A humane way to distribute a COVID-19 vaccine globally
WASHINGTON — In 2003 — when I first engaged with global health issues at the White House — the global distribution of treatments for HIV/ AIDS was in a state of almost complete inequity. While the overwhelming majority of Americans who needed antiretroviral drugs were receiving them, almost no one in Africa was. The world’s poor were at the end of the queue when it came to life-saving medicine. The President’s Emergency Plan for AIDS Relief, initiated by President George W. Bush, dedicated $15 billion over five years to address this deadly imbalance.
The swine flu pandemic of 2009 saw a similar pattern. A small number of wealthy nations bought up all of the vaccine supply and only later patched together small donations to developing countries.
As the COVID-19 pandemic of 2020 unfolds, many seem content for this Darwinian impulse to reappear. In a recent Harris poll, 66% of Americans agreed that, if the United States develops a vaccine, all domestic orders should be filled before any of the vaccine is made available abroad. Just to be ethically clear, such vaccine nationalism would mean that a robust American 20-year-old in a town largely devoid of infection would have a higher priority than a South African doctor or a nursing mother in Ghana or an elderly person with tuberculosis in Nigeria.
Ultimately, vaccine nationalism makes for bad medicine. The existence of large pockets of COVID-19 infection in the global immune system presents a continuing danger of reinfection for everyone. We are not safe unless everyone is safe.
But in the early days of a vaccine rollout — perhaps the first 18 months — there will be dramatic supply constraints. The scramble for doses won’t be pretty. Panic is already building. Right now, 33 countries have vaccine doses reserved. More than 160 nations do not.
It is naive to expect adherence to a global Golden Rule when it comes to vaccine distribution. But perhaps we could honor a bronze suggestion: to put the most urgent needs of poor nations somewhere above the least urgent needs of wealthy nations.
A mechanism is being developed to fulfill this mission. In keeping with the acronym mania of multilateral organizations, the Access to COVID-19 Tools (ACT) Accelerator is sponsoring COVID-19 Vaccine Global Access (COVAX), an initiative aimed at ensuring poor countries as well as rich ones get the same access to vaccines once they are licensed. COVAX is largely implemented through Gavi, the Vaccine Alliance. Of that list, it is Gavi you should remember, because it is one of history’s most dramatic humanitarian success stories. By helping poor countries buy and distribute vaccines over the past 20 years, Gavi has quietly prevented about 13 million deaths.
The new goal given to Gavi seems absurdly ambitious: to help purchase and deliver 2 billion doses of COVID-19 vaccines by the end of 2021. Getting those doses to front-line health professionals and vulnerable groups in the developing world depends on crossing a sea of uncertainty. Will vaccination require one, two or even three doses? What is the duration of protection? What level of vaccination will be required for herd immunity? How much vaccine skepticism and hesitancy will be encountered?
During an interview, Seth Berkley, a physician and the chief executive of Gavi, evinced the confidence of a man for whom wonders have become routine. “It is less intimidating when you break it down,” he told me. “Health-care workers are a maximum of 3% of populations.” Then you target “the high-risk elderly, meat-packing plants, prisons, nursing homes.”
Berkley explained that the “cold chain” — the continuous chain of refrigeration that vaccines require — is now sufficient to reach over 90% of the world’s children with at least one dose of delivered vaccine. This would be the backbone of efforts to distribute COVID-19 vaccines to adults. “People were skeptical we could deliver Ebola vaccine in a war zone” in Congo, Berkley recalled. “But we did it.”
To fight COVID-19, Gavi will help negotiate a broad portfolio of deals with pharmaceutical manufacturers so participating countries don’t need to depend on one or two bilateral agreements for drugs that may not pan out. And it will raise money to help poor countries purchase vaccines and deliver them.
The biggest question, as Berkley sees it, is simple: “Will we have enough resources?” His request for help from the U.S. government is not as unlikely as it first appears. Last year, in a tribute to Gavi’s remarkable effectiveness and broad support, its funding was increased significantly by the Trump administration. Now the administration — and other governments — should help unleash Gavi against the brutally unequal suffering caused by COVID-19.