Why are rich countries still monopolizing Covid-19 vaccines?

Half the world has gotten a Covid-19 shot. Yet the vaccination rate in some countries is less than 10 percent.

About half of the world’s population has received at least one dose of a Covid-19 vaccine. The 7 billion shots administered so far are a massive, record-breaking public health achievement.

But more than 50 countries have vaccinated less than 25 percent of their populations. Vaccines aren’t distributed equally: Rich countries have about twice the population of low-income countries, yet they have received about 50 times as many Covid-19 vaccine doses, according to an October report from the People’s Vaccine Alliance. The countries with the lowest incomes generally have the lowest Covid-19 vaccination rates.

This vaccination gap is one of the key reasons the disease is still killing more than 6,000 people per day. It’s putting a strain on health systems in countries with already limited resources, fueling hospitalizations, deaths, and economic harm.

This isn’t just a humanitarian crisis, it’s a global threat to the fragile progress already made in the pandemic. The longer the pandemic rages, the greater the chances of a dangerous mutation in the coronavirus that causes Covid-19, which could then spread around the world.

Tim Ryan Williams/Vox

Based on current trends, many countries will not have a majority of their people immunized against Covid-19 until well into 2022. Some of the poorest countries may not reach that point until 2023. So why exactly has the pace been so agonizingly slow?

Hoarding and production constraints are part of the story, but so are less-appreciated obstacles like clogged supply chains and breakdowns in communication between vaccine makers, donors, and recipients. These problems are solvable, however, and countries like the United States are uniquely positioned to contribute.

How to speed up international Covid-19 vaccine distribution

The World Health Organization has so far granted emergency approval of eight Covid-19 vaccines for international distribution. Many of these vaccines remain highly effective at preventing hospitalizations and deaths, including from highly transmissible variants of the virus that causes Covid-19.

Yet even in the best of circumstances, getting people vaccinated is a huge logistical challenge. The US, one of the world’s largest Covid-19 vaccine producers, has struggled with spoiled doses, confusing vaccination guidance, and misinformation. The US is still trying to convince holdouts to get their shots, despite the fact that most Covid-19 hospitalizations and deaths in the US are occurring among the unvaccinated.

“Even for the richest countries in the world, this is a really big lift,” said Lily Caprani, head of advocacy for health and pandemic response at Unicef, the world’s single largest vaccine buyer. “It’s been a real monumental, historic effort to get these rolled out.”

The Covid-19 pandemic has also wreaked havoc on global shipping and supply chains as economies rebound, demand for goods increases, and shipping companies cope with bottlenecks like crowded ports and trucker shortages. Vaccines, with their delicate handling requirements, as well as vital components like syringes, vials, and stoppers, have been particularly vulnerable to these disruptions.

All these hurdles get higher in countries that are unable to produce their own Covid-19 vaccines and have weaker health care systems.

If you add the stark inequities in global Covid-19 vaccine distribution, you end up with a deadly combination. In regions like sub-Saharan Africa, health officials are still struggling to get their hands on vaccines to protect workers on the front lines of the pandemic — while in the US, some adults are getting booster doses and shots are now available to children as young as 5.

The gaps in immunization go beyond vaccine production. “It’s not ‘supply’ in the sense that the world has produced enough vaccines to be able to protect at least front-line health care workers,” Caprani said. “It is a problem about how they are distributed and shared, which is extremely unequally.”

Misinformation and hesitancy around vaccines are problems in developing countries too. However, the unmet demand for Covid-19 vaccines is vastly greater. “There’s far more people that desperately want to get one that can’t get one,” Caprani said.

In September, President Biden set a goal of helping every country vaccinate 70 percent of its people by the fall of 2022. The US has pledged to donate 1.1 billion doses to other countries, and other wealthy countries have pledged hundreds of millions more. But deliveries so far have generally fallen drastically short of pledges.

Tim Ryan Williams/Vox

To meet that 70 percent target, the pace of vaccination in low-income countries would have to increase to 19 times its current level, according to the Kaiser Family Foundation. This will require wealthy countries to produce and donate more vaccines, and to hugely scale up the infrastructure needed to deliver them.

Here are several ways countries with high vaccination rates can bolster the rollout elsewhere.

Demand transparency and communication from pharmaceutical companies

Countries that are counting on Covid-19 vaccine imports, whether through donations or purchases, are often in the dark about when and where rich countries and pharmaceutical companies will ship their doses, Caprani told Vox. Some donor countries have also favored certain low- and middle-income regions over others in donations so far.

“We need to know where are the doses, who made them, which factory, when are we going to get them,” she said. “Otherwise it slows the whole thing down.” Without this information, governments have a hard time getting personnel in place to administer vaccines and getting people in line to receive them.

For instance, the United Kingdom donated 9 million Covid-19 vaccine doses to low-income countries this summer, but several of the countries receiving them warned that they would not be able to distribute most of them in time. Many vaccines have a limited shelf life, and donated vaccines are often close to expiration. In May, Malawi was forced to discard 20,000 doses of Covid-19 vaccines because the country’s health system could not administer them before the shots expired.

Donate resources for the rollout, not just doses

Without robust health care systems in place, vaccination efforts can get even more expensive for developing countries as they aim to protect everyone from major cities to far-flung rural areas. “They need to recruit an army of vaccinators. They need to train them. They need to pay them. They need to equip them with PPE,” Caprani said.

Prior to the pandemic, the World Health Organization estimated that about half of the vaccines distributed around the world go to waste, largely due to problems with the cold chain. Many Covid-19 vaccines are particularly fragile, with strict cold-storage requirements. That means low-income countries either need to invest in large-scale cooling infrastructure or they are limited to vaccines that are more tolerant of higher temperatures.

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Fixing all this takes money. Unicef launched the Access to COVID-19 Tools (ACT) Accelerator program to bridge the pandemic-response gap between wealthy and developing countries. Officials say the program needs an additional $23.4 billion to deploy a suite of tactics in developing countries including testing, treatment, and vaccines. According to Unicef, these measures could avert more than 5 million potential additional deaths and save the global economy more than $5.3 trillion.

That’s why Caprani argues wealthier countries should see their contributions less as donations and more as investments. “It’s a damn good investment,” she said.

Lift restrictive export bans

Countries that have pledged to donate vaccines are also struggling with their own epidemics. That’s created tension, and many vaccine-producing countries have decided to limit or ban exports. India, the world’s largest vaccine manufacturer, was initially expected to contribute Covid-19 vaccines to international vaccination efforts, but after a devastating wave of infections spurred by the delta variant of the coronavirus, India stopped donating and exporting vaccines, and even began importing them. That created a rupture in vaccination campaigns across other countries.

The US, the European Union, and others have also imposed export restrictions on critical supplies used to make vaccines, like chemicals and glassware. Many of these countries have made major strides in vaccinating their people, and advocates argue that it’s time for them to free up doses and raw materials for others to access. The WHO, and even some political leaders like French President Emmanuel Macron, have called on countries to drop export limits on vaccines and related supplies.

Macron said in March that the EU should block exports of vaccines until manufacturers had fulfilled their contracts with European countries. But in May, he told the US to take the opposite stance and “put an end to export bans not only on vaccines but on vaccine ingredients, which prevent production.”

In April, Adar Poonawalla, the head of India’s Serum Institute, the world’s largest vaccine manufacturer, publicly asked Biden to lift export controls on raw materials for vaccines.

Increase production

Initial estimates suggested that 10 billion to 11 billion doses would be enough to vaccinate the world’s 5 billion adults against Covid-19. But it’s becoming clear that more doses will be needed.

Several Covid-19 vaccines have shown that their protection can wane over time at least somewhat, so boosters may be necessary, particularly for older adults and people with preexisting health conditions. And some doses have gone to children, who are at lower risk than adults but can still experience severe Covid-19 and spread the coronavirus to some extent.

“Even in the United States, where most of the doses have been of the most effective vaccines, we’re already giving third doses,” said Chad Bown, a senior fellow at the Peterson Institute for International Economics who has been studying Covid-19 vaccine supply chains.

The urgency of booster shots is even higher “if you look at China or the places around the world that have administered the Chinese vaccines, which are less potent and have a greater need for additional dosage,” Bown added. “Arguably you need twice as many [doses] as we were thinking.”

Increasing the number of vaccine doses would also alleviate worries among vaccine-producing countries over whether they have enough doses for their own citizens as they fulfill their pledges abroad. So scaling up manufacturing even further is crucial to getting more Covid-19 vaccines to low-income countries.

This is one area where the US government can make an especially big impact as it procures vaccines from US-based suppliers. Using its leverage as a regulator and purchaser, the government could set terms for companies like Johnson & Johnson, Moderna, and Pfizer that spur them to invest even more in ramping up output. Moderna in particular has been accused of limiting much of its vaccine sales to wealthy countries, though the company says it is coping with its own production limitations and is not the only company facing criticism of vaccine deals.

“As policymakers, we should be writing contracts with these terms that say you need to double your production, triple your production of vaccines,” Brown said. That can include financing the construction of new vaccine production facilities and guaranteeing purchases. The government can also pressure manufacturers to sell more doses to low-income countries.

Experts predicted the vaccine gap. They still have a chance to close it.

What’s so frustrating about the vast and persistent chasm in Covid-19 vaccinations is that this was foreseeable, and the world has missed chances to stop these inequities in their tracks.

Covax, a global initiative that aimed to purchase and distribute 2 billion doses of Covid-19 vaccines for countries in need by the end of 2021, has only delivered 400 million doses across 145 countries. The program faced delays in funding, which meant that by the time it was ready to buy doses, most of the available production around the world was already reserved by countries that could afford them — and sometimes pay higher prices. (A large share of the doses Covax distributes are purchases, not donations.)

Joseph Odelyn/AP

While Covax was constrained by money and vaccine supplies, countries like the US are building up a massive vaccine stockpile. One recent estimate found that wealthy countries are on track to have 1.1 billion excess Covid-19 doses by early next year, very few of which are allocated for immediate donation. “A surplus of [hundreds of millions of doses] is so staggering that not sharing it with the world starts to look morally unjustifiable,” wrote Vox’s Sigal Samuel in May.

In a recent editorial in the Telegraph, Covax officials argued that the program should take priority with vaccine purchases they have negotiated with pharmaceutical companies. “Countries that have advanced sufficiently in their national programs should swap their place in manufacturers’ lines with Covax so that they can be put to work protecting the most vulnerable people in the world,” officials wrote.

If rich countries keep putting their own interests above the interests of the rest of the world, the world will continue to face a two-track pandemic, with some countries starting to return to normal while others remain under the threat of devastating outbreaks.

“We have not passed the test on solidarity,” Caprani said. The Covid-19 vaccination campaign may be a scientific triumph, she went on, but it has only served to “highlight and exacerbate the inequalities in the world — which is a sad indictment that even when it’s in our self-interest, we still as a world have failed to achieve that.”

And while pledges to donate vaccines are an important stop-gap, the world needs a more permanent solution to global health inequities, according to Georgetown University health policy researchers Ngozi Erondu and Renu Singh.

“Equitable vaccine access will come when there is equitable vaccine production,” they wrote in the Conversation. “There must be a particular emphasis on production capacity and increased access to technologies and knowledge transfer.”

There is still time to improve the global Covid-19 vaccination campaign, but speeding up further will require more forethought, planning, and generosity than has been shown to date. Covid-19 has shown itself to be a disease that does not respect national boundaries. Containing the pandemic wherever it lurks is in everyone’s interest.