With the World Health Organization’s (WHO) target of 40% COVID-19 vaccine coverage in every country by the end of 2021 looming and the world being completely off-course from achieving it, this blog analyses some of the decisions and factors that underpin our current state of inequitable access to COVID-19 tools, including vaccines and treatments. 

8 December marked one year since Margaret Keenan received the first non-trial COVID-19 vaccine in the world. Since then, 8.24 billion doses have been administered worldwide, but a fraction of these have gone to low- and middle-income countries, with just 6.3% of people in low-income countries having received at least one dose.  

Source: ourworldindata.org/covid-vaccinations

COVID-19 has exposed the fractures and fissures in our global society. Around the world, high-income countries bought up supplies of COVID-19 resources through deals with manufacturers, leaving low- and middle-income countries struggling to access life-saving tools like oxygen, tests, personal protective equipment and vaccines through multiple deadly waves of COVID-19. COVAX â€“ the global procurement mechanism created to supply COVID-19 vaccines to every country in the world – was described by Gavin Yamey of Duke University, who was part of the COVAX design working group, as, â€śa beautiful idea, born out of solidarity. Unfortunately, it didn’t happen…Rich countries behaved worse than anyone’s nightmares.”  

High-income countries used their political and financial clout at the start of the pandemic to secure doses to vaccinate their populations many times over. Now, with the emergence of the Omicron variant, many are doing the same again, with the UK securing 114 million more COVID-19 vaccines to “future proof the Great British vaccination effort.” This nationalistic approach to vaccine procurement and rollout has caused COVAX to suffer vaccine shortages, leading it to provide only around 610 million out of the 2 billion doses it had originally planned to distribute this year and cutting its forecast of deliveries to low-income countries by 25% for 2021 – 2022. The mechanism’s distribution methodology also meant that some high-income countries, such as the UK, were receiving more doses from COVAX than low-income countries, such as Botswana. The UK took doses from the COVAX facility, despite having stock-piled more than enough for its domestic population and being one of the slowest G7 countries to reallocate the doses they promised in Carbis Bay at the G7 this year. In short, high-income countries over-purchase for their populations to the detriment of lower-income countries. For all of the challenges COVAX faces, it is the best existing mechanism to ensure all countries get access to safe, affordable vaccines and is an essential part of the global COVID-19 response. It must be adequately resourced in order to live up to its promise of vaccinating all 190 countries participating in the mechanism, including 92 low- and middle-income countries. 

In the Autumn 2021 spending review, the Government outlined its intent to count reallocated doses as part of the UK’s existing Official Development Assistance (ODA) budget. This is a direct contravention of the Prime Minister’s guarantee in June that the 70 million doses planned for delivery in 2022 will be in addition to the ODA budget. Lack of clarity as to how these doses will be priced could lead to an effective cut of hundreds of millions of pounds from the already shrunk 0.5%  budget for ODA in 2021, and the Government’s accounts would effectively profit from doses originally bought for domestic use.

Reallocating high income country’s excess COVID-19 vaccine doses, whilst critical to the short-term COVID-19 response, is ultimately insufficient and unsustainable as a mechanism to address inequity in access. Both COVID-19 vaccines and newly developed treatments could be manufactured and accessed widely if intellectual property (IP) rights were waived – something campaigners are advocating for through a temporary waiver on the Trade-Related Aspects of Intellectual Property Rights (TRIPS) on COVID-19 health tools and technologies. However, pharmaceutical companies and some rich governments have professed scepticism over the ability of manufacturers based in low- and middle-income countries to produce COVID-19 health technologies, with Moderna chief executive StĂ©phane Bancel saying “You cannot go hire people who know how to make mRNA: Those people don’t exist.”  

A September protest in South Africa calling for a people’s vaccine. 
Source: The People’s Vaccine Alliance, 2021

Yet these manufacturers have proven time and again their advanced and technological abilities, with “extensive experience in large-scale vaccination campaigns”, in the words of WHO’s Director General Dr Tedros Adhanom Ghebreyesus. The need for sharing IP and technology and know-how also extends to newly developed treatments to ensure that low-income countries are not pushed to the back of the queue, as with vaccines. Despite this, the UK and EU continue to impede the waiver, and vaccine-producing pharmaceutical companies have ignored calls to share their life-saving technology and waive their patent rights. While manufacturers in low- and middle-income countries have been held back from beginning production, Pfizer and Moderna have made billions of dollars from COVID-19 vaccine sales. 

Even where there is successful delivery and administration of COVID-19 vaccinations in lower-income countries, the UK has cast doubt on their safety through highly controversial and discriminatory travel and quarantine restrictions. Under the rules, people fully vaccinated with Oxford/AstraZeneca, Pfizer/BioNTech, Moderna or Janssen shots in the US, Australia, New Zealand, South Korea or an EU country would be considered “fully vaccinated” and not have to quarantine, yet people with the same vaccines administered in Africa, Latin America or some South Asian countries would be considered “not fully vaccinated” and forced to quarantine. Not only is this policy discriminatory and scientifically baseless, there are serious worries it could exacerbate existing vaccine hesitancy around the world. Ifeanyi Nsofor, a doctor and chief executive of a public health consultancy in Nigeria, responded: â€śThe UK is one of the largest funders of the COVAX facility and now the UK is saying that the same vaccines they have sent, will now not be considered. It’s sad, it’s wrong, it’s discriminatory.”  

By refusing countries the possibility to produce vaccines and treatments and not giving low-income countries’ vaccine rollouts the same recognition as that of high-income countries, the UK is perpetuating harmful stereotypes about the capacity and ability of health and science facilities in these countries, as well as negatively impacting their economies and arbitrarily inconveniencing travellers. The detection of the Omicron variant by South African scientists has also led to travel bans imposed on countries across southern Africa – some of which currently have no detected cases of the variant – by higher-income countries including the UK, US, and Israel. Scientists in South Africa have warned that this decision could threaten future willingness to share information, as well as weakening global solidarity.  

Vaccine hesitancy is a complex and sensitive issue and decisions by major governments could have knock on effects. Chika Offor, CEO of the Vaccine Network for Disease Control in Nigeria, highlighted to RESULTS UK’s National Conference that mass COVID-19 vaccination is being hampered by the spread of misinformation (amongst other factors like a lack of available doses), with claims that the vaccine affects fertility. She calls for a holistic approach to tackle vaccine inequity in Nigeria, which has a population of over 200 million people with just 5 million vaccine doses administered.  

Mistrust of vaccines developed in Western countries in Africa is often rooted in the history of unethical Western medical practices and an Africa CDC 15-country study earlier this year found that approximately 43% of respondents believed that Africans were being used as guinea pigs in vaccine trials. However, instead of engaging with the complexity of historical mistrust and exclusion, pharmaceutical companies and high-income country governments are using vaccine hesitancy as an excuse to divert attention from their own role in creating and sustaining inequitable access to COVID-19 vaccines. In September this year, Pfizer CEO Albert Bourla claimed that there will be such an abundance of COVID-19 vaccines next year that vaccines hesitancy will become the limiting factor in global vaccination, arguing that “the percentage of hesitancy in those [low-income] countries will be way, way higher than the percentage of hesitancy in Europe or in the US or in Japan.” 

In reality, studies have proven that vaccine hesitancy is higher in rich countries than in poorer countries. Yet hesitancy is being wheeled out as a justification for not accelerating dose reallocations or scaling up domestic manufacture of vaccines. Bourla’s comments were likened to claims made during the Aids crisis that Africans wouldn’t be able to take antiretrovirals because they couldn’t tell the time, and Director of the Africa Centres for Disease Control and Prevention, John Nkengasong, surmises that: “Vaccine famine not hesitancy is our major challenge in Africa”.  

With a death toll of over 5.25 million and deadly third waves covering much of the world, it is time to call out insidious justifications for inaction on dose sharing and the TRIPS waiver for what they are: excuses grounded in racist narratives that place the blame for vaccine inequity on those suffering the most adverse effects of it. 

COVID-19 is a global crisis, requiring a truly global solution rooted in principles of equity and partnership. High-income countries such as those that make up the G7 must, as a start:  

  • Ground pandemic response and strategic priorities in the needs identified by low- and middle-income countries whose access to COVID-19 tools, including vaccines and treatments, continues to be been impeded. 

  • Support a temporary TRIPS waiver to facilitate scaled-up production of COVID-19 tools and expediate their manufacture around the world by sharing critical information – including production know-how, technology and trade secrets – via pooling mechanisms such as the Medicines Patent Pool and the COVID-19 Technology Access Pool. 

  • Finance the Access to COVID-19 Tools Accelerator to enable COVAX to live up to its promise, and strengthen global health systems to ensure future pandemic preparedness and response is informed by the pitfalls which have undermined COVAX’s ability to deliver on its ambitions to-date. 

  • Publish transparent, ambitious timelines for existing dose reallocation pledges as a short-term solution to the uneven global distribution of vaccines, and commit to setting the ODA price of these doses as close to $0 as possible. 

The global COVID-19 response to-date should weigh heavily on high-income countries’ collective conscience. Profit, prejudice and privilege cannot continue to get in the way of an equitable global response to the pandemic. Only when meaningful actions begin to be taken will a just, equitable and ultimately life-saving response to the COVID-19 crisis be in sight. 

If you want to get involved in campaigning on COVID-19 equity, check out our October action, calling for a TRIPS Waiver, and knowledge and technology transfer for vaccines and therapeutics. You can also get involved with the RESULTS Grassroots network of campaigners and support the work of our network of allies working with the People’s Vaccine Alliance.