Isabel Rodriguez-Barraquer currently works remotely from Colombia. As an epidemiologist, she has been watching from afar as her colleagues back at the University of California, San Francisco, have started receiving vaccines available to lab workers.

The situation is very different where she now lives. Colombia is suffering a massive covid-19 outbreak and is still waiting to see the first doses of vaccine arrive this month: 50,000 doses of the Pfizer and AstraZeneca vaccines are expected in February, and a couple hundred thousand in March. The country has been cutting deals directly with drug makers, including China’s Sinovac, and working through international partnerships to obtain more. But Rodriguez-Barraquer fears it will be too late.

The coronavirus vaccination programs for the world’s richest countries are now in full swing. Almost one-quarter of the UK’s adult population has now had a first dose. The US, while not quite at that pace, has now given at least one dose to more than 35 million people.

But for low-income countries around the globe, the picture is very different—and may be for some time. Many of the world’s poorest are still waiting for the first doses to reach them. Estimates by the Economist Intelligence Unit suggest that some 85 countries in the developing world may not be fully vaccinated until 2023 at the earliest. For example, in January, the World Health Organization warned that the West African nation of Guinea was the only low-income country on the continent to have started vaccinating: but only 25 people (all senior government officials, the AP reported) out of the country’s population of almost 13 million had received a dose at that point.

One of the big problems is there isn’t yet any global rollout, only talk of it, says Chris Dickey, who directs the global and environmental public health program at New York University’s Global Health School. Rodriguez-Barraquer agrees. “The burden of illness and death could be prevented if there was more global coordination in vaccine supply,” she says. 

This imbalance won’t just lead to more deaths. It will cause a raft of economic, social, and health effects—not just in the nations affected, but throughout the rest of the world. 

Addressing vaccine inequality

The supply to poorer countries is low mostly because the majority of the available vaccines have been purchased or promised to richer countries in North America and Europe. To address this vaccine inequity, a coalition of international organizations, including the World Health Organization and governments, created a nonprofit called Covax in April 2020.

The idea was to create a global supply of vaccines for 92 low- and middle-income countries. In December, the nonprofit announced that it had secured access to some 2 billion doses for 2021 through donations and commitments from some manufacturers, but it is unclear how many of those will actually be delivered this year. The problem becomes more complicated because many countries are both working through Covax and trying to secure deals with drug makers themselves—making it more challenging for Covax to make deals with those manufacturers at the same time. 

The group aims to vaccinate about 20% of the people in the world, focusing on hard-to-reach populations in Africa, Latin America, and Asia. To do so, it needs another $4.9 billion in addition to the $2.1 billion it has already raised. But there are other problems. The cheaper and easier-to-transport vaccines like the ones pledged by AstraZeneca have been slower to gain regulatory approval. Meanwhile, other companies seem less interested in pitching in: Doctors Without Borders found that only 2% of Pfizer’s global supply had been granted to Covax, and Moderna is still “in talks” with the organization.

“Covax is a critical starting point that—without a commitment from President Biden—had a high probability of failure. It’s looking better now, but could still fail if it doesn’t get money and vaccines,” says Barry Bloom, a global health researcher at the Harvard T.H. Chan School of Public Health. Biden officially directed the US government to join Covax in late January. 

If it can succeed, the international program has many upsides. It establishes a mechanism of fairness that doesn’t depend on colonial mentalities of quid pro quo, says Bloom. It also absolves individual rich countries from having to determine which countries get what percentage of the vaccines. “This is a way of saying somebody else will take the rap, especially for the delivery time,” he says. 

We’re not safe until we’re all safe

The motive for getting the vaccine to poorer countries more quickly is not just altruism: evolution will punish any delays. SARS-CoV-2 has already mutated into several worrying new variants, and this process will continue. If countries with large populations wait to be vaccinated for years, the virus will keep mutating—potentially to the point that the first available vaccines lose effectiveness. That will be bad for everyone, but poorer countries, with less access to updated vaccines, will again feel more of the impact.

“We get more mutants and they get more deaths,” says Bloom. 

Judd Walson, a global health researcher at the University of Washington, worries more about the indirect effects of the pandemic in the developing world, where in many places covid-19 doesn’t even rank in the top 20 causes of death. Health systems have directed a lot of personnel and resources to dealing with the pandemic—setting up quarantine centers, doing surveillance, and more. In addition, funders and ministries have been diverted away from diarrhea, malaria, and other killers. 

As a result, those other programs are suffering: rates of immunization for diseases such as measles, diphtheria, tetanus, and whooping cough are declining, both for lack of supplies and personnel and because people fear going to health centers. “All those other things that are killing people are being neglected, so not providing a covid vaccine stops governments from shifting back to their priorities before the pandemic,” says Walson.

And while virus variants can travel fast in a highly connected world, so can economic instability. That’s one takeaway from a recent paper published by the nonprofit National Bureau of Economic Research. Sebnem Kalemli-Özcan, an economist at the University of Maryland, and colleagues analyzed how delays in global vaccine distribution would affect the economies in countries whose populations had already been vaccinated.  

The economic cost of inequity

They found that a world where poorer countries have to wait to be vaccinated would see a global economic loss of about $9 trillion this year, with wealthy countries absorbing nearly half of those losses in declining trade and fractured supply lines. (A similar study by the RAND Corporation estimated that failure to ensure equitable covid-19 vaccine distribution could cost the global economy up to $1.2 trillion a year.) Ensuring equitable distribution is actually in the best interests of advanced economies. “Their hit will come back and hit you,” says Kalemli-Özcan. 

Yes, when the majority of the population in richer countries is vaccinated, restaurants and gyms may bounce back to life. But there are many sectors of the economy that buy from emerging markets—for example, retail, automotive, textiles, and construction. All will all be hurt by a slowdown in those markets. Also, those countries are often customers. “If the US improves and Europe improves and they want to sell goods, if those countries they want to sell to are still sick, they are not going to buy those goods,” says Kalemli-Özcan. “No economy is an island, and no economy recovers until every economy recovers.” 

Even though globalization amplified the pandemic, it’s also the only solution to the pandemic, Kalemli-Özcan argues. Rich countries cannot prevent economic pain by hoarding vaccines; rather, they must invest in initiatives to increase the supply and reinforce distribution. Canada, for example, has placed an order for five times more doses than its population needs. The country is considering donating the excess to Covax, but it’s not clear how those vaccines will be given back if unused.

The research assumed that wealthy countries would be vaccinated in 2021 and others would wait until 2022—but if the gap grows to several years, the economic pain will be much greater.

Vaccine nationalism, as hoarding doses for one country is known, would be likely to backfire politically as well as economically. People around the world are watching to see when vaccines are available. And what that means for the political perception of the US in the world is really important, says Walson: “Vaccine nationalism is going to fuel a tremendous sense that we are only out for ourselves, and that only adds fuel to the already-burning fire by some against the West,” he says. “I think there will be long-standing consequences to not addressing these inequities.” 

Other solutions

Funding Covax is the most immediate solution. There are also opportunities to license vaccine tech or ease intellectual-property rights so emerging countries can develop the capacity to either produce their own vaccines or complete the final steps of production, known as “finish and fill.” 

“I don’t see why South Africa and Kenya can’t produce vaccines and why Ethiopia and Botswana can’t finish and fill,” says Bloom. He says that early in the pandemic, there were only two places on the African continent that had the capacity to do covid-19 testing—and within a month, there were 11. African countries even joined forces to create a center for disease control for the whole continent, sharing information and best practices on covid-19 in a way that isn’t even done across all 50 US states. 

But time is of the essence. At the current rate of transmission, probably 50% of Colombia will be infected by the time mass vaccinations start. Rodriguez-Barraquer fears what that means for the country where she grew up: “The worry is that it will be too little, too late, and the epidemic is running its course.”

By ASNF