Senam Agbesi has been trying to make the best of lockdown in London. “I’ve done lots of Zooms, lots of walks,” he said. The 34-year-old NHS manager believes he could get the vaccine this month, as he is starting a new job that would mean visiting hospitals regularly.
Despite the good news about his own vaccine, he worries about his father, Yao, who lives in Accra, Ghana. Yao is 65 and has sickle cell trait, a condition that puts him at higher risk of suffering severe illness if he catches Covid-19.
A close family friend recently died of the virus and Senam wishes his father would be more careful. “He thinks he’s invincible. He drinks his little tea of lime juice and ginger in the mornings and thinks he has an invisible fortress around him,” he said.
Yao has not been given any information about being vaccinated nor seen any concrete information in the media about when any vaccines will arrive. Predictions suggest that the majority of the Ghanaian population will not be vaccinated until 2023, and some other sub-Saharan countries will be waiting until 2024.
Not only will poorer countries be forced to wait, but many are already being charged much higher prices for every dose. Uganda, for example, has announced a deal for millions of vaccines from AstraZeneca, at a price of $7 a dose – more than three times what the EU paid for the same jab. Including transport fees, it will cost $17 to fully vaccinate one Ugandan.
Campaigners and scientists warn that we are on course for a “vaccine apartheid” in which people living in the global south are inoculated years after those in the West.
The effects of this inequity would be stark. Modelling by Northeastern University indicates that if the first 2bn doses of Covid-19 vaccines were distributed proportionally by national population, worldwide deaths would fall by 61%. But if the doses are monopolised by 47 of the world’s richest countries, only 33% fewer people will die.
As the EU bickered with AstraZeneca last week over securing more vaccines, leaders in the bloc parroted the mantra “no one is safe until everyone is safe”. But globally unequal distribution will harm all of us – leaving reservoirs for the virus across the world in which new, potentially more dangerous variants will emerge and spread.
Distracted by in-fighting and protectionism in the West, we are sleepwalking into a world that will suffer more cases, more economic chaos and more deaths.
Survival of the quickest
In the rush to secure vaccines for their citizens, and before it was known which ones would be most effective, countries quickly arranged deals for billions of doses. About 12.7bn doses of various coronavirus vaccines have been bought so far, enough to vaccinate roughly 6.6 billion people. (All of the vaccines approved so far require two doses, but some nations have already ordered a single-dose vaccine that has yet to be approved.)
More than half of those doses – 4.2bn secured, with the option of buying another 2.5bn – have been bought by wealthy countries home to only 1.2 billion people.
Canada has bought enough doses to inoculate every Canadian five times, while the US, UK, EU, Australia, New Zealand and Chile have purchased enough to vaccinate their citizens at least twice, although some of the vaccines are yet to be approved.
These vast existing orders leave fewer doses for poorer regions and raise questions over whether Covax, an organisation created to ensure low-income countries can access vaccines, will be able to meet its target to vaccinate those most at risk across the world this year. (Covax told the Bureau that it was confident it would meet the target and hoped to exceed it.) Low-and-middle-income countries have made deals directly with pharmaceutical companies, but have so far secured only 32% of the world’s supply to cover 84% of the world’s population.
In Israel, which has the fastest vaccination programme in the world, more than a third of people have had one dose, and over a fifth have had both. The Palestinian Territories is still waiting for vaccines from Covax to arrive, although Israel recently announced it would transfer 5,000 doses to immunise Palestinian frontline health workers.
“We’re in such a massive crisis,” said Fatima Hassan, the founder of South Africa’s Health Justice Initiative. “If even in South Africa we can’t get even half of our population vaccinated soon, I can’t even imagine how Zimbabwe, Lesotho, Namibia and the rest of Africa will cope. If this is going to continue for another three years, we’re not going to get any kind of continental or global immunity.”
Demand exceeding supply
This frenzied grab for vaccines is happening because supply is finite. After developing their vaccine, pharmaceutical companies must modify their product so it can be manufactured on an industrial scale, before transferring the technology to licensed factories around the world.
AstraZeneca, the company behind the Adenovirus-based vaccine developed with Oxford University, has licensed ten other companies in the UK, India, Brazil, Japan, South Korea, China, Australia, Spain, Mexico and Argentina to make its product, on top of its own factories in the UK and Europe. While most of these companies have permission to make the vaccine only for a specific geographic area, it is at least an attempt to manufacture at scale globally. Campaigners have criticised other pharmaceutical giants for failing to license more manufacturing companies around the world.
Instead, some of these companies appear to have focussed on supplying the West. Public Citizen, a US think tank, has found that just 2% of Pfizer/BioNTech’s global supply has been granted to Covax, while last year people familiar with Moderna’s plans believed the US company intended to prioritise high income nations. In January, the South African government said Moderna has no intention of registering its vaccine in the country.
Pfizer and Moderna’s vaccines are also much more expensive. Although many of the vaccine deals have been kept secret, information leaked by a Belgian official showed the EU paid between $2 and $18 per dose, with Pfizer and Moderna’s mRNA vaccines the priciest at over $14 — much more than low income countries can afford.
Pfizer told the Bureau: “We have allocated doses for supply to low- and lower-middle-income countries at a not-for-profit price.”
AstraZeneca has promised to make its vaccine available at cost in the Global South in perpetuity (there is an as-yet unspecified time limit for that price in the West). But some poorer nations have already ended up paying more for the AstraZeneca vaccine too, under another name.
In India, where much of the world’s pharmaceutical manufacturing takes place, the Serum Institute is producing the largest shipments of both AstraZeneca and Novavax’s vaccines. However, because it has a non-commercial license for the AstraZeneca jab, the Serum Institute can export its own version – Covishield – to 92 of the world’s poorest countries. Unlike AstraZeneca, the Serum Institute has not promised to keep to cost price, and is charging India $3 per dose, South Africa and Brazil $5, and Uganda $7, where the EU only paid AstraZeneca $2. Neither AstraZeneca nor the Serum Institute responded to a request for comment.
Many nations, particularly in Latin America, Asia and the Middle East, have turned to Russian and Chinese vaccines, which are yet to be approved by what the WHO defines as a stringent regulator. According to the manufacturer’s website, more than 50 countries have also applied for Russia’s Sputnik V vaccine.
China has given at least 30m doses of its homegrown vaccines to its citizens and Indonesia and Turkey have begun administering doses. Last June, Chinese president Xi Jinping promised African countries they would “be among the first to benefit” from China’s vaccines, but it is not clear if any have yet arrived. In Uganda, at least one Chinese company has been allowed to import vaccines to inoculate its Chinese workers and their families before Ugandan nationals.
With inadequate supply at the root of both delays and inequity, many public health experts and campaigners are calling on pharmaceutical companies to waive patents to allow more factories to make vaccines. Within two months of declaring the pandemic, WHO had set up a mechanism for sharing intellectual property and data. Membership was voluntary. Not a single pharmaceutical company has participated.
In October 2020 a group of countries, led by India and South Africa, asked the World Trade Organisation to temporarily suspend intellectual property rights for Covid-19 vaccines and medicines, meaning any generic producer could start making them. While the WHO supports this, countries including the US, Canada, Australia, EU and UK are siding with pharmaceutical companies to oppose it. However, the recent row over AstraZeneca’s supply delays in Europe means even the EU Council is discussing waiving intellectual property rights.
Dr Mogha Kamal-Yanni, global health policy consultant at the People’s Vaccine Alliance, told the Bureau: “We’re all fighting for pieces of a small pie. Why not increase the size of the pie so everyone can get a fair slice?”
Critics from the pharmaceutical industry have argued there is no spare manufacturing capacity, either in approved factories or in trained technicians, so suspending vaccine patents would not increase supply.
Pfizer told the Bureau that those calling for IP waivers “disregard the specific circumstances of each situation, each product and each country”. It added: “IP will also continue to play a crucial role long after this pandemic is over, to ensure that the world is prepared with innovative solutions for future global health crises, in addition to other pressing healthcare needs.”
Counting on Covax
The difficulty in securing supply of the vaccine will leave many poorer countries dependent on Covax, an organisation created in April 2020 to provide “innovative and equitable access to Covid-19 diagnostics, treatments and vaccines”. It is coordinated by WHO, the Coalition for Epidemic Preparedness Innovations and GAVI, the international vaccine alliance.
Covax has a target of delivering 2bn doses globally, including at least 1.3bn for 92 low- and middle-income countries, by the end of 2021. This would be enough to inoculate 20% of each countries’ population – prioritising health workers, the elderly and those with underlying medical conditions – although that target has been criticised as inadequate to deal with the pandemic.
It has negotiated advance deals for these 2bn doses. However, Duke University analysts believe that the doses can only be delivered this year as planned if the Serum Institute can make all 900m doses ordered as “options”, which they judge unlikely given the company’s publicly stated capacity and extant orders. The analysts estimate instead Covax will provide between 650-950m doses, split between 145 nations – including some of those with enough confirmed deals for vaccines to inoculate their citizens several times over.
“The problem is GAVI has never worked in a situation where they’re competing with rich countries for vaccines,” said Prabhala. “They’ve never been in a situation where they are trying to supply highly, highly sought after vaccines to countries in developing countries and in the West.”
The Bureau understands that Covax is relying on a legally binding agreement with the Serum Institute to deliver all of its optioned doses, and that its figures do not include doses donated by other nations.
Although many countries entitled to Covax vaccines have already arranged other deals for more than enough doses, uncertainty over delays mean wealthy nations including Canada and New Zealand have opted to receive Covax vaccines in the first wave, rather than wait for poorer countries to receive theirs first.
Covax told the Bureau: “Nothing like COVAX has been attempted before, however we do know what would happen without it. As we saw in the 2009 H1N1 pandemic those countries without the ability to pay would be left with no vaccines, the best route out of this pandemic, potentially for a year or more after the first wealthier countries. We are now well on track to bring down this lag to a couple of months.”
In January, Cyril Ramaphosa, president of the African Union, announced a deal for 270m vaccines from multiple suppliers, and suggested the continent could not rely on Covax alone.
A fairer way forward?
Experts differ on the solutions to the vaccine supply crisis. The WHO has asked manufacturers to prioritise supplying Covax and urged countries ordering doses beyond their needs to donate – but that looks increasingly politically unpalatable as countries experience delays in supply.
Covax has only recently set up a mechanism for donation and, so far, only Norway, which has recorded fewer than 600 Covid-19 deaths, has agreed to donate supplies at the same time as rolling out their national vaccination plan. Canada will give up to CA$5m funding to this donating mechanism, but cannot commit to a timeframe of when it will begin handing over vials.
There are fragmented attempts at donation outside this mechanism. The EU, rowing back from earlier proposals for regular donations to Covax, has agreed to send vaccines to inoculate health professionals across Africa and the western Balkans. Australia and New Zealand have similar plans to sell or donate to neighbouring countries in the Pacific, Southeast Asia and Polynesian islands.
According to the Times, the UK’s health secretary Matt Hancock acknowledged that the 400m doses his department had ordered were “more than the UK population needs” and said the government would be generous while also completing its vaccination programme.
Some campaigners believe the WHO is foolish to think asking countries to donate is a good solution. “I think it’s honestly the most ridiculous, most unworkable … most problematic solution I’ve ever seen,” said Prabhala. “I just don’t understand how anyone in this moment could justify donating vaccines that they have, and getting away with it.”
A deadly and destructive delay
Without equal access to vaccines, there are fears many lower-income countries will not have enough stock to inoculate key populations, including healthcare workers, in 2021. On the ground, health workers are struggling. “The situation is very tense,” said Ireen Mutombwa, national disaster management co-ordinator at the South African Red Cross. “Everyone’s life is at risk, especially when you are someone who is involved in working with the community.”
Scientists are also concerned that allowing the virus to thrive unabated in some countries could lead to greater risk for all. “The more circulation there is, the more opportunity there is for the virus to mutate,” said Dr Marie-Paule Kieny, a virologist and director of research at Inserm. Mutated variants could result in more direct deaths in under-vaccinated countries, and may potentially make vaccines less effective over time.
The global economic cost could be vast. A study by RAND Corporation estimated that failure to ensure equitable Covid-19 vaccine allocation could cost the global economy up to $1.2tn a year. (Another study has put the figure even higher, at more than seven times that amount.) Even if wealthy countries vaccinated their populations, they could still lose around $119bn a year if the poorest countries are denied a supply, RAND’s modelling showed.
“If you ask a random person on the street, they would never think we were in any way dependent economically on low-income countries,” Marco Hafner, lead author of the study said. But because wealthy countries rely on global trade links, economic slowdown in poorer nations caused by pandemic restrictions will have a knock-on effect across the world.
“[There are] true economic incentives to provide equitable access to everyone, rather than just seeing this as some sort of act of charity,” Hafner said. “If you compare the costs of [funding Covax] to the benefits, just for wealthy nations, it’s kind of peanuts.”
“Governments are realising that this mantra, ‘nobody’s safe until everyone is safe,’ that they have been saying but then doing the opposite is true, they are in danger,” Kamal-Yanni said. “The mutations mean now rich countries realise they can’t just vaccinate their own people.”
Back in the UK, Senam and his two brothers are hoping to go to Ghana for Christmas, once they’ve been vaccinated. It seems unfair to them that they will likely receive the jab before their more vulnerable father.
“It’s very frustrating,” Senam said. “You see in the news at the moment these fickle bickerings between the EU and AstraZeneca: ‘me, me, me’. It just demonstrates the selfishness of the Western world.”
Reporters: Madlen Davies and Rosa Furneaux
Desk editor: Chrissie Giles
Global editor: James Ball
Investigations editor: Meirion Jones
Production editor: Frankie Goodway
Impact producer: Ben du Preez
Fact checker: Alice Milliken
This article is part of our Global Health project, which has a number of funders including the Bill & Melinda Gates Foundation. None of our funders have any influence over the Bureau’s editorial decisions or output.
Header image: A queue at a vaccine clinic in Mumbai, India. Credit: Satish Bate/Hindustan Times via Getty Images