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PLOS BLOGS Speaking of Medicine and Health

COVID-19 Vaccine Equity- The Neglected Pandemic Stepchild

By contributing author Dr. Boghuma K.Titanji (MD, MSc, DTM&H, PhD), Emory University and PLOS Global Public Health Academic Editor

The second summer of the pandemic was supposed to be much better, or so they said. With an abundance of effective vaccines which made COVID-19 preventable and less deadly for the vaccinated, all we needed to do was vaccinate the world and do it quickly. At face value the solution sounded fairly straight forward – global leaders will come together and pool resources to scale-up vaccine production, they would share vaccine doses equitably to control the global pandemic and life will return to normal as we once knew it.

The reality which has unfolded has been dismal and fallen well short of the expectations of the world coming together to fight a common enemy. Instead, the second summer of the pandemic feels a lot like the first, only more frustrating. Soaring case numbers and deaths driven by the surge of the delta variant, lock downs, travel restrictions and growing vaccine inequity have continued to place a disproportionate burden of the pandemic on the world’s most vulnerable.

High income countries (HICs) started vaccinating their populations on average 2-3 months earlier than low-income (LICs) countries and the gap in vaccination coverage has only widened since. An estimated 53.79% of populations (1 in 2 people) in HICs have been vaccinated compared to an a paltry 1.63% (1 in 61 people) of LICs. COVAX a program co-led by the WHO for fair distribution of vaccines has seen its ambitious goal of vaccinating 20% of vulnerable population in LICs falter, significantly undermined by wealthy countries putting themselves first and defaulting on pledges to donate excess vaccine doses towards this effort. Instead, many wealthy nations are moving forward with plans for booster doses for the fully vaccinated, while allowing excess unused doses of vaccine to be discarded. Despite support from the US government, an agreement on trade related intellectual property (TRIPS) waivers, which could help with scaling-up global vaccine production is far from being settled. The broken promises and failed attempts at global solidarity have left in their wake a pandemic that continues to rage out of control without end in sight and a vaccine inequity problem that currently stands as the biggest barrier to making meaningful progress in our fight to end the COVID-19 pandemic.

Map from Mathieu, E., Ritchie, H., Ortiz-Ospina, E. et al. A global database of COVID-19 vaccinations. Nat Hum Behav (2021),

To attain the goal of immunizing 70% of the population against COVID-19, HICs have to increase their healthcare spending by an estimated 0.8%. In staggering contrast LICs will on average have to increase healthcare spending by 56.6% to reach this same goal. This cost is likely to increase over time as pharmaceutical companies increase the cost of COVID-19 vaccines and rollout of booster doses in wealthy countries further drive-up vaccine demand and squeezes the market. The ripple effects of COVID-19 vaccine inequity are huge and threaten almost every facet of healthcare especially in countries with already very fragile health systems. The reality we are facing is seeing decades of progress on childhood immunizations, infant mortality, maternal mortality, Malaria, Tuberculosis and HIV control etc. erased by the collective failure of global leadership to address the pandemic.

The current situation is not without historical precedent and cannot be blamed on a lack of awareness of what happens when nationalism as a strategy is favored over collaborative and inclusive global efforts. In the early days of the HIV pandemic which is now in its 40th year, LICs were sent to the back of the queue for access to life-saving antiretroviral therapies, resulting in millions of avoidable deaths. Today the HIV pandemic has been largely controlled in most wealthy countries and developing countries in sub-Saharan Africa are still playing catch-up, accounting for the largest share of new cases and deaths from HIV. During the swine flu pandemic of 2009, wealthy countries hoarded vaccine doses with no consideration for poorer countries until much later in the crisis when limited doses were donated to LICs.

Despite promises to be better prepared and to do better in the next pandemic, COVID-19 has demonstrated that no lessons have been learned as we watch an almost deliberate re-enactment of past mistakes. A new outbreak of an infectious disease only appears to constitute a global pandemic when the lives of people in wealthy countries are under threat with the resources and focus rapidly shifting once the situation is controlled in these settings. Malaria and Tuberculosis for example once fit the billing as “global pandemics” and should still carry that label if we consider the number of lives claimed by these diseases globally every year. Instead, these have become endemic concentrated in the poorest countries once controlled or eliminated in HICs and struggle for funding to support the same efforts in poorer countries.

Unless we make equitable global access to COVID-19 vaccines the top priority in addressing the current crisis and focus a maximum of resources to make it happen, this pandemic will follow a similar progression to HIV, Malaria and Tuberculosis, signaling another moral failure to place equal value on human life everywhere regardless of geography. The reality facing millions in LICs right now is frontline healthcare workers without access to vaccines having to fight against more transmissible variants of the virus, vulnerable pregnant people and children in vaccine eligible age brackets without access to vaccines and the elderly and immunocompromised yet to receive first doses of vaccines. There is no doubt that we have to learn to live with COVID-19, SARSCoV2 is endemic and it is almost certain we will not be able to eliminate the virus from circulation. We do however have the choice of ensuring that everyone, everywhere is equally protected from the deadly consequences of COVID-19. It is not only a matter of moral imperative but also the most effective path to economic recovery for rich and poor economies and breaking the vicious cycle of new outbreaks driven by emerging virus variants.

At the time of writing this piece the FDA has just approved a 3rd dose of COVID-19 vaccine for immunocompromised persons in the US, the UK has ordered millions of Pfizer and Moderna vaccines for its autumn 2022 booster campaign, Israel is actively vaccinating everyone over age of 50 with their 3rd doses of vaccine and many other wealthy countries are following suit. In the interconnected world we share, these country centered policies are not a winning pandemic endgame strategy and will draw out the suffering and pain millions around the world are currently experiencing.

Global world leaders have the power to do the right thing but at present choose not to, because they can and we are letting them. Donating excess doses of vaccines to COVAX is a good deed which may temporarily assuage the guilt of failing to do more but it is grossly insufficient. Vaccine donations are imperfect, slow and unsustainable and ultimately ensure that the poorest countries remain firmly at the back of the queue awaiting a trickling down from the excesses of the wealthy. If the science ultimately supports a need for booster doses in every fully vaccinated person, it is impossible to imagine that we will achieve sustainable global vaccine equity with a model which has already failed to effectively deliver first vaccine doses to all.

Some have put forward the false argument that wealthy countries made the biggest investments towards developing COVID-19 vaccines and as such are more disserving of access than poorer countries. This viewpoint isn’t just wrong but is also callous in suggesting that human lives in wealthy countries have more value than those in poor countries. It also fails to recognize the truly global effort of scientists around the world that resulted in these life-saving vaccines. Chinese scientists while facing the outbreak in Wuhan, rapidly identified the causal agent of a new disease and shared its genomic sequence with the world enabling the development of mRNA vaccine candidates at record speed. Several COVID-19 vaccine clinical trials have been led by researchers and scientists in developing countries and have generated the data to show that these vaccines are not only safe but also highly effective.

Everyone is equally deserving of access to life-saving vaccines, that is why we need solutions centered on ensuring vaccine access for all and not just for a few. Moratoriums on booster doses in wealthy countries to prioritize getting first dose access to poor countries is an immediately actionable solution proposed by the WHO that will address some of the vaccine inequity. TRIPS waivers to facilitate technology transfer and investments to develop vaccine production capacity in LICs are longer term solutions which will ensure a more reliable vaccine supply for this pandemic and for future pandemics. The biggest challenge is holding those in power accountable and forcing them to act immediately because millions of lives depend on it. This is why we must all become vocal advocates for global vaccine equity, because no one is safe until everyone is safe. A pandemic endgame without global vaccine equity at its core is a losing proposition and now is as good a time as any to start learning from past mistakes and doing the right thing. 

Photo of author Dr. Boghuma Kabisen Titanji

Dr. Boghuma K.Titanji (MD, MSc, DTM&H, PhD) is a scientist and infectious disease physician at Emory University in Atlanta. Her current research focuses on chronic inflammation and non-AIDS related co-morbid conditions in people living with HIV. She is passionate about translating scientific research into policies that benefit the most vulnerable, promoting ethical practice of research in developing countries and conversations on global health equity. Her Twitter handle is @boghuma ​

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