As soon as the first COVID-19 vaccines get approved, a staggering global need will confront limited supplies. Many health experts say it's clear who should get the first shots: health care workers around the world, then people at a higher risk of severe disease, then those in areas where the disease is spreading rapidly, and finally, the rest of us. Such a strategy "saves the most lives and slows transmission the fastest," says Christopher Elias, who heads the Bill & Melinda Gates Foundation's Global Development Division. "It would be ludicrous if low-risk people in rich countries get the vaccine when health care workers in South Africa don't," adds Ellen 't Hoen, a Dutch lawyer, and public health activist.
Yet money and national interest may win out. The United States and Europe are placing advance orders for hundreds of millions of doses of successful vaccines, potentially leaving little for poorer parts of the world. "I'm very concerned," says John Nkengasong, director of the Africa Centres for Disease Control and Prevention.
To avoid such a scenario, the World Health Organization and other international organizations have set up a system to accelerate and equitably distribute vaccines, the COVID-19 Vaccines Global Access (COVAX) Facility, which seeks to entice rich countries to sign on by reducing their own risk that they're betting on the wrong vaccine candidates. But the idea has been put together on the fly, and it's unclear how many rich countries will join.
Recent history isn't encouraging. A cocktail of powerful antiviral drugs revolutionized HIV treatment in the West in 1996, saving many lives, but it took 7 years for the drugs to become widely available in Africa, the hardest hit continent. "That was catastrophic and that experience is high in my mind," Nkengasong says. During the 2009 H1N1 influenza pandemic, the United States and many European countries donated 10% of their vaccine stocks to poorer countries—but only after it became clear they had enough for their own populations. "Too many had to wait too long for too little," says Richard Hatchett, CEO of the Coalition for Epidemic Preparedness Innovations, a partner in COVAX.
This time, too, rich countries' biggest concern is to protect their own citizens. The U.S. government has signed deals worth more than $6 billion with several vaccine companies as part of Operation Warp Speed, which aims to provide the U.S. population with vaccines by January 2021. Europe's Inclusive Vaccines Alliance, formed by France, Germany, Italy, and the Netherlands, has signed a deal to buy 400 million doses of AstraZeneca's vaccine for use in EU member states. The United Kingdom has inked deals with AstraZeneca and other companies as well. China is developing its own vaccines; it's unclear how early it will be willing to share or whether the shots will come with political strings attached.
The idea behind COVAX is to invest in about 12 different vaccines and ensure early access when they become available. "The goal is to have 2 billion doses by the end of 2021," says Seth Berkley, director of GAVI, the Vaccine Alliance, the third COVAX partner: 950 million for high- and upper middle-income countries, 950 million for low- and lower middle-income countries, and 100 million for "humanitarian situations and outbreaks that are out of control." A first $750 million deal with AstraZeneca for 300 million doses was announced on 4 June.
Berkley accepts that many rich countries will do their own deals with manufacturers. But signing up to COVAX in addition is an insurance policy, he says. If the vaccines they have invested in fail to materialize, they would still have access to others through COVAX, although only enough for 20% of their populations. The money they invest will be used to guarantee lower prices for poorer countries. Separately, the COVAX Advance Market Commitment is collecting donations from the higher-income countries. GAVI says COVAX will need $2 billion in donations to pay for the vaccine doses in 90 countries. "We're trying to do everything we can to try to have a global approach because we think it's the right thing to do from a science point of view and from an equity point of view," Berkley says.
COVAX is planning to spread its own risk by investing in a variety of vaccine strategies. Single-dose vaccines could be easier to give in refugee camps, for instance, whereas a double-dose regimen might work fine at a European doctor's office. Some vaccines are based on new technology, creating more uncertainty about regulatory approval and manufacturing capacity. COVAX also hopes to source its vaccines from companies in different locations, so that no single country can stop them from being exported.
COVAX is a clever way to try to hold together the interests of different countries, says David Fidler, an adjunct senior fellow for global health at the Council on Foreign Relations. "Even from the point of view of raw self-interest that governments often have, you can see why this would look attractive," he says. "They're not ignoring the political reality." But he worries countries may hesitate to sign up, and that those that do may renege on the deal once the scramble for doses actually begins.
So far, more than 70 countries that plan to finance their own vaccine have expressed interest in signing up with COVAX. (They have to formally commit by the end of August and provide an advance of 15% of the overall amount.) Whether they will come through is another matter. Some countries in the European Union—which often stresses the importance of global solidarity—have indicated they intend to donate money, but may not order vaccines themselves through COVAX. "Where the procurement of doses for themselves is concerned, we are still actively discussing with them," Hatchett says. "There are models where we could work together."
Nkengasong says Africa needs to explore other avenues as well. "We welcome the COVAX Facility arrangement but we cannot just wait for discussions in Geneva," he says. "We need to take charge of our own destiny." At an African Union meeting in late June, South African President Cyril Ramaphosa called on leaders to secure vaccine supplies for the continent and ensure that vaccines are manufactured there. Nkengasong says African governments are approaching banks to finance deals with pharma companies similar to those signed by the United States. "We need to come together as a continent of 1.3 billion people to not be left behind."
Kate Elder, a vaccines expert at Doctors Without Borders's Access Campaign, sees COVAX as perhaps the best shot at an equitable distribution of vaccines, but says it should be more transparent. "How did they choose AstraZeneca? What conditions are there in the agreement with AstraZeneca if the company doesn't meet volume commitments?" she asks. "None of the conditions around that are known." Both COVAX and governments should also ensure that funded vaccine producers make their data freely available to any company that wants to use them, 't Hoen adds. "I'm very worried that they are doing this without strings attached, that the know-how that is developed with this public funding does not become publicly available for others to use," she says.
What's needed most for COVAX to work is political commitment at the highest levels of government, says Alexandra Phelan, a lawyer at Georgetown University who specializes in global health. Without "a really big international effort," for instance at the United Nations or the G-20, the early doses of vaccines are unlikely to go to those who need them most, Phelan says. "It will be slow, it will be inadequate, and there will be unnecessary deaths."
It didn't have to be this way, Fidler says. Experts have long warned that a devastating pandemic was likely to hit some day, but the international community failed to put in place a mechanism to ensure equitable access to a pandemic vaccine. "So for an entirely foreseeable, expected, predicted, global problem," he says, "we have nothing."