Inside Story

Vaccinating the world

Sharing vaccines fairly is not only an ethical imperative but also essential to controlling Covid-19

Lesley Russell 2 March 2021 2028 words

Health staff preparing for vaccinations in Bogota, Colombia, on 18 February. Colombia is one of the countries to receive vaccine supplies via COVAX. Chepa Beltran/VWPics/Alamy

Six weeks ago, not long before the anniversary of the World Health Organization’s declaration that the novel coronavirus was an international health emergency, WHO head Tedros Adhanom Ghebreyesus addressed the agency’s executive board. He reported that developed countries were already rolling out their vaccination programs, but stressed that unequal access was pushing the world towards a “catastrophic moral failure.” And not just a moral failure: “Unless we suppress the virus everywhere, we could end up back at square one.”

The extent of what’s being called vaccine nationalism is clear in the figures. As of early February, more than three-quarters of all vaccinations had been administered in the ten countries that together account for almost 60 per cent of global GDP, leaving some 130 countries, with 2.5 billion people, yet to receive a single dose.

Even before many of the vaccines had completed clinical trials or regulatory approval, the governments of the wealthiest countries had signed agreements with pharmaceutical manufacturers. As a British Medical Journal paper published in December revealed, some 3.76 billion courses (or 7.48 billion doses) of the projected manufacturing capacity of 5.96 billion courses by the end of 2021 were already committed by November 2020.

Of these, a shade over half were allocated to the high-income countries that account for only 14 per cent of the world’s population. Australia, Japan and Canada — countries with relatively small populations and few coronavirus cases — had collectively reserved more than a billion doses. Perhaps 2.34 billion courses would be left for low- and middle-income countries, the authors calculated. By 30 January, Britain had reportedly secured enough vaccines to give each of its citizens five doses, while Canada has ordered enough to give everyone nine doses.

The situation is reminiscent of the 2009 H1N1 influenza outbreak, when a handful of wealthy countries secured most of the vaccine supplies and relatively few of the populations who would have benefited most from the vaccine got it in time to make a difference.

Vaccine nationalism is rarely beneficial in the long run. Modelling by the International Chamber of Commerce shows that the economic benefits of funding equitable access to vaccines dwarf the costs. Advanced economies stand to lose as much as US$4.5 trillion if they fail to give developing economies access to coronavirus vaccines.

That didn’t stop EU health commissioner Stella Kyriakides from threatening to require companies making coronavirus vaccines in the bloc to “provide early notification whenever they want to export vaccines to third countries.” The statement contrasted with pleas for vaccine sharing from French president Emmanuel Macron, German chancellor Angela Merkel and other leaders.

The main international effort to secure equitable and affordable vaccine supplies for all countries, especially the poorest, falls under the auspices of COVAX, a joint initiative of Gavi (a public–private global health partnership dedicated to increasing access to immunisation in poor countries), the Coalition for Epidemic Preparedness Innovations (an Oslo-based fund supporting the development of vaccines against Covid-19) and the WHO.

COVAX aims to build manufacturing capabilities and secure two billion vaccine doses for distribution by the end of 2021. The plan is for more than a billion of these doses to be provided free or at a low cost to ninety-two low- and middle-income countries. The remainder will go to wealthier countries, which will pay for them.

Australia joined COVAX last September with a A$123.3 million commitment to its purchasing mechanism, which will enable Australia to purchase vaccines as they become available. This option may never be taken up, though: it comes on top of the agreements Australia has struck with Oxford–AstraZeneca, Pfizer and Novavax, which together will provide some 120 million doses.

COVAX’s work was initially hindered by the Trump administration’s refusal to participate. That was last September, after it had withdrawn the United States from the WHO, citing the agency’s “China-centric” response to the pandemic. It’s probably no coincidence that China announced its participation in COVAX the following month. In some diplomatic circles its motives for doing so are suspect. Russia, although a major vaccine developer and manufacturer, stayed on the sidelines.

All that changed with the election of Joe Biden, who acted quickly to rejoin the WHO and provide funding for COVAX. He has announced an initial US$2 billion and will release a further US$2 billion over two years once other donors have made good their pledges.

The US funds were appropriated by a bipartisan congressional vote in December — after Biden was elected but when Trump was still in office — and they provided a much-needed boost to the program. Indeed, the decision has been described as a “game changer” that will help mobilise other governments to start contributing to COVAX. The current funding shortfall for coronavirus testing, drugs and vaccines, and the resources to deliver them is estimated at US$27 billion for 2021.

Suddenly Russia, too, is interested in working with COVAX, although it has indicated it will not be substituting COVAX for its supplying of Sputnik V vaccine directly to other countries. China has taken this approach as well, offering priority access to its own vaccines to countries in Africa, the Middle East and Southeast Asia. While less is known about their efficacy, the Russian and Chinese vaccines are considerably cheaper than those produced in the West. These two jousting world powers clearly see their vaccines as a form of soft diplomacy, with more opportunities for this created by Trump’s weakening of America’s international standing and involvement. It is unlikely that the Biden administration will so readily cede this field.

Despite the boost from US involvement and recent pledges for increased support from G7 nations, COVAX faces a huge task in getting the leaders of wealthy countries to deliver their full funding commitments and to match their actions to their rhetoric.

Macron’s rhetoric is a case in point. Supported by Merkel, he called for 3 to 5 per cent of the European and US vaccine supply to be sent to developing countries. Diverting a small percentage of doses would not dramatically affect vaccine rollouts, he said, and would deal with the fear that Moscow and Beijing plan to wage what he called “a war of influence over vaccines.” Direct donations of vaccines, he argued at the Munich Security Conference last month, would be quicker than donating money to COVAX. But it isn’t clear when or even if these donations will happen. The British government said it will “share the majority of any future surplus coronavirus vaccines from our supply” with COVAX but gave no time frame.

Despite the problems, the good news is that vaccines are starting to arrive in Africa. This past week 600,000 doses of the Oxford/AstraZeneca coronavirus vaccine — developed in Britain, manufactured in India, with needles sourced from Dubai and funded by COVAX — arrived at the airport in Accra. This means that Ghana, a lower-middle-income country with a population of thirty-one million, can begin vaccinations this week.

African countries like Ghana have not been hit as hard by the virus as wealthier nations. So far, Ghana has recorded some 82,000 cases and nearly 600 deaths; but now, like many others in Africa, it is experiencing a second wave of infections. Managing the pandemic in Guinea and the Democratic Republic of the Congo has also been complicated by new outbreaks of Ebola.

Experts believe that the emergence of new coronavirus variants has contributed to a new wave of infections in many countries in southern Africa. They are concerned that unequal vaccine supplies and delays in vaccination programs will not only prolong the pandemic but also increase the possibility of hardier, more lethal variants. With more than 130 countries yet to vaccinate a single person, this is yet another reason for concerted international vaccination efforts.

COVAX has no power to compel states to share their surpluses. Some countries, Norway and Canada among them, have committed to sending their excess vaccines to COVAX. Others have used vaccines to advance foreign policy goals (Israel) or placate near neighbours (Spain).

And Australia? Prime minister Scott Morrison initially made a fairly tepid commitment to distributing coronavirus vaccines to the Pacific and some Southeast Asian countries “if Australia develops a supply.” Already, Australia has secured dramatically more vaccine than needed — and is also investing in increased local vaccine manufacturing capabilities — so Morrison should be able to ensure that “we’re doing our bit in this part of the world,” as he said in early February.

International availability of vaccines may also be boosted by cooperative initiatives to lift manufacturing capacity. French pharmaceutical giant Sanofi recently announced it would make its manufacturing infrastructure available to produce the Pfizer vaccine, and US company Merck, whose own vaccine candidates were not successful, has said it is in talks with governments and companies to potentially help manufacture already-approved vaccines. Brazil, China and India all have vaccine industries with enough capacity to manufacture supplies for their own use and for export.

The WHO has called on companies with vaccines to issue non-exclusive licences to allow other producers to manufacture their products, a mechanism that has been used before to expand access to treatments for HIV and hepatitis C.

As countries like the United States, Britain and now Australia are learning, successful vaccination programs require much more than simply getting the vaccines safely to vaccination centres. Trained personnel, technical assistance and equipment are needed, as are careful record-keeping and surveillance, transport and refrigeration. All this is considerably more costly and often more difficult to arrange than the vaccines themselves.

Last May the Australian government redirected A$280 million from overseas aid and humanitarian programs to the international Covid-19 response. Most of these funds (A$205 million) went to the Pacific region for technical assistance and supplies, laboratory diagnosis, personnel and surveillance. The Australian Council for International Development welcomed the decision but decried the repurposing of already-stringent aid funds. Additional resources are required.

The elephant in the room, especially where new vaccines are involved, is who bears the risk of any adverse side effects or injury to patients. Countries funding their own vaccine procurement must also undertake their own liability programs.

In the United States the Trump administration granted companies like Pfizer and Moderna immunity from liability for unintentional problems with their vaccines. It isn’t possible to sue the government or the Food and Drug Administration over side effects either. This rare blanket immunity deal, which extends until 2024, involved invoking the 2005 Public Readiness and Emergency Preparedness Act, which provides legal protection to companies making or distributing critical medical supplies, such as vaccines and treatments, unless there is wilful misconduct by the company.

The Australian government’s 2020–21 budget included a commitment to provide the suppliers of coronavirus vaccines with indemnity against liability for rare side effects. But experts have pointed out that it isn’t clear what this means in practice, and the government has not released any further details, citing “commercial in confidence” considerations.

The WHO, in what it describes as the “first and only” international vaccine injury compensation scheme, has agreed a no-fault compensation plan for claims of serious side effects in the ninety-two poorest countries due to get coronavirus vaccines via the COVAX scheme. This relieves recipient governments of a potentially serious financial and judicial burden.

Coronavirus vaccines have arrived in record time, and they will have a critical role in bringing the pandemic under control. But population immunity is required to end the pandemic, and this must be achieved internationally if the world and travel and open borders are to return to something like pre-pandemic times.

Achieving that level of immunity will take time and efforts well beyond vaccination programs; it will involve politics as much as science, political will as much as vaccination expertise, and recognition that a global pandemic requires a global response.

To return to the words of the WHO director-general: “Vaccine nationalism is not just morally indefensible. It is epidemiologically self-defeating and clinically counterproductive… Allowing the majority of the world’s population to go unvaccinated will not only perpetuate needless illness and deaths and the pain of ongoing lockdowns, but also spawn new virus mutations as COVID-19 continues to spread among unprotected populations.” •

The publication of this article was supported by a grant from the Judith Neilson Institute for Journalism and Ideas.