On 9 September 2021, the House of Lords is due to consider the following:
Lord Boateng to move that this House takes note of (1) the shortage of, and (2) the obstacles to the manufacture and distribution of, COVID-19 vaccinations in the Global South; and of the consequent implications for global public health.
Is there a global vaccine divide?
In response to the Covid-19 pandemic, a number of vaccines have been produced. Although the proportion of the population needed to safely achieve global immunity to Covid-19 is uncertain, the World Health Organisation (WHO) has highlighted that herd immunity against measles and polio requires about 95% or 80% of the population to be vaccinated. This means that to be effective, the use of vaccines will likely need to be widespread. However, currently their availability differs vastly from country to country.
Work by the Our World in Data project at the University of Oxford has shown the differences in availability of vaccines. Using data from governments and health ministries around the world, the project provides daily updates on global vaccination levels. On 23 August 2021, it reported that 32.5% of the world population had received at least one dose of a Covid-19 vaccine, with 24.5% fully vaccinated. However, only 1.4% of people in low-income countries have received at least one dose. Many of these low-income countries could be considered part of ‘the Global South’, a term often used to refer to regions outside of Europe and North America that are mostly, though not completely, low income.
This gap in vaccination levels between different countries and regions can be seen below:
Source: Our World in Data Project, University of Oxford, last updated 24 August 2021.
In addition, in March 2021, the Organisation for Economic Cooperation and Development (OECD) reported that high-income countries, which account for 16% of the global population, had negotiated supply agreements amounting to approximately half of the world’s vaccine supply.
Estimates have shown that under current arrangements, the situation is unlikely to change. Researchers from the International Monetary Fund (IMF) have argued that without urgent action on Covid-19 vaccines, many emerging and developing economies may have to wait until the end of 2022 or later to bring the pandemic under control. The Duke Global Health Innovation Centre has agreed, stating that low-income countries “will likely be waiting until 2022 before they are able to cover even vulnerable populations”.
What are the potential risks of a vaccine divide?
A variety of individuals and international bodies have raised concerns about the pace of the global vaccine rollout, highlighting the risks of new variants and economic damage.
If the virus is allowed to spread like wildfire in the Global South, it will mutate again and again. This can prolong the pandemic significantly, enabling the virus to come back to plague the Global North.
The Director-General of the WHO, Dr Tedros Adhanom Ghebreyesus, has also highlighted the risk, arguing that “none of us will be safe until everyone is safe”. In addition, the Peterson Institute for International Economics has said that “epidemics anywhere threaten immunisation efforts everywhere”.
The OECD has also argued that beyond ethical imperatives, there are compelling arguments for distributing vaccines fairly around the world. It has said that international supply chains and the movements of people and goods will inevitably lead to the transmission of any new variants. This could cause damage to populations and economies even where most are fully vaccinated. Citing research on the issue, it said that conservative estimates by the Peterson Institute found that the damage could exceed the costs of helping poorer countries vaccinate by as much as 10 to 100 fold. It also highlighted economic modelling published by the Centre for Economic Policy Research that estimated faster progress on ending the pandemic could raise global income cumulatively by $9 trillion (US dollars) between 2020 and 2025, with around $4 trillion for advanced economies.
What is causing the divide?
In April 2020, a global initiative called Covax was set up to ensure fair access to Covid-19 vaccines between countries, regardless of their income level. Jointly directed by the Coalition for Epidemic Preparedness Innovations (CEPI), the vaccine alliance Gavi, and the WHO, the initiative pools global funding to invest in the research, manufacture, purchase and distribution of vaccines. Vaccines have also been donated to the initiative. Covax either distributes vaccines at a cost for participating higher-income countries or as donations to eligible low- and middle-income countries.
Initially Covax was viewed as the method by which all countries would procure their vaccines. However, most high-income countries made direct deals with manufacturers. This has led to high-income countries dominating the purchasing and administration of vaccines. Work by the Duke Global Health Innovation Centre to track the number of vaccine doses ordered by each country has shown this. It found that in 2020:
Many high-income countries hedged their bets by purchasing enough doses to vaccinate their populations several times over, even before any candidates were approved and have continued to procure more doses of approved vaccines in 2021, in an effort to receive doses as quickly as possible.
While many high-income countries—including the UK—supported Covax and joined it, some commentators have argued that the initiative’s lack of purchasing power in comparison to them has caused problems. The Duke Global Innovation Centre has argued that as a result of the deals and global manufacturing constraints, “a smaller piece of the pie is available for low- and middle-income countries and for equity-focused partnerships like Covax in 2021”. Dr Faisal Shuaib, director of the National Primary Health Care Development Agency in Nigeria, has also said that “we recognise that Covax is working as hard as they can in an environment where richer nations are snapping up vaccines”.
Despite initial issues, Covax began to roll out vaccines in March 2021, with a goal to distribute 170 million doses by 31 May. However, only 76 million were delivered. Delays were caused by the Indian Government halting the export of vaccines in March 2021 due to increased domestic demand as Covid-19 cases surged. This affected the Indian Serum Institute, one of the largest global manufacturers of vaccines, which was due to supply 1.1 billion doses to Covax. Although Covax secured additional agreements to make up for the shortfall, the deliveries will not start until later in 2021.
Dr Seth Berkley, chief executive of Gavi, has highlighted that Covax is “more or less” on track to deliver 2.2 billion doses by January 2022 as originally promised. As of 19 August 2021, Covax had shipped over 209 million vaccines to 138 participants.
In 2021–22, Covax aims to supply enough vaccines to enable 92 low-income countries to vaccinate 30% of their populations. Beyond that, on average eligible countries are looking to cover 50% of their populations through Covax, however, participants will need to use other sources to vaccinate the rest of their populations. In June 2021, Reuters reported that Covax will be reformed, with many higher-income countries expected to voluntarily withdraw their membership.
Calls for change
Writing for the Conversation, Robin Cohen, Emeritus Professor of Development Studies at the University of Oxford, argued that it was not immoral for countries to order so many vaccines due to uncertainty over which would gain regulatory approval. However, he also said that despite the speed of development and the unexpectedly low number of failures producing a good number of potentially viable vaccines in a short space of time, the situation cannot be considered a success until the redistribution issue is resolved.
Various other individuals and organisations have argued for change to ensure vaccines are shared more fairly around the world. For example, in May 2021, a group of individuals including religious leaders and heads of international organisations—such as the Red Cross, UNICEF and the WHO—signed a declaration calling for action to be taken. Addressing the issue in January 2021, the Director-General of the WHO, Dr Tedros Adhanom Ghebreyesus, warned that:
The world is on the brink of a catastrophic moral failure—and the price of this failure will be paid with lives and livelihoods in the world’s poorest countries.
The WHO has called on higher-income countries to delay child vaccines and share doses with Covax. UNICEF has also argued that G7 nations and a group of European Union member states should donate 20% of their available supplies over the summer months. In addition, the World Bank has argued that access to vaccines is key to altering the course of the pandemic and stressed the need for countries with excess vaccine supplies to release them as soon as possible.
What is being done to address the problem?
The UK has primarily supported global vaccine efforts through Covax, for which it is the fourth largest donor. It has also pledged to donate 100 million vaccines overseas by June 2022, 80 million of which will go to Covax. It has also donated around 4 million doses directly to other states it has signed agreements with: Antigua and Barbuda; Belize; Cambodia; Guyana; Indonesia; Jamaica; Kenya; Laos; Malaysia; the Philippines; Saint Vincent and the Grenadines; Thailand; and Vietnam. In addition, the Foreign, Commonwealth and Development Office is responsible for arranging and funding vaccines for UK Overseas Territories, with the intention of delivering enough doses to offer vaccines to every adult.
The Government has also highlighted its funding of the Oxford/AstraZeneca vaccine, which was 97% funded from public sources. To July 2021, this type of vaccine had accounted for 65% of the 152 million doses provided by Covax.
In June 2021, the G7 pledged to share Covid-19 vaccines internationally. It committed to sharing 1 billion doses by June 2022, half of which will come from the US. It also said it would donate 870 million doses via Covax, half of which would be delivered before the end of 2021. In addition, it announced it would:
Create the appropriate frameworks to strengthen our collective defences against threats to global health by: increasing and coordinating on global manufacturing capacity on all continents; improving early warning systems; and support science in a mission to shorten the cycle for the development of safe and effective vaccines, treatments and tests from 300 to 100 days.
Calls for further action
Although the G7’s commitment was welcomed by many, it has also been argued that it does not go far enough, fast enough. The WHO’s Dr Tedros Adhanom Ghebreyesus said that he thanked leaders for the donations, but that “we need more, and we need them faster”. Former UK Prime Minister Gordon Brown also argued that the G7’s commitment falls billions short of what’s needed, stating that at least 11 billion doses “are needed to guarantee all countries the same levels of anti-Covid protection as the west”.
Commenting on concerns about some countries’ ability to store and administer vaccines, Dr Bruce Aylward, senior adviser to Dr Adhanom Ghebreyesus, has also argued that countries need to receive a steady supply of vaccines so that they could set up systems that worked. This would require training a workforce and funding. Liam Sollis, head of policy on UNICEF UK’s national committee, has agreed that more funding is needed. He said that while dose sharing was the first priority, the second is scaling up manufacturing to enable sufficient supply. To do this, he argued that financing has to be in place and while it has been generous this year, “there’s still not money available for the rollout through 2022”.
Some countries have called for intellectual property (IP) rights on vaccines to be waived to increase production. The idea is that by forcing manufacturers to share their IP rights, other manufacturers can also start to produce them, increasing supply. However, Gavi has argued that the sharing of IP rights alone would not be enough, stating that manufacturers also need the other know-how to allow technology transfer. The head of the World Trade Organisation (WTO), Ngozi Okonjo-Iweala, has agreed, stating that she is “convinced that we can agree a text that gives developing countries that kind of access and flexibility, whilst protecting research and innovation”.
Countries supporting the idea of an IP waiver include India, South Africa, the US, Italy and France. The UK Government said in March 2021 that it would not support a waiver of IP rights as the existing framework had effectively mobilised and delivered vaccines. However, in May 2021, the Guardian reported that the Government had entered talks on the waiver issue. In June 2021, the G7—which the UK is a member of—agreed to “engage constructively” with discussions at the WTO on the IP issue and noted the impact voluntary licensing and technology transfer had made to global vaccine supply.
Cover image by Pato González on Unsplash.