# Global Health Inequalities: Vaccines

December 2020 has been a pivotal month in the global fight against Coronavirus. Having pre-ordered enough COVID-19 shots to immunise their populaces a few times over, subject to governmental approvals, the US, UK, Canada and the European Union have already begun administering the first shots of Pfizer and BioNTech’s vaccine.

But in the world’s poorest countries, the wait for any doses at all could be much longer.

As governments across the world negotiate vaccine deals in this critical game of medical logistics – where supply is minimal but demand is immediate and universal – wealthy nations are accused of snatching up orders before they are even ready and in greater amounts than they need. According to research at Duke University’s Global Health Innovation Center, this race for deals could prevent poor countries from gaining access to enough vaccines for most of their populations until 2024. People’s Vaccine Alliance, a collaboration between several aid groups which include Amnesty International, has also stated that, given the current situation, an estimate of nearly 70 poor countries will be unable to inoculate 90% of their populations in 2021.

Looking into barriers that affect the global access to a vaccine, scientists and researchers have been able to find countless factors that allow the western world to put themselves at the front of the line. It is not just the obvious cost and availability of vaccines that puts the lower-income countries at a disadvantage, but also, these countries lack the basic infrastructure they need to transport, store and distribute these vaccines with the same capacity as other more developed countries.

### Manufacturing

Earlier in December, Pfizer became the first company in the world to have developed a COVID-19 vaccine authorised for emergency use in the West. Now, a little under a month later, more than 10.8 million doses have been supplied and administered in 29 countries. Expectedly enough, 83% of the total number of doses have been given out only in the US, UK and China alone, while the remaining 17% have been administered across Canada and Europe.

However, it takes time to manufacture doses.

The most effective vaccines use several different technologies, such as mRNA, recombinant protein and adenoviruses, and each of these has its own complex manufacturing process. This means that, although the leading vaccine developers and providers have been extensively scaling up production, we can safely conclude that worldwide demand will not be met anytime soon. Additionally, supply is further constrained given that all authorised vaccines require people to get two shots a few weeks apart. But the limitations of the production process do not end here; the last mile of the journey may be the most challenging. Many of the vaccines, including Pfizer’s and Moderna’s, have special storage requirements and conditions. For example, both developers must keep the doses in freezers at very low temperatures. This poses a major infrastructure issue for the developing world, especially where electricity may not be widespread.

Pfizer’s target vaccine supply goal for 2021 is at least 1.3 billion doses, while Moderna aims to produce between 500 million and 1 billion doses. While we can now see the light shining through at the end of the tunnel, we are nowhere near celebrating this triumph. According to researchers from Duke University, the current production capacity indicates that it could take at least three to four years to produce enough vaccines for the global population. Wealthier nations will most likely be able to issue multiple doses to inoculate their entire populations before the vaccines even become widespread in lower-income countries.

### Cost

One other obvious factor which limits the spread of the vaccine to poorer countries is the expensive cost. BioNTech announced that Pfizer has charged $19.50 per dose for the first 100 million doses that were supplied to the US. Given that one person requires two doses of the vaccine to be effectively immunized, the cost rises to$39 per person. Meanwhile, Moderna is currently charging from $25 to$37 per dose and $50 to$74 per person.

These numbers immediately eliminate any chances of achieving herd immunity amongst the poor communities. However, several drugmakers have announced that those extremely vulnerable segments of society will also be guaranteed access to the vaccines. Having promised to reserve 400 million doses of its vaccine for low- and middle-income countries, AstraZeneca will also be selling all vaccines at a cost between $3 and$5 per dose. In addition, Johnson & Johnson has announced a no-profit guarantee from its sales to the poorer nations as well, while China’s vaccine will be made a “global public good”.

### Covax

Since May, and way before being anywhere near developing safe and effective vaccines, wealthier countries have been placing pre-orders for potential ones. In an effort to prevent them from snatching up scarce doses, a scheme called Covax was launched in April by the World Health Organization (WHO), Gavi (the Vaccine Alliance) and the Coalition for Epidemic Preparedness Innovations (CEPI). The scheme allows countries access to an equal share of successful vaccine candidates, ensuring that doses are shared amongst all countries, regardless of their classification based on income and standard of living. Covax’s aim is to ensure that the poorer countries are provided with enough vaccines to cover at least 20% of their population.

So, Covax is quite literally a lifeline for the citizens of lower-income countries, who would otherwise be unable to get vaccinated. Further, as of January 1, evidence of any direct deals made between manufacturers and these poor countries is yet to be found. This suggests that they are relying entirely on the 20% population coverage from Covax.

Despite being a remarkable effort of global collaboration and solidarity, Covax is so extremely underfunded that even its founders are worried. Gavi has stated in a report issued in December that the likelihood of Covax failing its mission is “very high”. According to the report, the scheme has only managed to buy 200 million doses, which is just a 10th of the 2 billion it aimed for over the next year. Having originally signed advanced purchase orders for 700 million doses, Covax is currently unable to finance the purchase of the remaining 500 million, as it has fallen \$5 billion short of the money needed.

This is mainly because some countries, including the world’s largest economy, haven’t contributed. The US alone could eventually have access to 1.8 billion doses, which is estimated to be about a quarter of the world’s near-term supply. The number is not only shocking because this is more than their population of 328 million people could possibly ever use or need, but also since none of it would be shared with lower-income countries via Covax.

As for the many wealthy countries which have joined the scheme, such as the UK, Canada and the European Union, they have also made “side-deals” with manufacturing companies to guarantee their own supply. But this hoarding and stockpiling of vaccines does nothing but undermine the global efforts to ensure that everyone across the world is provided with a chance for protection from Coronavirus. Richer nations have simple human-rights commitments not only to abstain from activities that make the access of vaccines elsewhere challenging but also to aid countries that need this assistance the most.

### Transport and storage

Distributing the vaccines globally is proving to be yet another formidable hurdle. Cargo airline representatives have already said that distributing COVID-19 vaccines to everyone in the world could very easily take up to two years, making this one of the greatest challenges facing the transportation industry.

Some vaccines require significant investment to satisfy the conditions needed for transporting and distributing them. For example, Pfizer’s vaccine must be transported at -70 degrees Celsius through a system of deep-freeze airport warehouses and dry ice refrigerated vehicles. Not only do lower-income countries lack the finances to afford these specially-adapted vehicles, but they also lack the transport links and road networks needed to distribute the vaccines to all those in need.

Nevertheless, even if developing countries can push past these restrictions and vaccines eventually reach their target destinations, they will still have to be kept in cold-chain storage. Given that some of the most well-established US hospitals lack adequate facilities to store the doses, it is safe to conclude that lower-income countries will most likely not have access to the ultra-cold freezers and storage systems needed. Additionally, the vaccines can be thawed in regular fridges – and in this case, must be injected within five days. However, even then, several villages and informal settlements may not have a working fridge or electricity.

The various vaccines developed have different storage needs that are all proving to be unsuitable for the developing world. But still, some may be better than others. For example, AstraZeneca’s vaccine can be stored, transported and handled at normal fridge temperature for over six months. This means that it can be administered within existing healthcare settings and does not require investment in expensive cold-chain facilities.

### Cause for optimism

Despite the myriad of challenges facing lower-income countries today, mass global vaccination is still possible. There may always be a selfish reason motivating wealthier countries to ensure the vaccination of the whole world. Even if the US, the UK and other large economies achieve herd immunity, immunizing between 60 to 72% of their populations, the rest of the world would still serve as a threat to their safety. Hopefully, this will be enough incentive to provide aid, because like German President Frank-Walter Steinmeier said, “even those who conquer the virus within their own borders remain prisoners within these borders until it is conquered everywhere.”