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The Peril of Not Vaccinating the World

When Gregg Gonsalves was a young AIDS activist and researcher, in the nineteen-nineties, he was struck by a pattern that kept showing up in the data: the distribution of antiviral medications fell neatly along socioeconomic and racial lines: wealthy people got them, and poor people, many of them Black or Hispanic, did not. Later, as an associate professor at the Yale School of Public Health, Gonsalves illustrated the persistence of these kinds of health disparities to his students by overlaying a map of pre-Civil War slave-holdings on a contemporary map of life expectancies, which, not surprisingly, showed that life expectancy was lowest in those regions. “It’s not rocket science that we’re seeing COVID-vaccine distribution following those same demographic patterns,” he told me. “We’re just remaining true to form.” According to a recent analysis of C.D.C. data by Kaiser Health News, only twenty-two per cent of Black Americans have been vaccinated, and Black vaccination rates are significantly lower than those of whites in almost every state. Much of what has been called vaccine hesitancy is actually a problem of vaccine access.

As it turns out, vaccine distribution follows a similar socioeconomic pattern all over the world, with most COVID vaccines going to what are called high- and middle-income countries. According to Nature, as of mid-March, those countries had secured more than six billion out of 8.6 billion doses. Less than a week later, the Times reported that “86 percent of shots” that went into arms across the globe were “administered in high- and upper-middle-income countries.” By early May, when less than eight per cent of the world’s population had received one dose, the Open Society Foundation estimated that the world’s poorest countries may not be able to vaccinate their populations until 2023. This disparity—what Gonsalves and others are calling vaccine apartheid—is a problem that will not be borne solely by the people living in those locales. It has the potential to undermine the gains made on the virus in places where vaccine adoption is high and a post-pandemic future is starting to feel possible.

There are two reasons that a person in London or Los Angeles should care about vaccination rates in Lagos or São Paulo: simple humanity and simple biology. If left unchecked, the loss of human life for families and societies worldwide will be staggering. Viruses are international travellers, and over time they mutate. Wherever vaccine coverage is patchy, there is selective pressure for the virus to evolve resistance. We’ve already seen robust virus variants from South Africa, Brazil, the U.K., and India spread around the world. So far, the first generation of COVID vaccines is holding the line against them, but that protection is not guaranteed. It’s possible that the virus, which has already infected vast numbers of people, won’t evolve in a way that fatally undermines our vaccines. On the other hand, some epidemiologists think that we have a year or less before the virus breaks through and renders them less effective. Pharmaceutical companies are working on shots that are as effective against the variants as they are against the original virus, but their efficacy hasn’t yet been proved. And, as the Oxford evolutionary virologist Aris Katzourakis told me, even if they do prove effective, “the idea that we could revaccinate the whole country or the whole world annually is not an easy challenge. That’s one of the reasons why many people, myself included, think that we should be exploiting the fact that we have vaccines that are incredibly effective right now.”

A race to vaccinate the world is not an effort to achieve herd immunity. At least in this country, that goal was a kind of marketing device, a way of inspiring people to abide by masking and social-distancing rules while waiting for a vaccine, and then to encourage everyone to do their part by getting immunized once vaccines were available. In the beginning, public-health officials, including Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases, suggested that herd immunity would occur when sixty to seventy per cent of the population had been vaccinated. On the other side of that threshold, they suggested, was a magical return to the land of indoor dining, casual sex, and visits to grandparents. Later we were told that the number was more likely eighty per cent. Most recently, Fauci notched that number upward again, to ninety per cent. (When asked why he stuck with the earlier numbers when he knew them to be too low, he said that he didn’t think the country was ready to hear the truth.)

For reasons ranging from vaccine access to outright rejection by around twenty-five per cent of eligible Americans, getting to ninety per cent is not possible. Even if it were, we’d still likely have to contend with low rates of immunization elsewhere in the world, including at our northern and southern borders. (According to the latest Times tracker, less than ten per cent of Mexicans and only about six per cent of Canadians are fully vaccinated; the United States is rising from forty per cent.) A more realistic objective is to use mass vaccination to create a bulwark of resistance to prevent the virus from tearing through populations like wildfire. While there still would be flareups, they would die down once the virus lacked a sufficient number of hosts. But, without a concerted global commitment to vaccine equity, poorer regions will remain vulnerable to ferocious outbreaks, giving the SARS-CoV-2 virus the opportunity to evolve and, in a worst-case scenario, result in a chronic, never-ending pandemic.

Last summer, more than a hundred Nobel laureates, former heads of state, clerics, and business leaders urged the World Health Organization to designate COVID-19 vaccines “a global common good.” Their petition asked the W.H.O. to “set up an international committee responsible for monitoring the vaccine research and to assure equal access to the vaccine for all countries and all people within a publicly announced pre-determined time frame.” There were then around a hundred and seventy vaccine candidates, none of which had crossed the finish line; the most promising were still in the early phases of clinical trials. As those trials progressed, a movement also began to coalesce around the idea of a “people’s vaccine.” It would be patent-free, mass-produced, and available to everyone, in every country, free of charge.

That, of course, did not happen. As soon as the mRNA vaccines developed by Pfizer-BioNTech and Moderna proved to be both safe and effective, countries with deep pockets, like the United States, signed contracts to buy hundreds of millions of doses, eventually contracting for far more than they needed. The same thing happened later with the vaccines from Oxford University-AstraZeneca and Johnson & Johnson. If you were an American or an Israeli or a Brit, this kind of vaccine nationalism was, most likely, comforting. If you weren’t, well, it felt, as a senior Indian researcher put it, like staying behind as the first-class passengers board the plane and then watching them sip champagne while you shuffle back to the economy seats.

It wasn’t as if these disparities were not anticipated. As early as April of last year, Gavi, a twenty-one-year-old international vaccine alliance, partnered with the W.H.O. and the Oslo-based Coalition for Epidemic Preparedness (CEPI) to create COVAX, an initiative aimed at distributing COVID vaccines equitably around the world. Their ambition was to fund vaccine research while also creating mechanisms for any country, regardless of national income, to have access to those vaccines. Participating countries would receive vaccine doses in proportion to their population.

As of mid-May, COVAX had distributed sixty-eight million doses—a long way from the goal according to the W.H.O. of two billion by year’s end. (Most are formulations of the AstraZeneca vaccine.) Some participating countries, such as Pakistan and Bangladesh, haven’t received any doses from COVAX. The organization has received a pledge for direct donations of more than a billion doses from pharmaceutical companies and three and a half billion dollars from the U.S. When I asked Chris Elias, the president of global development at the Bill & Melinda Gates Foundation, what it will take to end the pandemic, getting COVAX fully funded was one key component. On June 2nd, that goal was reached.

But COVAX has been stymied by the very thing it was meant to circumvent: vaccine nationalism. One of COVAX’s biggest suppliers is India’s Serum Institute (S.I.I.), which is partnering with AstraZeneca to manufacture its COVID vaccine. COVAX contracted with S.I.I. to buy more than a billion doses, most of which were slated to go to low- and middle-income countries. But, when the second wave of infections began to devastate India, the Indian government halted vaccine exports. (India has a robust and well-regarded vaccine industry; in a typical year, it supplies sixty per cent of the world’s vaccines.) Though the Indian government has denied imposing an export ban, COVAX has informed a number of participant countries that their vaccine orders are currently on hold.

The United States, the biggest donor to COVAX, has also been under pressure to do more to help countries struggling to get more vaccines. At the end of April, the Biden Administration committed to releasing sixty million doses of the AstraZeneca vaccine to countries in need. “That’s showing up to a four-alarm fire with an eyedropper full of water,” Asia Russell, the executive director of Health GAP, an AIDS advocacy group, told the Times. The next week, Katherine Tai, the U.S. Trade Representative, announced that the Biden Administration supported a proposal before the World Trade Organization to waive intellectual-property rights to COVID vaccines during the pandemic. The move, which marked a policy reversal for the White House, was lauded by public-health officials, including the head of the W.H.O., Tedros Adhanom Ghebreyesus, who called it “a monumental moment in the fight against COVID-19.” (The Gates Foundation also supported the decision, although Bill Gates personally did not.) In theory, lifting the patent restrictions on COVID vaccines would uncouple the profit motive from production and enable nonprofits, as well as drug companies, to use proprietary formulas to boost manufacturing around the world. In other words, something akin to a “people’s vaccine.” But the W.T.O. works on consensus. Even if this proposal were to prevail—which seems unlikely, since most European countries oppose it—negotiations will take months, maybe longer. In the meantime, there will be more viral replication, and more COVID deaths.

Biden’s reversal was widely panned by the pharmaceutical industry. Pfizer, which spent two billion dollars to develop its messenger-RNA platform—without knowing whether it would prove safe and effective—expects to make fifteen billion dollars from its COVID vaccine this year. Industry representatives point to such gambles when they argue that lifting patent restrictions will discourage companies from investing in research and development. In a letter, obtained by The New Yorker, in response to calls from a group of Democratic senators, including Elizabeth Warren, of Massachusetts, and Jeff Merkley, of Oregon, for vaccine developers to share their intellectual property, Jennifer Walton, Pfizer’s vice-president for U.S. government relations, wrote, “Without a strong IP framework, we would not have mRNA vaccine technology, a breakthrough discovery that is helping to address the global pandemic. We believe the IP system is an essential facilitator to the availability of the vaccine, not an impediment or risk and remains a critical enabler of the future research that will be necessary to end the pandemic.” Walton also argued that opening up the Pfizer vaccine to other manufacturers ran the risk of shutting down the company’s own production, which is now on schedule to deliver a hundred million doses a month. “Manufacturing of our vaccine involves the use of over 280 materials,” she wrote. “These materials come from 86 suppliers in 19 different countries. If any one of the 280 different components from suppliers, however trivial, is not provided, we cannot manufacture or release the vaccine.”

The C.E.O. of Moderna, Stéphane Bancel, took a different tack. In an earnings call shortly after the Biden Administration’s I.P. announcement, he told a group of analysts and investors that he “didn’t lose a minute of sleep” over the news. In fact, in October, the company, which, unlike Pfizer, received billions of dollars from the government to develop its vaccine, had announced that it would not enforce its COVID-related patents. Having the recipe for making the vaccine, Bancel explained, was not the same as having the ability to make the vaccine. “There is no mRNA in manufacturing capacity in the world,” he told the group. “This is a new technology. You cannot go hire people who know how to make the mRNA. Those people don’t exist. And then, even if all those things were available, whoever wants to do mRNA vaccines will have to buy the machine, invent the manufacturing process, invest in verification processes, analytical processes. And then they will have to go run a clinical trial, get the data, get the product approved, and scale the manufacturing. This doesn’t happen in six or twelve or eighteen months.”

Still, some degree of technology transfer is happening already. AstraZeneca is working with the Serum Institute, as is Novavax, whose vaccine looks to be ninety-six-per-cent effective. Johnson & Johnson is collaborating with Aspen Pharmaceuticals in South Africa. The French pharmaceutical giant Sanofi has agreed to fill and pack the Pfizer-BioNTech vaccine at its Frankfurt plant. And a group from the University of Pennsylvania, which pioneered some of the earliest and most consequential work on mRNA, is working with Chulalongkorn University, in Bangkok, to build a vaccine-manufacturing facility.

Increasing vaccine production through technology transfers, although crucial, is insufficient for ending the pandemic. Elias pointed to research that shows that, without equitable global distribution, we are likely to be dealing with COVID for a very long time. Those of us in the United States and other wealthy countries may imagine that to mean living with SARS-CoV-2 the way we live with the flu. But, as Katzourakis, the Oxford virologist, told me, “The analogy we choose to draw now may paint a picture of the future we want to live in. The flu future is one possibility, but it’s a reactive one that condemns us to a perpetual race of trying to keep up with the virus, and we may find that things aren’t so simple. We’ve been blessed with vaccines whose effectiveness against this virus is absolutely remarkable. They give us a shot at potentially eliminating the virus right now in very large parts of the world. If we resign ourselves to perennially trying to keep up with the virus, we could have wasted a remarkable opportunity to rid ourselves of this disease.”


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