COVID-19 vaccine equity: a global failure?

Image description: a Hawaiian newspaper with the headline “Mass vaccinations begin”

As vaccination proceeds apace in the UK and amongst high-income countries around the world, there are growing concerns over vaccine inequity in a global context. Countries in Europe, Asia and the Americas have begun vaccination campaigns, delivering more than 175 million doses since December 2020. In the UK alone, triumph was claimed as the 15 million mark was passed on the 15^th of February, and as of 19^thFebruary, just under 17 million people have been vaccinated – or 25.45 per 100 in the population. Meanwhile, within lower-income countries, vaccination programmes have not been started, even amongst health care workers and the most vulnerable. Many countries have yet to vaccinate anyone. Whilst the UK has vaccinated 25% of the population, in Guinea a total of just 25 individuals have received a dose.

Ensuring global access to COVID-19 vaccines presents considerable challenges. As of February 2021, there were 289 experimental COVID-19 vaccines in developmental stages, of which 66 were in different phases of clinical trials. Of these, 3 have been recently authorised by the WHO (World Health Organisation), and an additional 7 have been authorised by varying other regulatory agencies. Despite these impressive numbers and the unprecedented speed of vaccine development, scaling up production to meet global demand is a prodigious challenge. Current models suggest there will not be enough vaccine produced for full global coverage until 2023 or 2024.

But how will this vaccine be distributed? High-minded plans for equitable global distribution were agreed on in 2020, particularly with the COVAX (COVID-19 Vaccine Global Access) Facility set up by the WHO, aiming to provide all countries with access to the vaccine during the acute phase of the pandemic in 2021. COVAX recommended a 20% proportional distribution policy – where initial vaccination should be prioritised for health care workers and those at highest risk in all countries, with an initial stock for 20% of each population, followed by further international distribution on the basis of need. With subsidised vaccines for lower-income countries, this would lead to no country exceeding the 20% threshold until all countries had vaccinated 20% of their populations. 190 countries signed up for the COVAX scheme, including the UK and many other high-income countries. Although lack of funding is certainly an obstacle for COVAX, lack of vaccine availability due to “vaccine nationalism” presents an even greater challenge. Rich countries strike bilateral deals to secure adequate vaccine doses (many of which are produced in their own country) for their own citizens, leaving the rest of the world of a profound disadvantage.

20 doctors died in a week from COVID-19 in Nigeria in December – and this hits hard in a country with 36.6 doctors per 100,000 people

As of February 2021, governments in high-income countries (representing 16% of the global population) have arranged pre-orders totalling at least 4.2 billion doses of COVID-19 vaccines. This is in comparison to only 1.12 billion doses ordered by COVAX. Canada has pre-ordered enough doses to vaccinate its entire population five times over. “Vaccine nationalism” creates a damaging spiral: as more doses are ordered, concerns over the COVAX supply increase, further incentivising purchases on a national basis. But not all countries can afford to do this, and those that cannot are left reliant on an under-supplied and under-funded COVAX programme.

In the countries where vaccination has not yet begun, high-risk individuals continue to die. A recent article in Science describes the recent deaths of African health care workers: a heart specialist and an HIV/AIDS researcher in Zimbabwe, an anaesthesiologist, a urologist and a gastroenterologist in Mozambique. 20 doctors died in a week from COVID-19 in Nigeria in December – and this hits hard in a country with 36.6 doctors per 100,000 people (for comparison, the UK has 280 per 100,000).

Deaths will be avoided by cooperative global distribution – modelling suggests a cooperative approach to the roll-out of the first 3 billion vaccine doses (at an estimated efficacy of 80%) would avert 61% of deaths, compared to 33% for an uncooperative approach where these doses are mostly amassed by the 50 wealthiest countries. However, this is not merely a moral problem. Economic models suggest that the large economic costs of the absence of a global vaccination programme will be mainly borne by economically advanced countries due to their tight connections with unvaccinated trading partners. Allowing the virus to circulate for longer also gives more time for new strains to arise, including vaccine-resistant ones, as we have already begun to see. To summarise, it is not only that “none of us will be safe until everyone is safe” (WHO director Dr Tedros Ghebreyesus and President of the European Commission Dr. Ursula von der Leyen), but also that “no economy fully recovers until every economy recovers” (Çakmaklı et al. 2021).

Peter Singer, special advisor to the director general of the WHO, recently said: “vaccine equity will be the defining challenge of 2021”. This is a challenge we are failing to meet.

Image credit: little plant on Unsplash