What’s the Plan for Vaccinating the World?

Thirty-six. That is how many more COVID-19 vaccine doses have been administered per person in high-income countries compared to low-income ones; the difference was nearly 70-fold in mid-June. Even as wealthy countries roll out booster shots, the vast majority of the world’s most vulnerable remain unprotected, even health workers risking their lives to save others. Thus far, President Biden’s pledges to make the U.S. “the world’s arsenal of vaccines” ring hollow. This is not just an unconscionable injustice, but also a grave threat to Americans, as dangerous SARS-CoV-2 variants emerge abroad and travel here.

Will the President finally fulfill his pledge? Today, Biden hosted a virtual Global COVID-19 Summit at the United Nations General Assembly, and called for global shared targets, aiming to vaccinate 70% of the world’s population — in all income brackets — by September 2022. That would be transformational. Yet, we can’t afford to wait a year. The current pipeline of vaccines in high-income countries, together with ramped up production, should be enough to reach Biden’s 70% target, within 6 months. By next September, we should aim higher to reach 80% worldwide vaccination coverage. We offer a plan for how to reach that target.

Wealthy Nations Are at Fault for Vaccine Inequity

The U.S. and other high-income countries have a moral obligation to vaccinate the world. Of the more than 6 billion doses administered globally, 79% have been in high- and upper-middle-income countries, and 0.5% in low-income countries. A mere 2% of people in low-income countries have received even a single dose.

The U.S. and other high-income countries are directly responsible for these cavernous gaps in vaccine coverage. Before vaccine candidates even completed clinical trials, wealthier countries signed pre-purchase agreements with vaccine manufacturers, ensuring they would be at the front of the line. Furthermore, European and U.S. export controls on vaccines, raw materials, and equipment proved to be major obstacles for lower-income countries.

Global COVID-19 vaccine inequities also reflect what wealthy nations did not do. Funding for COVAX, which was meant to be the mechanism for equitable global vaccine distribution, was inadequate. And wealthy countries failed to use their legal and economic leverage to expand global vaccine supply.

Biden’s Plan Must Be Big and Bold

U.S. funding and donations thus far don’t rise to the level needed to respond to a once-in-a-century crisis and fall far short of our response to the AIDS pandemic — with PEPFAR (President’s Emergency Plan for AIDS Relief) and the Global Fund. What would an audacious plan look like?

Accelerate donations. The most immediate need is more doses now. Biden proposed a global target of 1 billion donated doses, but without a clear deadline. That deadline should be the end of this year and should build on existing pledges, including President Biden’s earlier commitment to buy 500 million Pfizer doses for COVAX and the African Union. To coincide with the Global COVID-19 Summit, the Biden administration is purchasing an additional 500 million Pfizer doses for donation. It’s an important step, but not enough. President Biden should accelerate the earlier Pfizer pledges, and donate the hundreds of millions of surplus doses the U.S. should have by year’s end.

Limit boosters. We recognize the intense political pressure on Biden to prioritize Americans. But his initial plan to boost the entire eligible U.S. population was tone deaf to global suffering, and a slap in the face to WHO’s call for a booster moratorium. Last Friday, an FDA advisory committee dissented, recommending limiting boosters only to the most vulnerable. This should free up over 100 million additional doses this year.

Bump COVAX to the head of the line. Biden should permit COVAX to go before America for more doses – as his Global COVID-19 Summit targets propose. COVAX has underperformed but its multilateral equity platform is inspirational. Biden should provide previously pledged COVAX funds now, while contributing significant additional funding. He could help both COVAX and low- and middle-income countries (LMICs) by lifting the raw materials export ban imposed earlier under the Defense Production Act (DPA) (the ban was eased in April to enable exports to India).

Expand vaccine manufacturing in high-income countries. About 11 billion doses are required to vaccinate 70% of the world’s population. The world is on track to reach that number by 2022, although that figure includes Chinese vaccines with uncertain effectiveness. We also need to anticipate raw material needs and manufacturing disruptions that could slow production, and create sufficient global capacity to ensure that in the coming years people everywhere can get timely booster shots or variant-specific vaccines if needed. Investing in domestic manufacturing and using legal tools like the DPA could provide a badly-needed supply cushion.

Empower regional hubs to manufacture state-of-the-art vaccines. Ramped up domestic vaccine manufacturing is necessary, but not nearly enough. When a rich country donates a dose, it could save a life. But empowering regional hubs to produce their own vaccines could end reliance on the Western philanthropy at the heart of vaccine inequity. President Biden’s draft shared commitments pays lip service to expanded manufacturing in LMICs, but without details or production targets. What would it take?

Biden should lobby hard for an intellectual property waiver at the World Trade Organization (which the European Union has been blocking) but even a waiver would be insufficient. Biden must push western vaccine manufacturers to share their technology, trade secrets, and know-how to make cutting edge vaccines, and the U.S. should invest in building and retrofitting manufacturing facilities in LMICs. mRNA vaccines are most promising. They can be manufactured at scale and are more adaptable to fighting emerging variants. Countries like India, Brazil, and Vietnam have a track record in vaccine production. South Africa is already establishing the first WHO-backed COVID-19 mRNA vaccine technology transfer hub. Asian countries like Australia, Singapore, and South Korea are seeking mRNA manufacturing capacity, which could supply the whole region. The NOVID Act, backed by more than 100 Members of Congress, would authorize $25 billion expanding domestic manufacturing and technology transfer.

Biden has leverage over domestic producers. The NIH supported basic research to develop mRNA platforms; the U.S. paid premium prices to domestic manufacturers and lavishly funded Moderna under Operation Warp Speed; and the NIH also holds key patents. Our vaccine producers, moreover, have a moral responsibility to be good global citizens.

What’s most exciting is regional vaccine hubs could ensure rapid and equitable access for future health crises. Low-resource countries would be empowered to serve their own health needs without having to ask for life-saving medical resources, which never seem to come on time or at the scale needed.

Build vaccine infrastructure. Having sufficient vaccine supply is not enough; doses must make it into people’s arms. In many LMICs, this requires large investments in trained vaccinators, cold storage, supply chains, and data systems. The Biden administration should provide the billions of dollars needed. The targets include $3 billion this year and $7 billion next year. That is too slow, and the amount may be insufficient. In addition, vaccine hesitancy is a global phenomenon. The administration’s plan should include funding for local education campaigns to ensure vaccine uptake.

The World Needs a Plan

Most importantly, the world needs more than vague targets. It needs a plan. Which countries will provide funding? How will capacity and donations be ramped up and doses directed to where they are most needed, and equity ensured? What resources are required to support end-to-end delivery? The Summit must urgently be followed with a robust plan. And wealthy countries must be held accountable for amply funding and implementing that plan. The global vaccine dashboard that the Global COVID-19 Summit agreed to is a start, and should include information on manufacturing pipelines and constraints. More accountability will be needed, though, including clear metrics on countries’ financial and dose donations, and any other commitments — and progress towards achieving them.

A global plan must meet the moment in its scale and creativity. It will save countless lives and is also economically smart — helping the global economy recover and yielding immense dividends to higher-income countries. And above all, the faster the world’s people are vaccinated, the sooner this pandemic, and its ongoing risk of ever more dangerous variants, will come to an end.

Lawrence O. Gostin, JD, is university professor, Georgetown University’s highest academic rank, where he directs the O’Neill Institute for National & Global Health Law. He is also director of the World Health Organization Collaborating Center on National & Global Health Law. He is the author of the forthcoming book, Global Health Security: A Blueprint for the Future. Eric A. Friedman, JD, is Global Health Justice Scholar at the O’Neill Institute for National and Global Health Law at Georgetown University Law Center.

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