Early agreements to purchase Covid-19 vaccines are beginning to pay off for the likes of Britain, the U.S., Canada and the European Union, but much of the world is waiting. Although there are ambitious efforts to ensure that the shots reach low- and middle-income countries, it’s unclear when that will happen. Public health specialists warn that delays are likely to prolong the pandemic, bringing more suffering and economic pain. The health crisis has already exacerbated global inequality. Now, there’s the prospect that frontline health workers in poorer nations could lag vast numbers of people in wealthier regions in gaining access to shots.

1. What’s at stake?

Health experts say the pandemic will be controlled fastest if safe and effective vaccines are deployed in the most efficient way possible -- with the first doses going to groups at the highest risk, such as medical workers, nursing-home staffers and the elderly, rather than to whole populations in rich countries. Research in December by the Eurasia Group found that leaving lower-income countries without access to vaccines during the pandemic would cause significant economic damage both for those regions and advanced economies. A study by Northeastern University in Boston concluded that monopolization of vaccines by wealthy nations -- what’s known as “vaccine nationalism” -- could cause almost twice as many deaths as distributing them equally.

2. How are richer countries first in line?

By securing doses from a variety of drugmakers, increasing the chances they’d have access to early winners, such as the vaccine designed by Pfizer Inc. and BioNTech SE and another by Moderna Inc. Some 96% of Pfizer’s first supplies and all of Moderna’s doses were snapped up by wealthy countries, according to a report by health advocates including Oxfam. In all, prosperous nations representing 14% of people on the planet purchased more than half of the most promising shots. Canada signed contracts to obtain enough potential doses for five times its population. China and Russia focused on domestic production and authorized their own shots before they’d been fully tested. They’ve vaccinated more than a million people, according to data compiled by Bloomberg.

3. Where does this leave low-income nations?

The People’s Vaccine Alliance, a coalition advocating rapid production and equitable deployment of shots, found that 67 lower-income countries, from Kenya to Pakistan, are at risk of being left behind. Researchers at the Duke Global Health Innovation Center estimate that the last in line may not get vaccines until 2024. Access now will depend on the vaccine developers trailing Pfizer and Moderna. AstraZeneca Plc and the University of Oxford, whose shot awaits approval, plan to commit almost two-thirds of their doses to developing nations, according to Oxfam and its partners. At most they may reach less than a fifth of the world’s population by the end of 2021, they said.

4. Has this happened before?

During the 2009 swine-flu outbreak that swept the globe, vaccine supplies flowed mostly to wealthy countries. Seth Berkley, head of Gavi, the Vaccine Alliance -- a nonprofit group focused on increasing access to immunization in poorer countries -- has warned that if the same scenario played out during the coronavirus pandemic, the virus would continue to spread and deaths would keep rising.

5. How might lower-income countries get vaccines?

Supply could play out in a variety of ways.

• At the heart of the effort is Covax, a global program led by Gavi, the World Health Organization and the Coalition for Epidemic Preparedness Innovations. Although the initiative has faced doubts it will be able to meet its goals, it has gained access to almost 2 billion doses of potential shots, thanks in part to pacts with drugmakers Johnson & Johnson and AstraZeneca.

• As part of Covax funding, Canada pledged to invest in the development of a mechanism to redistribute doses, through donations or exchange.

• Other groups have provided some relief. Mexico and Argentina, for instance, signed a deal with AstraZeneca through billionaire Carlos Slim’s foundation to fund the production of up to 250 million doses.

• India, where cases have climbed to more than 10 million, will likely rely in part on doses produced by the Serum Institute of India. That company joined with AstraZeneca to make at least 1 billion doses, half of which are earmarked for the country.

• Some vaccines, including AstraZeneca’s future shot, are expected to cost less and be easier to deploy than others like Pfizer’s that need to be stored at ultracold temperatures. More are on the way.

• There are calls to reallocate supplies to those most in need. Since wealthy nations will likely have more than enough doses, they should consider such a step, according to Mark Suzman, chief executive officer of the Bill & Melinda Gates Foundation.

6. What about vaccines from China and Russia?

While worries about vaccine nationalism are on the rise, some countries are pursuing “vaccine diplomacy” -- aiming to boost supplies while also strengthening political and economic ties. China has inked deals with countries such as Indonesia and Turkey. Very little data on efficacy and safety from the late-stage vaccine trials has been made public. A 2018 scandal that uncovered instances of Chinese vaccine-makers cutting corners hurt the industry’s global reputation. Backers of a Russian vaccine, despite skepticism from scientists, said they’ve applied for approval in 40 countries and that the inoculation will cost less than $20 for a course of two shots, cheaper than some Western vaccines. Argentina secured doses to begin giving Russia’s Sputnik V vaccine, and African health officials have discussed partnerships with both China and Russia to ensure the continent is not last in the queue.

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