By Ana V. Diez Roux, MD, PhD, MPH

Like the pandemic itself, the allocation and distribution of the vaccines we developed so quickly to combat COVID-19 has illustrated with stark and even shocking clarity how the structures and systems in our society fail to achieve the values of equity and opportunity for all that we so often claim to espouse. Early in the pandemic, before we even knew when a vaccine would be available, there were many well-intentioned efforts to plan how the vaccine should be distributed to maximize its effectiveness in stopping the pandemic while at the same time addressing the inequities that the pandemic itself had so clearly highlighted. I was part of one of these efforts, a committee convened by the National Academies of Science, Engineering and Medicine at the request of the National Institutes of Health (NIH) and the Centers for Disease Control and Prevention (CDC) to develop a framework and guidelines for vaccine distribution.

The National Academies committee worked intensely during the late summer of 2020 to identify the principles and also the steps and processes that should guide vaccine allocation. The committee’s recommendations highlighted key values of fairness, transparency and equity and proposed the basics of a schema for allocation aligned with these values, and also highlighted the critical role of engaging with communities and many different partners to increase vaccine uptake. Most importantly to many of us, the report emphasized achieving equity in vaccine distribution as a key goal not only within the United States but also across the globe, even proposing that the United States allocate vaccines to other countries. Not a perfect report by any means, and in my view the recommendations could have gone even further with respect to global equity, but looking back now, and knowing what has transpired, it was incredibly hopeful and also, admittedly, naïve.

Inequities in uptake of vaccination by race/ethnicity, region and socioeconomic position continue to exist in the United States despite wide vaccine availability for a set of complex reasons. These inequities certainly need to be addressed because of what they mean for the perpetuation of inequities not only in COVID but also in a multiplicity of other health outcomes. But the inequities that we see on a global scale are even more shocking. Recent data show that 61% of residents of high-income countries have received at least one dose compared to only 3% in low income countries. Moreover the cost of vaccinating in low income countries is prohibitive: it has been estimated that the total cost to vaccinate a person is US$35 whereas the average annual per capita health expenditure in low income countries amounts to only US$41. And there is no clear solution in sight. COVAX, a platform which was to make vaccines available to lower income countries has failed miserably: it struggled to obtain doses and also to deliver them effectively. The recent donation committed by the Biden administration comes at the expense of diverting hundreds of millions of dollars promised for vaccination drives. Not only does the amount of vaccine available on a per capita basis differ starkly across countries, there are also clearly tier 1 and tier 2 vaccines with lower income countries having access to vaccines often considered (accurately or inaccurately) to be of lower quality than those available for example in the United States.

Calls by the WHO to prioritize vaccine allocation to countries with limited vaccine coverage over boosters (of debated effectiveness) in higher income countries have been blatantly ignored. Meanwhile the profits of pharmaceutical companies that produce what are rightly or wrongly perceived to be the best vaccines have soared and they have launched campaigns to accelerate the approval of boosters shots which will mean even larger profits. Calls to share patented knowledge and technology so that vaccines can be manufactured in the global south have also gone unheeded, despite recognition by experts that regional manufacturing is critical to worldwide vaccination in a crisis. In yet another ironic twist, vaccines being produced in Africa were actually being shipped to Europe.

Unfortunately, this global crisis will not be solved by pledges from rich countries, well-intentioned and generous as they may be. The vaccine distribution we see (fraught not only with inequities but also gross inefficiencies and discarded doses) reflects the functioning of a system in which vaccines are a commodity that is produced for profit and bought and sold. Ironically, significant public investments over decades supported the research that allowed us to develop novel vaccines so quickly. Remarkably, even the fact that only global vaccination can protect the rich in rich countries from the deadlier and more contagious strains that can emerge if transmission continues unabated, is not enough to overcome the dynamics of the system we have in place. The system we rely on to produce vaccines is of course not designed to do harm (and it has indeed produced large quantities of vaccine very quickly) but its distributional and equity consequences are clear for all of us to see. Vaccines are the paradigm of prevention in the interest of the collective. Many have begun to call for vaccines as a common good to be distributed at no cost across the world. Is humanity with all its accomplishments and creativity really not able to create a system in which vaccines are allocated not only fairly, but in a way that is truly effective in stopping COVID-19?