By contributing author Dr. Boghuma K.Titanji (MD, MSc, DTM&H, PhD), Emory University and PLOS Global Public Health Academic Editor The second summer…
By guest contributors Malvikha Manoj, MSPH; Hloni Bookholane, MBChB MPH; Reiner Lorenzo Tamayo, RN; Ghiwa Nasser Eddine, RPh, MPH; Magali Collonnaz, MD, MPH, MSc; Marali Singaraju, MPHc; Bhavna Seth, MD, MHS; Ramonde Patientia, MD; Joy Muhia, MSc; Meg McCarty, MSc; Ivan Mufumba, BSc, Msc; Toluwani Oluwatola BChD; Manik Inder Singh Sethi MBBS, MD; and Laura Neenan BSc, MA
At the intersection of historical, social, economic, and racial injustices, the COVID-19 pandemic lifted a smokescreen to reveal our collective inability to address entrenched decay in global public health ecosystems. Global vaccine inequity is the canary in this coalmine, driven by colonial-era socio-economic and political orders. Whether the argument is ethical, economic, or epidemiological, we need to rise above vaccine injustice, if we are to be liberated from this pandemic.
As young professionals in health, we’re at a critical juncture, caught in the middle of geopolitical power-plays that test the noble ideals of equity and justice. We are uniquely positioned to hold leadership to higher standards and urge them to rebuild the broken systems we are inheriting, and to be directly involved in the process of re-imagining and shaping the future of these systems.
Malvikha Manoj, a recent graduate of public health, and Chair at the IWG, turns to fourteen current/recent graduates in health to weigh in on the manifestations of vaccine inequity in their countries, the path ahead, and what this historic moment requires from both current and future leaders.
Manifestations of COVID-19 Inequity: Expected and Unexpected
“In the face of (geo)politics, corruption, leadership vacuums, and scarce accountability, the many efforts of health professionals have often been left understated. Despite how tough this may be, it is a consequential time to be involved in this field,” says Hloni Bookholane, reflecting on his experiences as a young physician in Cape Town.
As young professionals, many of us took to the frontlines to respond to this unprecedented crisis, and can relate to the sentiments Hloni shared. While glimpses of hope emerged in some contexts, we continue to witness radical politicization of health, vaccine nationalism, strategic ambiguity, absence of global solidarity, and shocking diplomacy around the world.
In many places, vaccine strategies reflect the whims of the powerful and privileged, despite efforts from scientific communities to advocate for equitable evidence-based programming. Marali Singaraju, a graduate student in the US, experienced this while working at the State Health Department in Minnesota, “Despite plans for equitable vaccine distribution, our expertise and leadership were dismissed when the governor’s office took control. What mattered most to them were vaccination numbers, not our communities.”
Public health is often sidelined for monetary or personal gain, as illustrated by Laura Neenan, a PhD candidate in Ireland, “In Dublin and Limerick, vaccine centers were temporarily shut down to accommodate horse racing events to avoid loss of revenue in the community.” Moreover, anti-vaccine propaganda and vaccine hesitancy thwarts well-intentioned rollout plans, worsening mis-and-disinformation. Magali Collonnaz, a French physician and PhD candidate notes that the main issue in France has not been vaccine access but vaccine hesitancy, “people here are not realising how privileged we are, especially considering that access itself remains a major barrier in many low-and-middle income countries (LMICs).”
Stuck at 1%: Vaccine Inequity in LMICs
At the time of writing, only 1.4% of individuals in LMICs had received at least one vaccine dose. At this glacial pace, LMICs will have to wait until 2023 before most are vaccinated; this collective failure is projected to cost the world $2.3 trillion in lost GDP. Sadly, high income countries (HIC) hoard vaccines and make plans for booster shots while the rest of the world contends with new variants sans vaccines. “We need to unite and address vaccine nationalism,” emphasizes Toluwani Oluwatola, a research officer in Nigeria, “this pandemic has already disproportionately affected LMICs, and will continue to do so if we don’t take action.”
Reiner Tamayo, a graduate student in the Philippines, highlights that, “people working minimum wage jobs and have no work-place protections are the most vulnerable. Many want to be vaccinated, but current supply falls short.” The discordance between supply and demand is worsened by patent laws which prevent development and distribution of vaccines by LMICs. “The monopoly of who can and cannot manufacture vaccines puts LMICs at a disadvantage,” notes Ivan. Unfortunately, despite efforts to advance waivers, HICs remain unmoved.
If profits are favored over people, as they appear to be, we cannot trust big pharma and world leaders to get us out of the pandemic. It is worth noting that continued donations of vaccines and funding are urgent stop-gap measures, however, long-term sustainable solutions are non-negotiable. Meg McCarty, a recent graduate and policy analyst in the US, adds, “we need to strengthen manufacturing power in LMICs. Countries like Rwanda, where health systems have been restructured for public trust and equity from the outset, are poised to become regional powerhouses that deliver effective rollout.”
Talks of vaccine equity need to be translated into action, says Joy Muhia, a Kenyan medical psychologist studying in the UK. Failing that, they will continue to “expose the power dynamics between and within countries.” For example, Ghiwa Nassereddine, a recent graduate in Lebanon, reflects on the personal impact vaccine inequity had on her life, “My mother, who lost her battle to the pandemic, was a victim of vaccine inequity. She was 48 years old with no [medical] comorbidities, therefore was not deemed high risk for COVID-19. However, in Lebanon, the risk stratification was non-existent. Powerful individuals with political and economic advantages jumped the COVID-19 vaccine line as they pleased, and in the end, political connections, sectarian origins, and socio-economic status determined access.”
Similarly, in the Philippines, the government developed a priority list where the entire population was grouped according to vulnerabilities. “This appeared to be a logical system, but the list was continuously revised to accommodate new sub-groups. It ended up confusing people, and revealed how politics complicates policy-making,” says Reiner.
Corrupt leadership in countries like Lebanon, Brazil, and South Africa (SA) does little to help the situation. “We have a malignant problem of government corruption [in SA] which continues to metastasise during the pandemic. Although the vaccination campaign is being brought back from the brink, millions of pandemic funds were siphoned off by government officials, which could have been used to procure vaccines sooner,” reflects Hloni. Ramonde Patientia, also a physician in SA expands upon Hloni’s remarks, saying, “these funds were designated for COVID-19 communication efforts early in the pandemic, which has made it difficult if not impossible for the government to be trusted with vaccine promotion. As such, vaccine hesitancy and anti-vaccine protests are not uncommon.”
In India, overwhelmed systems with a lack of stuff, space, and staff worsened inequities, notes Bhavna Seth, a physician from India currently in the US, “it was angering having followed the heartening vaccine allocation framework ethics discussions, and then realizing none of it was being implemented.” Finally, centuries-old-caste-based-discrimination in the country further marginalizes the vulnerable. Manik Singh, a resident psychiatrist in India shares, “When I asked my patient’s mother if they got vaccinated, she said, “I am from a low caste; people won’t let us fetch water from their wells, how do we get vaccinated?””
Call to action: If not now, then when? If not us, then who? And if not together, then how?
First, those with power must act now: it is not too late to re-imagine and re-create a world where vaccines are equitably distributed. This will require committed leadership and collective action at all levels. We call on world leaders to step up: follow through on pledges to donate one billion vaccines; support Intellectual Property waivers to strengthen local capacities in LMICs, commit to the World Health Organization’s (WHO) moratorium on holding booster vaccines, and lead with compassion, integrity and shared accountability. Further, we call upon the WHO, UN, WTO, and all (public) health institutions to hold leadership accountable in and out of closed rooms that we cannot yet access. And, we call on them to get us inside these rooms. If leaders don’t act now, history will repeat, and we will be forced to re-learn the lessons from this pandemic.
Second, we call upon fellow young professionals to join our efforts to hold systems and actors of power accountable. Our unique power is that we are the future of these health systems; this is our fight too. The decisions of current leaders directly impact our communities, livelihoods, and the duty of care we have to the people we serve. We call upon youth to unite, collaborate, advocate, and ask the tough questions of our leaders, and demand just action.
Vaccine inequity has manifested in varying ways including economic stagnation, rising burden of mental health crises, or continued systemic and domestic violence. In order to realise the noble goals of equity and justice, stakeholders across these equally and differently affected sectors must come together.
We encourage all within our global community to rise up, prioritize people over profits, and commit to work together and re-create a world where vaccines are equitably available and health systems work for all. Although appeals to the ethics, morals and principles of utilitarianism have failed thus far, we believe there is time to course correct.
We can be better than the status quo; for the future of global public health, we have to be.
To our fellow young professionals (in and out of health), join us! Some of the contributors of this piece are members of the International Working Group for Health Systems Strengthening (IWG), and we invite you to participate in our Global Vaccine Equity Pledge. Strengthen our youth-led advocacy movement and tell us why you support vaccine equity and what it means to you. Follow the link here: https://bit.ly/37z9lbr.
Malvikha Manoj, MSPH, is a recent graduate from the Health Systems program at the Johns Hopkins Bloomberg School of Public Health. She is interested in global public health policy and systems strengthening, with a focus on child and adolescent protection and mental health. Malvikha serves as Chair at the International Working Group for Health Systems Strengthening (IWG).
Hloni Bookholane, MBChB MPH, is a doctor from South Africa and a graduate of the Johns Hopkins Bloomberg School of Public Health. His interests are in global health, diplomacy, and health policy. He is the author of Becoming a Doctor – Learnings and unlearnings about life and the politics of medicine.
Reiner Lorenzo Tamayo, RN is a graduate student taking health policy studies at the University of the Philippines Manila. His interests include human resources for health, advanced practice nursing, and non-communicable diseases. He serves as the Research, Policy, and Communications Manager of Innovations for Community Health – a Filipino NGO based in Mandaluyong City, Philippines. Reiner serves as a Board Member for the Western Pacific Region at the International Working Group for Health Systems Strengthening (IWG).
Ghiwa Nasser Eddine, RPh, MPH; is a recent graduate from the Masters in Public Health (Epidemiology and Biostatistics) program at the American University of Beirut. She is interested in health equity, social determinants of health, in addition to sexual and reproductive health among young adolescent girls and women. Ghiwa is a regional leader with the Eastern Mediterranean Region at the International Working Group for Health Systems Strengthening (IWG).
Magali Collonnaz, MD, MPH, MSc; is a recent graduate from the Masters in Public Health (environment and health stream) program at the London School of Hygiene and Tropical Medicine and a PhD Candidate in Epidemiology at Université de Lorraine (France). She is interested in environmental health, the social determinants of health, as well as in child and adolescent health. She serves as a regional leader in the European region of the International Working Group for Health Systems Strengthening (IWG).
Marali Singaraju is a MPH Candidate at the University of Minnesota School of Public Health specializing in Community Health Promotion, Epidemiology, and Global Health. She is passionate about maternal and child health, mental health, social epidemiology, and global health systems and leadership. Marali serves as an Americas Regional Leader at the International Working Group for Health Systems Strengthening (IWG).
Bhavna Seth, MD, MHS is a pulmonary and critical care fellow at Johns Hopkins originally from India, with an interest in medical education, access to acute and palliative care systems in low and middle income countries. Laura Neenan BSc, MA; is a doctoral candidate in the Department of Psychology at the University of Limerick. She serves as a member in the European region of the International Working Group for Health Systems Strengthening (IWG) and her research interests include suicide prevention, health literacy and mental health promotion.
Ramonde Patientia, MD, is a Health Innovation graduate from the University of Cape Town who has worked for 15 years in youth and adult infectious disease clinical trials for novel medications and vaccines. She is passionate about health literacy and leveraging community networks in LMIC health systems, and serves as the African Region Co-Director for the International Working Group for Health Systems Strengthening (IWG).
Joy Muhia, is a Candidate in the Master of Science in Global Mental Health from King’s College London and London School of Hygiene & Tropical Medicine. She serves as a regional leader and board member for the European Region at the International Working Group for Health Systems Strengthening (IWG). She is interested in strengthening mental health systems ensuring equitable and quality access.
Meg McCarty, MSc is a recent graduate of the Masters in Public Health program at the London School of Hygiene and Tropical Medicine, and regional leader in the European region of the International Working Group for Health Systems Strengthening (IWG). Meg is a researcher and implementer with interests in health systems, health financing, and Universal Health Coverage.
Ivan Mufumba, BSc, Msc: is Research Laboratory Technologist and Epidemiologist in the CHILD Research Laboratory in Uganda; a research collaboration between Makerere University Department of Pediatrics and Indiana University School of Medicine. His research interests include maternal child health, health systems strengthening and social behavior change communication
Toluwani Oluwatola BChD, is a trained dentist, he currently works as a research officer at Lagos State Health Management Agency, Nigeria. He is a regional leader for the African Region in the International Working Group for Health Systems Strengthening (IWG) and is interested in health systems, policy and financing.
Manik Inder Singh Sethi MBBS, MD Psychiatry Resident in SRMIST, Chennai, holds a Fellowship in Mental Health Education, from NIMHANS, Bangalore. Research interests include Technological Advances in Medicine, Translational Psychiatry, Child & Adolescent Psychiatry & Addiction Medicine. Currently serves as the Co-Chair (Research WG) at the European Federation of Psychiatry Trainees. Manik serves as a regional leader in the South East Asia region for the International Working Group for Health Systems Strengthening (IWG).
Laura Neenan BSc, MA; is a doctoral candidate in the Department of Psychology at the University of Limerick. She serves as a member in the European region of the International Working Group for Health Systems Strengthening (IWG) and her research interests include suicide prevention, health literacy and mental health promotion.
Acknowledgements: The authors would also like to provide sincere acknowledgements to Kim Vu, Bronte Davies, Riddhi Wanchoo, Phong Truong, Nadine Nanji, Sudipta Ghoshal, and Jaime Marquis for their support in reviewing and supporting the progression of this piece at various points. We would also like to thank Dr Madhukar Pai, Ms Julia Robinson, and the team at PLOS Global Public Health for this opportunity.
We would also like to acknowledge the sustained efforts of all those who have been at the essential frontlines of this pandemic for the past year and a half, and to those who continue to fight for the noble goals of justice and equity at all levels, everywhere. Finally, we want to acknowledge those in our own networks, and those near and far, that have been victims of vaccine inequity. We persist for those we know, those we have heard of, and those whose stories remain beyond our reach or untold.