Poorer countries might not get Covid-19 vaccinated until 2023

This inequality is baked into the vaccine manufacturing process.

High-income countries have purchased 53 percent of the Covid-19 vaccine supply to date, and low-income countries, just 9 percent, according to Duke University’s Global Health Innovation Center. This is why a country like the US is close to vaccinating half the population with one dose while the rate in a place like Guinea is less than 1 percent and not budging.

Our World In Data

If these glaring inequities in vaccine access continue, it will take at least two years for the world’s poorest countries, who couldn’t compete for early doses of vaccines, to immunize 60 percent of their populations.

This means we’re on track for a long period where people in rich countries enjoy the benefits and safety of being fully immunized, while people in poorer countries continue to get sick and die from the coronavirus.

“That’s not just unconscionable, but it also is very much against the interests of high-income countries,” said Georgetown global health law professor Lawrence Gostin. With the virus continuing to circulate, and variants picking up pace around the world, outbreaks in even the poorest countries will pose a threat to the world.

To learn more about the root causes of the problem, and how inequalities are baked into the vaccine manufacturing system, check out our new Vox video and read on.

Wealthier countries had a home-court advantage to develop vaccines

It’s not an accident that many of the world’s first-approved Covid-19 vaccines — from companies like Pfizer, AstraZeneca, and Moderna — were developed and rolled out in high-income countries. As the pandemic took hold last year, wealthier nations — including the US, UK, and EU block — began making deals with the pharmaceutical companies that were developing Covid-19 vaccines, which also happened to be headquartered within their borders.

These bilateral deals involved governments essentially giving the companies billions of dollars to speed up research and development in exchange for priority access to vaccines, should they prove to be effective. But the deals also pushed poorer countries, which didn’t have the resources to pre-purchases millions of doses of vaccines that might not even get approved for market, further down the access line.

In May 2020, for example, the US government gave AstraZeneca $1.2 billion for 300 million doses — a Covid-19 vaccine that still hasn’t even been approved in the US. That was just one deal of many. By January 2021, rich countries had already pre-purchased 96 percent of the doses BioNTech/Pfizer was scheduled to make for the year, while 100 percent of Moderna’s supply was spoken for. And the EU appears ready to finalize another 1.8 billion-dose deal with Pfizer.

All together, these agreements covered the populations of rich countries many times over in the event that some of the vaccines failed. By March, Canada had secured enough vaccine for five times its population, and the US bought at least double the amount of vaccine it’d need. In terms of doses administered, while high-income countries are home to 16 percent of the world’s population, they’ve doled out 46 percent of Covid-19 vaccine doses. The poorest countries, home to 10 percent of the world’s population, have given out just 0.4 percent of doses, according to Our World In Data, and lower-middle income countries, with 40 percent of the world population, 19 percent of doses.

“[Since] vaccine makers are head-quartered in high-income countries, and [vaccines are] developed there for the most part, many of the ones that made it across the finish line first were from high-income countries, and because of that, they had a home court advantage,” Andrea Taylor, a researcher with Duke Global Health Institute who has been analyzing the deals, summed up.

Vaccine-producing nations have used export controls to hoard supplies

Through this home-court advantage, wealthier countries not only ensured first dibs — they’ve also used export restrictions to control vaccine supplies and doses leaving their borders.

On April 16, for example, the head of the Serum Institute of India — the world’s biggest producer — took to Twitter to ask President Joe Biden to lift embargoes on raw material exports that were hampering vaccine production overseas:

The result of the pressure: The US lifted the restrictions to help speed up production overseas, and vowed to send 60 million doses of the AstraZeneca vaccine to India. India is also now using them to hang on to Covid-19 doses produced there amid a devastating outbreak.

American and British vaccine export bans, meanwhile, have been a source of diplomatic tensions with the EU, which put in place its own export restrictions in March to alleviate supply shortages.

Rich countries undermined Covax, the global group set up to deliver vaccines to the world’s poor

The vaccine hoarding has happened in parallel with an unprecedented multilateral effort to support the development and equitable distribution of 2 billion doses of Covid-19 vaccines to the world’s poorest countries before the end of 2021, called Covax.

The initiative has two parts: a purchasing pool for higher-income countries, and a fundraising effort for poorer countries. By promising to buy a certain number of vaccine doses from manufacturers, countries that join get access to any vaccines that are approved in Covax’s portfolio, while also creating a global market for the shots and driving prices down.

More than 190 countries signed on — including rich ones. “Covax was trying to create a reality — they appealed to the better angels of all countries,” said Saad Omer, director of the Yale Institute for Global Health.

But the bilateral deals took a lot of power away from Covax. Rich countries “want to have it both ways,” Gostin said. “They join Covax so they could proclaim to be good global citizens, and at the same time rob Covax of its lifeblood, which is vaccine doses.”

Rich countries also didn’t fund Covax’s purchasing pool to the levels the group called for. And for the majority of its supply, Covax also relies on India, which, again, is currently restricting exports.

The result: Covax, according to Duke, has only delivered about 1 in 5 of the doses that were expected by end of May.

There are other bottlenecks even waiving patents can’t fix

Some have suggested Covid-19 vaccine-makers should waive their patents, making it possible for more manufacturers to come online and produce vaccines. But that’s only part of the solution to vaccine inequality, Taylor said. “We know there is manufacturing capacity that isn’t being used.”

That’s because of another bottleneck that’s emerged in recent months. Vaccine makers have been reporting that they’re struggling to access basic supplies needed to safely manufacture vaccines. For example, there have been reports that the filters used in the manufacturing process, and large plastic bags (for lining bioreactors where pharmaceutical ingredients are mixed) have run short. It’s unclear how big this problem is — we don’t have systematic data on global shortages — but many suppliers and even countries have cited these shortages as a reason for delays.

Companies can’t just turn to anybody to bolster their supplies — they can only use qualified companies that meet the global standards set by regulators like the US Food and Drug Administration. These suppliers sell products that have been vetted through studies proving their plastic bags, for example, don’t leak toxins into vaccines or cause allergic reactions.

“Those tests take time — it’s months of lab studies and animal studies,” said Matthew Johnson, associate director of the Duke Human Vaccine Institute. So even companies that could pivot to producing the vaccine products in short supply would need to study them and ensure safety.

There’s another problem IP waivers can’t solve: Technology transfer, from one vaccine maker to another, involves sharing trade secrets, knowhow, and even trained personnel. The companies currently making Covid-19 vaccines “might not have 20 to 40 people to send to these other locations” to help new producers get up to speed, Johnson added. So that’s why patents are only part of the hold up.

Vaccinating the world doesn’t need to take so long — rich countries could take action now

Still, it’s not a given that it’ll take years to vaccinate the world from Covid-19. There are ways to speed up the process.

Rich countries could donate more doses to poorer countries — a move global health groups have been calling for for months and one that’s finally happening in response to the crisis in India.

Rich countries like the US and UK could simply start investing more in helping poorer countries respond to the crisis. Omer called for something akin to PEPFAR, America’s global heath program to combat AIDS around the world. (To date, it’s provided $90 billion toward fighting AIDS.)

“It sounds lofty but the cost to everyone, including high-income countries, is huge with each passing month or week where there is transmission going on around the world,” Omer added. “What is happening in India can happen in other large chunks of population and that should concern us all.”