In January 2020, world leaders and industry titans gathered in Switzerland for the World Economic Forum’s annual Davos conference. Much of the conversation centered around the mysterious new coronavirus that had emerged in Wuhan, China, a month earlier, and had at that point infected nearly 300 people in four countries.
Two of the conference’s attendees were Dr. Seth Berkley, CEO of Gavi, the Vaccine Alliance, and Dr. Richard Hatchett, CEO of the Coalition for Epidemic Preparedness Innovations (CEPI). Over scotch and nachos one night, Berkley and Hatchett got to talking about worst-case scenarios. “‘If this does evolve into a pandemic,’” Hatchett remembers discussing, “‘how are we going to get [vaccine] doses to developing countries?’”
Hatchett, who served in both the George W. Bush and Obama administrations, oversaw the U.S.’ vaccine donations to other countries during the 2009 H1N1 pandemic. As COVID-19 began to spread in early 2020, he didn’t know if vaccines would prove necessary. But he knew from experience that, if they did, wealthy countries were likely to buy out and hoard whatever limited supply of doses came together—unless “aggressive action,” as he describes it, was taken to stop them.
In March 2020, as the COVID-19 virus continued to spread across the planet, Hatchett wrote a white paper laying the groundwork for a solution: a global initiative to support the development of COVID-19 vaccines through advance agreements with numerous pharmaceutical companies, and to distribute shots to countries around the world, whether or not those nations could pay for them. Those ideas ultimately helped inform COVAX, the global vaccine distribution project co-led by CEPI, Gavi and the World Health Organization (WHO), with logistical support from UNICEF.
“It was a breathtakingly important initiative,” says Lawrence Gostin, a WHO adviser and a professor of global health law at Georgetown University. “The first of its kind ever in the world.”
But it was far from perfect. The very issues that Hatchett feared—vaccine nationalism, self-interest, unequal access to limited supply—soon scarred COVAX’s idealistic facade. While COVAX struggled to secure funding, wealthy countries struck out on their own, signing unilateral deals with vaccine makers and buying up limited supply. And as wealthy countries rocketed ahead, COVAX’s pledge to distribute vaccines in poor countries at the same time they rolled out in rich countries faltered.
As of Sept. 8, COVAX had distributed more than 240 million vaccine doses in 139 countries. That sounds like a lot—and it is, relative to any other public-health crisis in history—but it will almost certainly leave COVAX well short of its goal of distributing 2 billion doses by the end of 2021. The initiative now expects to have access to 1.4 billion doses by the end of 2021 and to hit 2 billion in the first quarter of 2022, the group said in a statement.
COVAX is largely placing the blame on the shoulders of the world’s richest countries, some of which have purchased more than enough vaccines for their populations. While many wealthy countries have begun to donate unneeded doses to COVAX, “The global picture of access to COVID-19 vaccines,” COVAX representatives said in the statement, “is unacceptable.”
Indeed, in the U.S., about half the population is now fully vaccinated. In other wealthy countries, like the U.K., an even larger share of citizens have gotten their shots. By contrast, experts have estimated it could take until 2023 for many lower-income countries to vaccinate the majority of their populations, even with COVAX’s assistance. Meanwhile, people are dying, economies are struggling and the virus continues to mutate.
“As an ideal, [COVAX was] an A+,” Gostin says. “In its implementation, a C.” Flawed though it may be, COVAX represents a step toward international health equity—and improving its implementation could be lifesaving not just during this pandemic, but also the next one.
The plan to ensure no country was left behind
COVAX’s funding model is complex, but the basic plan went like this: Wealthy countries would purchase at least some of their vaccines through the COVAX facility, even if they also signed their own deals on the side. With that group purchasing power, COVAX would negotiate cost-effective deals with various vaccine makers, and participating countries would have an insurance policy in case their own vaccine procurement plans failed. Meanwhile, another arm of COVAX would collect donations from nonprofits, businesses and countries to support the donation of billions of doses to low- and middle-income nations.
This model enabled COVAX to spread its bets by backing numerous vaccine makers; that way, plans would be in place with whichever companies ultimately succeeded in developing an effective vaccine, and it wouldn’t matter as much if some failed. The group’s donation arm was meant to guarantee that poorer countries would get access to vaccines at the same time as richer ones. COVAX’s initial goal was to provide enough vaccines to protect some 20% of each country’s population, before any participating country got more than that.
COVAX officials always knew wealthy countries would make some deals with vaccine makers on their own, Gavi’s Berkley says. But the group’s goal was to streamline the process enough to avoid a total free-for-all. “Let’s just say there’s no COVAX,” Berkley says. “You have 204 countries all going after the same manufacturers in a competitive fashion, trying to do deals, undercutting each other.” Centralizing a significant chunk of that activity, COVAX’s leaders hoped, would prevent lower-income countries from getting left behind. But some wealthy countries, most notably the U.S. and China, initially opted out of COVAX entirely.
Meanwhile, COVAX was struggling to sign major deals. As a brand-new organization, it didn’t have any funding in the bank. And many countries—even those that pledged to be part of the initiative—were slow to turn promises into actual financial contributions. It didn’t help that wealthy countries weren’t only depriving COVAX of much-needed funding by relying on their own side deals, but also buying up large chunks of the vaccine supply before the shots were even available.
After the Biden Administration took over from Donald Trump in early 2021, it did shift polices, pledging $4 billion to COVAX over two years. (China eventually pledged to buy enough shots through COVAX to vaccinate 1% of its population.) But by then the damage was done. As soon as highly effective vaccines were authorized in late 2020, manufacturers began shipping much of their supply directly to the U.S. and other rich countries.
Some experts say it was naive for COVAX’s leaders to even pretend that rich countries would whole-heartedly buy into a system that aimed to vaccinate the rest of the world at the same rate. “Do you think [20% vaccinated by the end of 2021] would be considered a success for the U.S.? No,” says Mark Eccleston-Turner, a medical law and ethics expert at Keele University in the U.K. “Having such a low target perpetuated this injustice.”
Why COVAX had to play catch-up
In the summer of 2020, members of the WHO’s ethics committee met with leaders from COVAX to discuss its population-based allocation plan. Immediately, says someone who attended the meeting (and who asked to remain anonymous so they could openly discuss it without fear of reprisal), members of the WHO’s ethics committee expressed concerns. Why were all countries set to receive the same proportional number of vaccines, when need varied drastically? (A WHO spokesperson said the discussions were confidential and did not confirm or deny that account.)
Some experts—both part of and independent from the WHO ethics committee—say it would have been more sensible to distribute vaccines based on the severity of COVID-19 outbreaks in various countries, rather than by a fixed measure of population. “You want to put the hose on the fire,” Gostin says. That is, COVAX could make the biggest impact by bringing vaccines to countries with the largest amounts of death and disease, rather than by distributing shots uniformly, he argues.
Of course, there’s no guarantee that an in-need country will actually be able to use the doses it is given. Already, many poor countries that have received doses from COVAX have wasted large amounts of vaccine because they lack the cold storage and health infrastructure needed to distribute them.
But more importantly, argues CEPI’s Hatchett, the needs of a country at any given moment are not enough to establish an ethical distribution of vaccines, since it’s impossible to predict when or if a country will struggle with a future COVID-19 outbreak. For example, India was doing relatively well during the first year of the pandemic, and as a result, the Serum Institute of India (SII), a massive facility located in Pune and licensed to produce AstraZeneca-Oxford University and Novavax’s shots, felt comfortable committing to produce hundreds of millions of doses that COVAX could distribute to other countries. But in the spring of 2021, India was pummeled by COVID-19, and the nation decided to temporarily pause all exports and focus on distributing domestically made shots at home, in hopes of minimizing damage associated with the surge. That left COVAX about 190 million doses short of its goals by the end of June 2021.
The delay at Serum Institute is “one of the largest reasons [COVAX] has been behind schedule,” Gian Gandhi, the COVAX coordinator for UNICEF’s supply division, says. That raises the question of why COVAX relied so heavily on a single manufacturer.
While COVAX was trying to scrape together money in the summer of 2020, one of its partners, the Bill & Melinda Gates Foundation, along with GAVI, signed a deal with the Serum Institute to ensure that 100 million vaccine doses would be available for low- and middle-income countries during the first half of 2021; they later expanded the agreement to cover an additional 100 million doses. “Gates was comfortable working with SII because they’d done a lot of these types of deals [with them] and felt this was an affordable way to proceed,” Gandhi says. The Gates Foundation’s support was critical for COVAX, but it made SII its primary supplier and, to a large extent, dictated its ability to provide vaccines. “I’m not sure that there would have been another way, because there wasn’t any other money,” Gandhi admits.
Things might have turned out differently if global economic leaders like the U.S. put up money from the beginning, potentially inspiring other wealthy nations to do the same. In that alternate reality, perhaps COVAX would have had enough cash on hand to sign bigger deals with vaccine makers and to secure a more diverse array of manufacturers, boosting supply and safeguarding itself against unexpected delays.
Even better, of course, would be if COVAX hadn’t had to scramble for funding during an ongoing pandemic. The true blame, medical law expert Eccleston-Turner says, lies with the international community’s failure to create something like COVAX before it was needed. A global vaccine hub could have been developed after the 2009 H1N1 pandemic, which revealed similar disparities in vaccine access, but it never came together. “In the intervening years between 2009 and COVID, we did very little to solve this problem, to prevent this from being a problem in the future,” Eccleston-Turner says. “COVAX was always playing catch up.”
It’s hard to imagine any organization built on the fly in the midst of a public-health crisis overcoming centuries of entrenched issues in global health. It’s not COVAX’s fault that some countries simply don’t have the public-health infrastructure required to store, distribute and manufacture vaccines, nor that centuries of inequality have left some countries able to vaccinate their populations many times over while others cannot afford to sign a single contract.
COVAX couldn’t single-handedly change the way high-income nations carry out their foreign relations and political maneuvers, which were always going to include some amount of nationalism, Gostin says. Some rich countries that bought enough vaccines for themselves haven’t been shy about requesting even more from COVAX. The U.K., as the Associated Press reported, asked for nearly half a million doses in June. “The primary function of a sovereign state is to serve the interests of its own population and you’re always fighting against that,” Eccleston-Turner says.
If there’s a silver lining…
COVAX has indisputably helped get vaccines to countries that otherwise could not have purchased them, and faster than has ever been done before. “There’s no question, if you compare it to the [H1N1 pandemic]…we’ve done much better this time,” Berkley says. “But of course, it’s not good enough.”
Dr. Ann Lindstrand, unit head for the WHO’s Essential Programme on Immunization, agrees that distribution has been a “disappointment,” but also argues that the groundwork laid by COVAX will have a significant positive impact moving forward. “In the end,” says Lindstrand, “COVAX will prove itself as a very important mechanism for global equitable distribution when we have a common threat.”
COVAX has made many mistakes. But perhaps the biggest would be using its errors as license to scrap it completely. If the COVAX saga has shown anything, it is that the world can’t afford to wait for a solution to be built once a problem has already arrived. There must be a tool standing ready—funded and organized and able to spring into action—the moment a new health crisis emerges.
Now that we have the basis of such a tool, the international community needs to commit to funding it, so it doesn’t have to beg in the middle of a crisis, says Ezekiel Emanuel, vice provost for global initiatives at the University of Pennsylvania. Gostin adds that COVAX could stand to be improved operationally—for example, it could be more transparent about who is making its decisions and why, something that can get lost in the shuffle of an initiative co-led by four different organizations. Eccleston-Turner says COVAX and other global health groups also need to pay more attention to building out manufacturing and public-health infrastructure in countries that need it, rather than simply parachuting in and offering vaccines that many don’t have the capacity to use to their full extent.
There’s room for improvement, to be sure. But Gostin says it’s more sensible to improve upon the existing—if imperfect—COVAX model, rather than starting from scratch.
“If we didn’t have COVAX,” he says, “we’d have to invent it.”
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Contributor: Jamie Ducharme