The global response to the coronavirus disease 2019 (COVID-19) pandemic has been complicated by the scarcity of medical resources. Since early 2020, healthcare workers have been driven to economize essential personal protective equipment and make difficult decisions about the distribution of life-saving ventilators to COVID-19 patients . With the first pool of approved vaccine doses on the horizon, we face the dilemma of resource scarcity yet again; vaccines cannot simply be developed quickly enough to serve the entire world population immediately . To maximize their impact, vaccine supplies must be distributed equitably, prioritizing the protection of those most at risk of COVID-19 infection and mortality globally . This is the goal of the COVID-19 Vaccine Global Access (COVAX) Facility, a global initiative co-led by Gavi and the World Health Organization (WHO) . However, this is no easy feat. As vaccine nationalism shapes the global distribution of COVID-19 vaccines, prospects for equitable distribution — and an efficient end to the COVID-19 pandemic — are threatened.
Vaccine nationalism describes the ways in which countries prioritize the vaccination of their citizens over others. In response to the COVID-19 pandemic, many countries have struck bilateral deals with pharmaceutical companies to place pre-market holds on promising vaccine candidates. Advance market commitments have effectively enabled countries to reserve their citizens — and only their citizens — a place first in line to receive vaccines when the vaccines are approved . Nationalism is also evident in the decision of some countries to create national vaccine development programs. The Sinopharm vaccine developed in China, for example, has recently received regulatory approval and will be provided for free to Chinese citizens . That being said, vaccine development requires a significant financial and material investment, in addition to a degree of risk; the majority of vaccine candidates in the research and development pipeline do not prove successful . Therefore, even countries which have national vaccine development programs may engage in bilateral deals with pharmaceutical companies to increase the chances that a vaccine candidate they have invested in will quickly receive approval . The result is that each country becomes responsible for the vaccination of their citizens.
However, advance market commitments to pharmaceutical companies are expensive and not a viable option for many countries. As of November 2020, 7.48 billion doses of vaccines have been purchased by countries around the world . Over half of these vaccines are set to be distributed to high-income countries (HICs) and vaccination has already begun in the United Kingdom, the United States, and Canada . At the same time, 92 countries remain without an independent means of vaccinating their populations . If nothing is done, these countries will likely be left unprotected — at least until the wealthiest countries have been vaccinated. Models predict that such a scenario would cost the world US$1.2 trillion a year in GDP and result in twice as many deaths as a distribution scheme that would protect the most vulnerable first [4,10]. In this way, vaccine distribution guided by nationalism can ultimately become detrimental.
This is where COVAX becomes crucial. COVAX provides a way to establish equity in vaccine distribution, ensuring that vulnerable groups globally will have access to vaccines, irrespective of their country’s GDP . To achieve its aims, COVAX pools funds from participating countries and private donors to gain purchasing power and negotiate vaccine deals with pharmaceutical companies . To date, COVAX has established partnerships with AstraZeneca/Oxford, Sanofi-GSK, and Janssen, in addition to an agreement with the Serum Institute of India for either doses of Novavax vaccine candidates or additional doses of the AstraZeneca/Oxford vaccines . COVAX has recently secured 2 billion vaccine doses, which would enable its 190 participating countries to vaccinate at least one-eighth of their populations by the end of 2021 — nearly one billion people . This makes COVAX currently short of its goal of vaccinating 20% of the world by the end of 2021 . However, for many, COVAX represents the only hope for receiving a COVID-19 vaccine in the upcoming year.
When countries prioritize national interests over protecting the rest of the world, they can directly undermine the goals of COVAX. Engaging in bilateral deals with pharmaceutical companies can push COVAX partner countries further down the queue to receive vaccines . AstraZeneca, for example, has pledged doses to both COVAX and Britain but is prioritizing the latter due to its partnership with Oxford University . Furthermore, countries which purchase more doses than are needed for their populations divert vaccines away from people in need; an analysis by the People’s Vaccine Alliance found that HICs have placed holds on enough doses to vaccinate populations three sizes larger than their own . Canada has pre-ordered enough vaccines to vaccinate their populations ten-times over . While over-buying vaccines is a justifiable precaution given the uncertainty of success in vaccine development, countries hoarding excess medical supplies is a risk not without historical precedent . Ultimately, funds invested into national interests are diverted away from COVAX. This limits its ability to achieve equity and provide vaccines for countries unable to secure vaccines independently.
Within this web of competing interests, COVAX grapples with a challenging task. It must balance the concerns of HICs, low- and middle-income countries (LMICs), and pharmaceutical companies to provide an equitable solution to vaccine distribution. COVAX addresses this conflict through its vaccine distribution scheme, which is designed to make participation in COVAX attractive to all countries, regardless of their GDP. Self-financing countries — countries able to buy their own vaccines — pledge funds to COVAX to place holds on vaccines for a desired percentage of their populations . However, once 20% of their populations have been vaccinated through COVAX, additional vaccines will not be provided until all other participating countries have vaccinated 20% of their populations . Self-financing countries benefit from participation in COVAX because they buy into COVAX’s portfolio of candidate vaccines. This can serve as a safety net if vaccine candidates secured through bilateral deals with pharmaceutical companies take a long time to develop. Funded countries — countries unable to pay for their own vaccines — will receive enough doses to vaccinate up to the most vulnerable 20% of their populations .
Based on the number of participating countries, COVAX would appear to have succeeded at balancing diverse geopolitical interests; 98 HICs and 92 LMICs are participating alike . However, despite the extensive global support which COVAX has garnered, work must still be done to secure enough vaccines to achieve its goal of vaccinating 20% of the world by the end of 2021. Russia and the United States are two notable countries that are missing from COVAX . Pharmaceutical companies Pfizer and Moderna have yet to establish a deal to provide vaccines to COVAX and are thus far engaged primarily in bilateral deals with HICs . Furthermore, participating countries have been recently urged by the WHO to honour their donor pledges . These actors must increase their commitments to COVAX if it is to succeed. Notwithstanding, new challenges still lie ahead as COVAX and participating countries prepare for the logistical task of delivering vaccines to people .
In an increasingly globalized world, the COVID-19 pandemic is revealing the dangers of nationalism. While vaccine nationalism may protect one’s citizens in the short-term, a distribution scheme guided by equity is ultimately the most reliable and effective way of ensuring safety in the long-term . COVAX offers a promising avenue to achieve this; however, its goals are only possible with global cooperation from HICs, LMICs, and pharmaceutical companies alike. As the world plans for the distribution of vaccines in 2021, no one should be left behind. In the words of the WHO Director-General, Dr. Tedros Adhanom, “images of people receiving vaccines are giving us hope, but it must be hope for all, not hope for some” .
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