The world has failed at vaccine equity. Will 2022 be different?

On December 4, 2020, a 90-year-old grandmother in the United Kingdom became the first person in the world to receive a vaccine proven to be highly effective against COVID-19, kicking off a rollout of inoculants developed with unprecedented speed under dire circumstances in high-income countries across the globe.

Two and half months later, on February 24, the first vaccines shipped under the COVAX initiative, a World Health Organization (WHO), GAVI vaccines alliance, and Coalition for Epidemic Preparedness Innovations (CEPI) mechanism that sought to coordinate simultaneous distribution to both wealthy and poor countries, arrived in Accra, Ghana.

Public health officials warned at the time that an equitable vaccine rollout – through COVAX, regional organisations, and bilateral donations – was essential to preventing mutations of dangerous variants that would prolong the pandemic, and potentially evade vaccines.

As 2022 approaches, with nearly nine billion vaccine doses administered worldwide, public health experts say goals of global vaccine equity have fallen woefully short. Not only has ramped-up vaccine production failed to address shortages in low-income countries, but there remains a long way to go in addressing the myriad challenges related to getting vaccines from tarmacs in low-income countries into residents’ arms.

Meanwhile, the emergence of the Omicron variant, which some widely-used vaccines appear less effective against, could cause even wider upheaval in global supply and delivery.

“By virtually every measure, global vaccine distribution and equity have been an abysmal failure and a deep moral crisis,”  Lawrence Gostin, the director of the O’Neill Institute for National and Global Health Law at Georgetown Law, told Al Jazeera. “I think that’s unquestionable.”

The COVAX scheme initially aimed to achieve a 20 percent vaccination rate in all countries in the world by the end of 2021. The World Health Organization later set a target of 40 percent vaccination rates in all countries.

But just five nations in Africa are expected to hit the 40 percent goal, with the majority of countries on the continent falling far below the 20 percent mark.

As of November, the median vaccination rate of populations in 92 countries identified by COVAX as the most in need of donations – the vast majority in sub-Saharan Africa – was just 11 percent, according to data compiled by COVID GAP, a monitoring initiative launched by Duke University and the COVID Collaborative, a grouping of public health experts.

In contrast, most high-income countries have fully vaccinated more than 50 percent of their populations, and several have administered booster doses to more than 20 percent of their populations, according to Our World in Data.

While vaccine production over the last year has scaled up to a level where it is close to being able to address the global demand, the situation remains precarious due in no small part to constraints related to technology sharing, supply chains, and the uncertainty surrounding the Omicron variant, experts and advocates say.

In a November report, COVID GAP found that G7 countries, the informal grouping of the world’s most advanced economies, and European Union countries are projected to have in excess of 834 million high-quality vaccine doses by the end of the year, even when accounting for providing boosters to 20 percent of the population and rollouts to children.

Meanwhile, when accounting for planned deliveries, they projected the world would be about 650 million doses short of reaching the 40 percent goal by the end of the year.

The COVID Gap report was released days before the Omicron variant was first identified in Southern Africa. Its rapid spread around the world has seen governments push for faster and wider booster campaigns, with early studies showing some jabs, notably the Pfizer and Moderna mRNA vaccines, appear to give high protection against Omicron infection only after a booster has been administered.

“We’re now at a point of having more than a billion doses a month of vaccines being produced, but it’s a slow trickle still to get to low-income countries and lower middle-income countries,” Dr Krishna Udayakumar, founding director of the Duke Global Health Innovation Center, told Al Jazeera. “So we have not solved the supply challenge by any means, but we are closer to solving it than we ever have been.”

But, he added, supply is only part of the issue.

“Looking forward to 2022 I think the entire game is really going to be about vaccination. So how do we get from airports to arms? How do we convert vaccines to vaccinations?” he said.

“I think we are woefully under-resourced and under-prepared for that … There’s good progress to build from but much, much more work to do and financing gaps in the billions if not tens of billions of dollars.”

‘We’re not there yet’

Vaccine hoarding by wealthy countries, stalls in development and approval of some promising vaccines and other production hiccups, notably a months-long halt on exports from India’s Serum Insititute, a key COVAX provider, led the initiative to more than halve its target of delivering two billion doses in 2021, 1.3 billion of which were to go to the 92 countries considered to have the highest need.

As of December 17, COVAX has shipped 610 million vaccines of a targeted 800 million.

While the WHO has encouraged donations to go through COVAX, several countries have donated both through the scheme and directly to countries, raising questions over whether geopolitics has taken precedent over need.

China, which has been opaque in its vaccine deliveries, has generally favoured donations and sales to countries in Latin America and Asia, according to Bridge Beijing, which tracks Chinese donations. Countries on the African continent have received 113 million of the more than 1.2 billion vaccines China has distributed internationally, with 50 million of those going to Morocco.

Benjamin Schreiber, who leads country vaccine readiness and delivery for UNICEF, which organises the international transport for COVAX, said he expects vaccine supply for low-income countries to remain limited at least into the first few months of 2022, adding that vaccine donations from wealthy countries will remain essential.

“People say supply is solved. And now it’s all about demand. But it’s not. We’re not there yet,” he told Al Jazeera.

“We still have countries that only have a small fraction of their health facilities providing vaccines … We are far from yet having offered each person who needs the vaccine a vaccine.”

Beyond supply shortages, Schreiber said distribution in low-income countries – hindered by weak healthcare systems, equipment shortages, political constraints and social inequity – remains a challenge.

Amid an end-of-year surge in COVAX deliveries, Schreiber said many low-income countries are struggling to find cold storage to keep the vaccines, underscoring the need for increased support going into 2022.

As of November 10, COVID GAP data showed that the 92 highest need countries in the world were administering about 75 percent of their total supplies, a phenomenon blamed on a mix of factors including little pre-notice before deliveries, receiving donated vaccines that are close to their expiration date, difficulty in delivering the vaccines to high-need areas, and hesitancy among some populations.

Global health officials have also warned of an impending syringe shortage.

Schreiber said UNICEF has identified about 20 countries requiring an “all hands on deck” approach in the coming year, adding that leading funding needs include money to buy “cold chain” equipment essential to storing and transporting many vaccines, as well as funds to train and recruit staff, develop infrastructure, and aid public information campaigns.

In October, the World Health Organization said it would need $23.4bn through next September in its broad campaign to address vaccine inequity, support testing and treatment, and to achieve a 43 percent vaccination rate in the countries with the greatest need.

That money must also go towards addressing vaccine hesitancy in low-income countries, similar to that seen in the US and Europe, said Dr William Moss, the executive director of the internal vaccine access centre at Johns Hopkins Bloomberg school.

“There’s certainly misinformation, disinformation that has fuelled vaccine hesitancy to levels, I would say, in sub-Saharan Africa that we never saw before with childhood vaccines,” he told Al Jazeera.

However, he noted, raising funds for things like supporting healthcare infrastructure and public information campaigns has historically posed unique challenges.

“That is a longstanding common problem in these settings, where commodities are very easy to donate, whether it’s bed nets or vaccine doses. You can count them. You can say we donated all these,” he told Al Jazeera.

“It’s a lot harder to get funds donated to invest in the primary healthcare system, the vaccine delivery chain, or the transportation. All those are less appealing to outside donors and funders, but they’re critically important.”

‘Inequity 2.0’

Looming over the intertwined issues of vaccine supply and delivery is the Omicron variant, a better understanding of which could prove an “inflection point” in the push for global vaccine equity, said Duke’s Dr Udayakumar.

If vaccines need to be redeveloped, “then we’re going to be back into a seriously supply-constrained scenario”, he said. Meanwhile, the increased need for boosters poses its own complications.

“We’re seeing more booster doses per day in high-income countries than we are first doses in low-income countries,” he said.

 

In a recent interview with the Associated Press news agency, CEO of the Gavi vaccine alliance Seth Berkley said that an increase in people receiving boosters in wealthy countries, and a shortening of timelines of when boosters are recommended, “means that we could see in the future a situation where those vaccines are not available for developing countries”.

“We also are beginning to see donors not wanting to donate their doses as fast as they might have because of the uncertainty now of where we are,” he said.

The concerns have led to renewed calls by rights groups for vaccine manufacturers to share technology more broadly.

Human Rights Watch recently highlighted a list identifying more than 100 companies in Africa, Asia and Latin America that health experts say have the capacity to make mRNA vaccines like those produced by Pfizer and Moderna, which have shown promising results – when boosters are administered – in protecting against Omicron infection. Those vaccines are currently only manufactured in Europe and North America.

Georgetown’s Gostin said boosting global manufacturing outside of current hubs should be prioritised in the coming year.

“Low-income countries always know that donations come too little too late,” he said. “And they’re fed up of begging hat in hand for charitable donations. They want the power to make the vaccines themselves.”