effort to fix the problem, undone by the problem itself.
Global health officials now say they want at least 70 percent of people in all countries to be vaccinated by June 2022 — after the world repeatedly missed its targets in 2021. Number of doses required to meet that target? At least 11 billion — roughly the amount produced last year. Cost for delivery and distribution? An estimated $55 billion. Also required: a reordering of global priorities. That’s because the vast majority of last year’s doses ended up in well-off nations.
The vaccine rich-poor story involves global politics, corporate decision-making and critical gaps in infrastructure. Public health experts say changes must come in all these areas, not only because it is the right thing to do — but because it is the smart thing to do to help end the pandemic.
By the numbers
From the beginning, the world has seemed one step behind.
By the beginning of 2022, around 60 percent of the global population had received at least one vaccine dose, with some 35 million shots administered daily. In several European countries, more than 70 percent were fully vaccinated. And in the U.S., for all its vaccine skeptics, the rate was more than 60 percent. In Americans aged 18 and above, the figure currently stands at more than 73 percent.
But across the world’s lower-income countries, a mere 8.5 percent of people had secured even a single shot. Nigeria? Just over 2 percent fully vaccinated. The Democratic Republic of the Congo? Around 0.1 percent. More than 3 billion people — among them front-line healthcare workers who continue to face a high risk of exposure to the virus — had no vaccine protection at all.
It wasn’t supposed to be this way.
Well before the first covid-19 vaccines were approved in 2020, an international mechanism was put in place to secure doses for the world’s poorest countries.
Backed by the World Health Organization and called Covax, the plan envisioned a three-step process to ensure global vaccine equity: First, strike deals with vaccine manufacturers even before the shots were cleared by regulators; second, once the new shots were authorized, secure as many doses of working vaccines as possible; and third, and most important, distribute them equitably around the world.
To do so, Covax needed something that’s been in short supply since the pandemic’s early days: international cooperation. “Every country was thinking about itself,” the WHO’s Chief Scientist Soumya Swaminathan told Grid.
Several wealthy nations, including the U.S. and China, initially opted out of Covax, instead striking direct deals with vaccine makers.
“High-income countries, particularly, who had a lot of money that they could put into [vaccine] contracts did so at an early stage and booked a lot of the doses from multiple companies,” Swaminathan explained.
Covax has been hobbled by other issues — including a sudden cutoff in supplies of the AstraZeneca vaccine when India, a major manufacturer, imposed an export ban as the delta variant wave tore through the country.
AstraZeneca’s shot had been touted as a critical weapon in protecting the low-income world, as it could be transported more easily than the Pfizer shots, which must be stored in special freezers. India’s ban led to a critical shortfall beyond its borders. Neighboring Nepal signed deals for 2 million doses in February 2021; only half as many were delivered before India turned off the tap. The move wasn’t reversed until October.
Meanwhile, in the U.S., the Trump administration spent $1.6 billion to fund an easy-to-transport vaccine manufactured by Maryland-based Novavax, another ray of hope for poorer countries. But production problems have delayed its rollout. And on several occasions, vaccine doses have landed in countries just shy of their expiration dates.
Last month, Nigeria destroyed 1 million expired doses of the AstraZeneca vaccine. “We had developed countries that procured these vaccines and hoarded them,” Faisal Shuaib, head of Nigeria’s National Primary Health Care Development Agency, told the Associated Press. “At the point they were about to expire, they offered them for donation.”
The global supply problem is most evident when you look at where the bulk of doses has gone. According to the International Federation of Pharmaceutical Manufacturers and Associations (IFPMA), a pharmaceutical trade group, by the end of November 2021 the world had produced almost 10 billion doses of various covid-19 vaccines, a figure forecast to rise to just over 11 billion by the end of the year. Deliveries of vaccines to poor and low-income countries, either via Covax or through direct bilateral initiatives, totaled just over 784 million doses by the end of November.
In other words, fewer than 1 in 10 shots went to the world’s poorer nations. That, experts say, needs to change — and fast. “Unchecked spread in any one part of the world is a threat to other parts of the world,” Priya Sampathkumar, the chair of infection prevention and control at the Mayo Clinic, told Grid.
The IFPMA says that at current production rates, the world is on track to produce almost 20 billion vaccine doses by the end of June. But with most of the doses produced so far going into arms in the rich world — and “fully vaccinated” in better-off countries now defined as three or even four shots — the key question as we head into year three of the pandemic remains the one that has been worrying public health experts since 2020: Will the doses reach everyone who needs them?
Getting “from tarmac to arm”
“Reach” here is about more than just global supply. Getting doses into the arms of those who need them requires an array of medical expertise and infrastructure — freezers to store the vaccines, syringes used to administer them and experienced healthcare workers to manage the process.
The U.S. and global health organizations have been aware of this “tarmac to arm” imperative — the need to help poorer nations store, transport and administer vaccines — since the early days of the pandemic. But on this front as well, global efforts have fallen short.
Syringes alone tell the story. Based on its assessment that 7 billion people would need two shots by 2023, the WHO warned recently that the world could find itself short of at least 1 billion syringes unless urgent efforts were made to boost production. And that was before the arrival of omicron, which has brought a rush for booster shots — again, largely in “vaccine-rich” nations — thus putting greater pressure on the global syringe supply.
“When you think about the magnitude of the number of injections being given to respond to the pandemic, this is not a place where we can afford shortcuts,” said Lisa Hedman, a senior WHO official who tracks such infrastructure concerns, addressing the syringe gap.
The shortfall is already hitting vaccination efforts in developing countries. Nepal was supposed to start inoculating children aged 12 to 17 with the Pfizer vaccine just after Christmas. But the effort was put on hold indefinitely. The reason? A shortage of the needles needed to administer the shot. “Our plans to roll out the Pfizer-BioNTech vaccine have been affected due to a lack of syringes,” Sagar Dahal, who heads the country’s vaccination program, told the local Kathmandu Post.
The issue also threatens routine immunization programs in low- and middle-income countries, according to Path, the public health nonprofit. In year one of the pandemic, as health systems around the world focused on covid, the syringe gap meant that millions of children missed out on routine tetanus, diphtheria and other vaccines.
The scope of the vaccine infrastructure challenge is reflected in recent pledges and programs to help with these “tarmac to arm” problems. The U.S. has committed more than $1.6 billion to help with “global vaccine readiness,” including a $400 million commitment made in December to help ensure vaccines can be delivered and stored at the right temperatures, as well as funds for mobile vaccination sites in remote regions. The European Union, meanwhile, has been funding vaccine infrastructure and delivery programs in several low-income countries, including a $100 million initiative to help roll out vaccines in some of Africa’s poorest nations.
Generous? Perhaps. Sufficient? Probably not. And — with omicron already raging in several of these countries — too late for many.
The patent question
That now-postponed WTO meeting was meant to untangle another critical knot on the path to vaccine equity: the refusal of private manufacturers to share their vaccine recipes with poor-world counterparts. Sharing the intellectual property would not only lead to a significant boost in supply, it would also allow millions of new doses to be made closer to the people in need.
An example is the WHO-backed effort currently underway in Africa to manufacture a copy of the highly effective Moderna vaccine.
At its heart is the ever-present tug-of-war between major pharmaceutical companies and smaller firms in countries where resources are few and the need is great. Among the latter companies is Afrigen Biologics, which is trying to build a version of the Moderna vaccine using publicly available information. The company’s managing director, Petro Terblanche, told the Washington Post she believes it will take Afrigen three years to replicate the vaccine.
Why so long? Because of Moderna’s refusal to share its know-how.
The company’s stance is said to have irked the White House, given that Moderna received billions of dollars in U.S. taxpayer support to develop its vaccine and worked closely with the National Institutes of Health to develop its vaccine. Although Moderna has pledged not to enforce its intellectual property rights for the duration of the pandemic, it still hasn’t openly shared its expertise and technology with other manufacturers. Last month, the global nonprofit Doctors Without Borders called on Moderna and rival Pfizer to make their know-how available to broaden vaccine access.
The U.S. supports the sharing of intellectual property, as do more than 60 other countries, including India and South Africa. Among those opposed are the European Union and the U.K., where many of the world’s pharma giants are based or have substantial interests. This matters; the patent rules can’t be changed without unanimous consent among the WTO’s 164 members.
In a November 2021 letter, a coalition of nursing unions across 28 countries implored the U.N. Human Rights Commission to take action. The world’s rich nations, they wrote, “have violated our rights and the rights of our patients — and caused the loss of countless lives — of nurses and other caregivers and those we have cared for.”
It wasn’t an abstract moral issue, they said. In their view, opposition to the patent waivers amounted to a human rights violation.
Merging the lanes
Omicron’s surge could further complicate the road to vaccine equity. More countries in the rich world will seek booster shots, perhaps in some cases even a fourth dose; WHO Director Tedros Adhanom Ghebreyesus warned in his end-of-2021 briefing that “blanket booster programs are likely to prolong the pandemic, rather than ending it, by diverting supply to countries that already have high levels of vaccination coverage, giving the virus more opportunity to spread and mutate.”
There may also be a new shot needed to counter omicron. “I believe in principle at a certain time point we will need a new vaccine against this new variant,” Ugur Sahin, the CEO of BioNTech, the company behind Pfizer’s shot, told Reuters in early December.
All this as people in low-income nations wait to get their hands on the current vaccines — in many countries, waiting for whichever shots they can find. And while richer nations have recently stepped in with pledges to remedy the problem — the Biden administration has promised more than 1.1 billion doses for poorer countries, most of them via the Covax initiative — supply outside the wealthy world remains constrained.
Meanwhile, those “tarmac to arm” issues persist, as do the intellectual property claims made by the major pharmaceutical companies. To many critics, the fate of that WTO meeting on patents and intellectual property was telling. It was canceled because of omicron’s arrival, and when a lower-level group met virtually to review the issue, it failed to resolve the deadlock.
One thing global health experts agree on: Generosity and greater global cooperation will be essential to turn the tide. In his year-end address, Tedros said that “as we approach a new year, we must all learn the painful lessons this year taught us. 2022 must be the end of the covid-19 pandemic. But it must also be the start of something else — a new era of solidarity.”