We, the wealthy nations, are the problem: vaccine inequity in the COVID-19 pandemic
By Rae Kim
As Pfizer celebrated the first authorization of COVID-19 vaccines for emergency use in 2020, Albert Bourla, the Chairman and Chief Executive Officer of Pfizer, declared, “Today's news brings great pride and tremendous joy that Pfizer has risen to the challenge to develop a vaccine that has the potential to help bring an end to this devastating pandemic. We have worked tirelessly to make the impossible possible, steadfast in our belief that science will win”. This news brought tremendous hope to the world. People were optimistic, after a depressing year of hopelessness, that the pandemic would soon end. In 2022, however, the virus still circulates around the world and global death tolls remain high. If science has won, what else could be the problem? Even with the availability of effective vaccines, successful containment of the virus depends largely on human behavior: “We need social science, not just medical science, to beat the pandemic.” Back in 2020, when the first COVID-19 vaccines advanced through clinical trials, wealthy nations laid claims to the vast majority of doses that could be produced by the following year. They made pledges to share them with other countries, yet as always has been, the initial stance of rich countries quickly changed when uncertainty arose. While rich countries are hoarding excess doses of vaccines and pharmaceutical companies are spurning the opportunity to share their vaccine technology with drug manufacturers, the sheer scale of the health, economic, and humanitarian crises indicates that now is not the time for business as usual; rich nations, therefore, must stop pursuing their own interests, mandate pharmaceutical companies to share their patented vaccine technology, and provide logistical support needed to ensure equitable, universal distribution of vaccines.
Goals set for global vaccine equity have fallen woefully short. Upon emergence of COVID-19 variants, rather than meeting their pledges of support, rich countries started dispensing booster shots not just to the elderly or the immunocompromised, but to their entire populations. As a result, the number of vaccine doses distributed as boosters quickly surpassed the total number of all doses administered so far in poor countries. As people living in rich countries are posting selfies on their social media after receiving their third dose, 86.3% of people in low-income countries are still waiting for their first dose. In response to this large disparity, Madhukar Pai, an epidemiologist at McGill University highlighted, “I fear we are heading down a path where fundamentally nothing is going to change”. What is even more outrageous is that the possibility of fourth doses is being discussed in some of the wealthiest nations. With rich countries rapidly moving with their vaccination programs and loosening the last pandemic restrictions, a set of questions have been raised. Will COVID-19 become a “Third World disease”, a threat to poor countries only? Will rich nations, on the other hand, soon return to normal? The answer to these questions requires an interdisciplinary analysis by a variety of actors, including epidemiologists, public health officials, economists, and social scientists. Notably, experts of different disciplines are reaching a consensus: vaccine inequity benefits no one.
Scientists and health officials have consistently warned that booster programs risk prolonging the pandemic. Their concern stands in sharp contrast with the rationale of ongoing booster campaigns, which is to enhance the immunity of vaccinated individuals, to eliminate possible threats, and to end the pandemic. Such disagreement was explored by a recently published study that was conducted by scholars from City University of Hong Kong. They examined distinct vaccine allocation strategies using a multistrain metapopulation model, a system which factors in the dynamics of viral evolution and its subsequent impact on vaccine efficacy. With this system, they demonstrated that the inequitable vaccine allocation strategy initially leads to a rapid decline of cases in high-income countries (HICs) and a slow decline in low- and middle-income countries (LMICs). Benefits to HICs under these conditions, however, are temporary and limited, the scholars argued: “Short-term benefits […] come at the sacrifice of running a much higher risk of new strains’ outbreaks, eventually leading to unnecessary deaths in not only LMICs but also HICs.” Meanwhile, in the counterfactual scenario where the portion of vaccines donated by HICs is at least 46%, rates of infections and deaths in LMICs decrease significantly; at 80%, LMICs as well as HICs start experiencing a “life-saving difference” that is also long-lasting. Booster doses may strengthen the immunity of vaccinated populations, yet as denoted by the research finding, they ironically create an ideal situation for the virus by letting it undergo evolution in areas with low vaccination rates, and then puncture national boundaries by the accelerated air travel. Because the world is so interconnected, vaccine equity is needed not only for the benefit of developing countries, but for the benefit of all. Without equity, prolonged vulnerability to new surges of cases will inextricably exert devastating effects on every aspect of life, especially health systems.
The COVID-19 pandemic not only exposes but exacerbates long-standing cracks in health systems, particularly in developing countries. Aside from the death and disease directly caused by COVID-19, persistent circulation of the virus leaves already fragile healthcare systems with limited ability to provide care for other health conditions. Among many health services disrupted by the COVID-19 pandemic, the impact on routine immunization has been particularly severe. WHO reported that in 2020, 23 million children failed to receive basic vaccines through routine immunization services. Compared to the previous year, an additional of 3.7 million children remained vulnerable, promoting resurgence of vaccine-preventable diseases such as measles and polio. Safia Ibrahim, a survivor of polio, criticized such phenomenon and shared her childhood memory of facing challenges as a polio patient. After contracting polio as a toddler, her muscles were paralyzed which caused her to “[spend] the first six years of her life crawling” at home and “watching [her] peers walk to school.” If we continue allowing the virus to circulate and disrupt health systems, there will be countless more individuals who will contract not only COVID-19, but other infectious diseases that are preventable. And very often, these diseases will cause life-long suffering. While it seems at first glance that vaccine equity is needed only for the health systems of developing countries, equity is equally important for the health systems of developed countries.
In summer of 2021, a 67-year-old man living in Montreal, Francois Shalom, was informed by his doctors that his heart was malfunctioning. He scheduled a heart replacement surgery at the end of January 2022, but a couple of weeks before the scheduled date, he was notified that his surgery had been postponed indefinitely. “My life is at stake here,” he said in his interview. “This is not a facelift that I’m waiting for. This is surgery to save my life.” Shalom is not the only one experiencing a delay in life-saving surgery. Dr. Liane Feldman, a surgeon-in-chief at the Health Centre of McGill University, recently wrote, “I’m worried about the thousands in our own hospital, tens of thousands in our province and hundreds of thousands in our country of patients whose surgery has been postponed over and over again, delayed, postponed, cancelled.” Though there may be differences in the extent depending on the country, it is evident that even health systems of countries like Canada collapse when a high volume of COVID-19 patients flow in during a new wave. During these waves of infection, countless individuals lose their lives, either directly from COVID-19 or from the lack of timely interventions needed for other health conditions. Equity is needed, therefore, for the maintenance of essential health services and systems, for all the patients who depend on those systems, and importantly, for healthcare workers.
For the past year and a half, frontline healthcare workers involved in diagnosis and management of COVID-19 have consistently been exposed to risks of mental, physical, and emotional exhaustion. They have spent countless hours working in chaotic environments, listening to the cries of patients and their families, and witnessing deaths on a scale they had never seen before. The ethical dilemmas they face, as they are forced to decide which patients to save or give up, as well as the risk of infection for themselves further make them vulnerable to exhaustion. According to the U.S. Bureau of labor Statistics, nearly half a million workers in the U.S. have quit since February 2020, which accounts for around 18% of all healthcare workers in the United States. An exodus of healthcare workers leaves hospitals seriously understaffed, which in turn perpetuates a cycle of burnout in those remaining in healthcare and inevitably worsens the quality of care given to patients. To prevent more healthcare workers from quitting in droves, we must prevent further waves of infections. Again, future waves can only be prevented through vaccination of global populations. Once the number of cases decreases through equitable access to vaccines, not only can health systems return to normal, but economies that collapsed due to COVID-19 can also recover.
“Happiness is easily forgotten, but every detail of grief is etched on the soul”, cried Begum who lost her job and her daughter during the COVID-19 pandemic in India. She continued, “If I had just 50 000 rupees, I wouldn’t have lost my daughter”. Begum’s tragedy reflects a much bigger problem prevalent in today’s world: the employment crisis and the global economic recession promoting poverty and death. The International Labor Organization estimates that 8.8% of the global working hours were lost in 2020 alone, which are equivalent to 255 million full-time jobs across the world and global labor income of $3.7 trillion USD. These losses are estimated to have pushed 95 million people into extreme poverty, and another 200 million individuals are estimated to be at risk between now and 2030. As indicated by the statistics, important gains in reducing global poverty are rapidly being reversed. To stop this trend of economic recession, we must take decisive steps towards universal distribution of vaccines. Quite surprisingly, recent evidence suggests that equitable vaccine distribution not only benefits the emerging economies of LMICs but also the advanced economies of HICs.
With rapidly progressing vaccination campaigns in rich countries, many were optimistic that their economy would soon recover. Optimism over economic recovery, however, is now tempered by novel variants that cause constant resurgence of COVID-19 cases around the world. This is not unexpected or new. When rich countries started stockpiling excess doses of vaccines, social scientists or philanthropists were not the only ones to speak against vaccine inequity; even economists warned that inequitable vaccine allocation benefits no one. Nevertheless, world leaders ignored their advice. The economic repercussions of such decisions are described in a recently published working paper by economists from Koc University. Using a framework that combines an epidemiological study model with international production and trade networks, the authors estimated that developed countries bear up to 49% of global gross domestic product (GDP) losses occurred in 2021. These losses were mainly due to the advanced economies of developed countries having strong connections with the emerging markets and the developing economies of unvaccinated countries. Because of this interdependent relationship, even if the domestic economic losses are eliminated by countrywide vaccinations, rich countries still bear non-negligible costs from the prolonged pandemic. If not to ensure the right to health, which is an ethical and humanitarian responsibility, rich countries, for their own economic benefits, must coordinate efforts to distribute vaccines equitably.
With COVID-19 vaccines that are highly effective, at least for the moment, we still have the opportunity to end this pandemic, but only if the decisions about vaccine distribution strategies are made independently of traditional power structures. So, what do these strategies look like? First, rich countries must use their surplus vaccines to immunize individuals who are still waiting for their first vaccine doses, rather than to use them as boosters for double-vaccinated populations. While generous donations from rich countries can make a significant difference, donations themselves are not enough. To fully address the disparities in vaccination coverage, rich countries must allow LMICs to purchase and even produce their own vaccines at affordable costs by mandating pharmaceutical companies to share their patented vaccine technology and knowledge. And even with access to vaccines, there are also logistical problems to overcome, such as the storage and transport issues. Rich countries, therefore, must also help the poorest nations build the capacity and infrastructure required to store, deliver, and administer vaccines. Lastly, we must be prepared to confront the perplexing challenge of vaccine hesitancy. Though less is known about how people in LMICs will react to COVID-19 vaccines since large-scale vaccination has not yet started in many countries, educational offering may be needed to combat misinformation. With these steps, we can fight vaccine inequity that is prolonging the health, economic, and humanitarian crises. And once vaccine inequity is resolved, we can finally return to our normal lives.
Vaccine inequity is the biggest failure of our time. Because of this failure, we now enter the third year of this devastating pandemic even with effective vaccines in our hands. The consequence of vaccine inequity is devastating. The prolonged COVID-19 pandemic alters every imaginable aspect of life in developing countries and threatens decades of hard-won gains in healthcare and economies. Though not as evident, the same applies to developed countries. New waves of infections constantly overwhelm health systems of HICs, exerting detrimental impacts on the lives of patients as well as healthcare workers. The economies of developed countries also bear significant losses due to the connections they have with the emerging economies and markets of unvaccinated countries. For these reasons, rich countries not only have moral obligations, but also strong incentives to invest in universal allocation of vaccines. While there have been several initiatives launched to tackle vaccine inequity, it is evident that these efforts are not sufficient. Without further delay, rich countries must redirect vaccine doses earmarked as boosters to countries with low vaccination coverage and mandate big pharmaceutical companies to share their knowledge on how to manufacture vaccines. World leaders must also provide resources that can help developing countries tackle logistical issues and vaccine hesitancy. As always has been, science is not the problem; we are the problem. And before it is too late, we must step up to fix the problem, to fix us.
About the Author:
Rae Kim is a recent graduate of McGill University. Rae majored in Microbiology and Immunology, and upon graduation, she is planning to pursue a career in healthcare. She is passionate about equity and social justice issues in global health. Through her work, she hopes to raise awareness of those issues, advocate for marginalized populations in underserved communities, and improve their access to quality healthcare.