Nationalism and the accumulation of vaccines continue to contribute to the protracted COVID-19 pandemic, threatening the global plan to distribute and distribute COVID-19 vaccines fairly and effectively. Both phenomena reveal the current limits of global health governance and the failure of even well-resourced countries to understand why vaccination is also in their interest.
Necessary, but not enough
There remains a large discrepancy in the proportion of people vaccinated against COVID-19 when comparing low- and high-income countries: Since the beginning of 2022, more than 80 percent of the population in high-income countries has been vaccinated compared to less than 10 percent of the population in low-income countries. This inequality in vaccination status reflects inequalities in access to vaccines.
One mechanism set up to prevent this unfair access to vaccines worldwide was the Global Vaccine Access to COVID-19 (COVAX), a multilateral vaccine delivery mechanism led by Gavi, the Coalition for Innovation in Preparedness for Epidemic (CEPI) and the World Health Organization (WHO). COVAX was created to provide access to vaccines against COVID-19 to people worldwide and to function as a mechanism through which governments and key stakeholders work together to keep the pandemic under control.
COVAX supports the supply and delivery of COVID-19 vaccines to 92 low- and middle-income countries, while supporting orders for more than 97 higher-middle-income countries; an effort of this ambition and scale has been unprecedented in global healthcare. By early 2022, COVAX had distributed more than one billion doses of vaccine to 148 nations, mostly in low- and low-income countries, revealing that the participation of higher-middle-income and high-income countries was rhetoric rather than reality. . .
So, we have to ask, if one of the main missions of COVAX is to prevent serious differences in global vaccination levels, what is behind the persistent differences we see today? And is COVAX really a disappointment – even though it distributes more than one billion doses of the vaccine to 148 nations, mostly in low- and low-income countries?
In fact, many politicians, politicians and advocates have been quite critical of COVAX, its delivery system, its communication with governments and the public, and its governance. Many argue that COVAX’s goal was naively ambitious without securing funding and delivering vaccines; some argue that COVAX did not place its burden on intellectual property waivers and was not transparent about its contracts with pharmaceutical companies.
However, the nationalism and the accumulation of vaccines that we have seen over the last year and a half signal problems beyond COVAX. Nationalism and the accumulation of vaccines occur when governments sign agreements with pharmaceutical manufacturers to carry out vaccinations and increase supply in their own country, including ensuring supplies far beyond the projected needs of their populations. The goal is to stockpile and vaccinate the nation as soon as possible, despite the distribution restrictions that this may impose on the rest of the world.
We believe that this global protectionism has undermined COVAX’s mechanism and efforts for equitable distribution. If the founders of COVAX are responsible here, it is too much faith in the solidarity of rich countries with poorer countries in a global pandemic, even when such solidarity would benefit the citizens of rich countries. In this respect, his critics are partly right. Apparently CEPI, WHO and Gavi and their leadership expected too much from rich countries; they expected too much funding, too much logistical support, too much willingness to wait in line. Moreover, many critics of COVAX underestimate or disregard its very real contribution to helping vaccination in the world, even if not in a strong way based on justice.
One of us, Yu and colleagues, assessed the fairness of the distribution and distribution of COVID-19 vaccines in 148 countries and territories participating in COVAX. The study, just published in Bulletin of the World Health Organization, found that despite the challenges it faces, COVAX is the main single source of assistance in balancing global inequalities in the distribution and distribution of COVID-19 vaccines. We also found that countries and territories with low gross domestic product (GDP) per capita benefited more than countries with higher incomes in terms of how many vaccines they received from COVAX. This benefit increased even more when we adjusted according to the country’s population aged 65 and over.
In other words, to vaccinate the world, COVAX was needed, but not enough. Its failures are the failures of the global health paradigm, which for too long relied on charity rather than solidarity, elevating the concept of response to sustainability. COVAX alone would probably never be able to raise sufficient resources and mechanisms for the equitable distribution of COVID-19 vaccines worldwide; in the world of health, no such expansive effort has ever achieved such a broad goal or reached so many people so quickly – neither for HIV / AIDS, nor for malaria, nor for tuberculosis, nor for polio, nor even for smallpox, the only disease the world has ever successfully wiped out.
So how can we do better next time?
We believe that indeed allowing unjust access to vaccines – for COVID-19 or for any threat to public health – is beyond what is possible for COVAX in its current role and efforts. Leaders in high-, middle- and low-income countries need to think more broadly. States, especially high-income countries, must also comply with their existing obligations under the WHO International Health Regulations, in particular the binding obligations of States to “commit to co-operation with each other”.
At their core, these differences stem in part from the fact that many high-income countries see valuable medical technology as a scarce resource for accumulation. Instead, they must not only see them as global public goods, but also acknowledge that it is in their best interest. The global loss of life and economic productivity over the last two or more years must be sufficient evidence of this reality. The fruitful tendency of the virus to create variants and the complete disregard of the national borders of these variants must be the same.
What would such an admission look like in practice?
First, high-income countries must participate in COVAX without also signing exclusive vaccine purchase agreements.
Second, high incomes must guarantee funding for COVAX for a three-year (or longer) period, similar to the replenishment models of the Global Fund and the World Bank’s International Development Association. This is an imperfect model, but one donor country understands it.
Third, nations must support the transfer of intellectual property rights and related technologies to qualified vaccine manufacturers in low- and middle-income countries (LMICs) so that doses of vaccines intended for people in LMICs can be made closer to home.
These few proposals do not constitute an exhaustive list of the legal and structural reforms needed to prevent the next pandemic from creating the same inequalities and injustices shown today. It is clear that the policies and decisions – of COVAX, the WHO and many other actors that make up our global public health and preparedness system – are not working as we have imagined over the years leading up to this pandemic. Fortunately, we know how to do better next time. We have the tools to promote opportunities, justice and global solidarity. And we must do it for the life and livelihood of the people of the world.