Wealthy countries have hogged Covid-19 vaccines, providing a glaring illustration of how unfair the world can be. While 57% of people in high-income countries had received at least one dose of vaccine by Aug. 30, the figure in low-income countries was just 2%, according to the United Nations. Health advocates worry that the imbalance will be aggravated by plans in wealthy countries to provide booster shots to fully inoculated people to combat the super-contagious delta variant of the coronavirus. The uneven distribution -- which many scientists say will likely prolong the global health crisis -- has prompted proposals to expand production of Covid shots, reallocate rich countries’ excess doses, and ensure vaccines are deployed more equitably in future pandemics.

1. Why were some countries first in line?

As inoculations were being developed, a number of affluent countries signed advance contracts with a variety of companies, securing the lion’s share of initial doses. The U.S., as part of its multibillion-dollar program hastening the development of Covid vaccines, also used wartime powers to require manufacturers to fill massive U.S. government orders first. The U.S., U.K. and European countries had the added advantage that companies with local manufacturing plants were the first to deliver vaccines with proven efficacy; China and Russia also rolled out vaccines early, before final trial results were in.

2. Where did this leave other nations?

A number of middle-income countries, such as Turkey, Malaysia, Serbia and El Salvador, have now managed to procure enough supply to inoculate significant portions of their populations. But the poorest nations are still waiting for anything beyond a trickle of the life-saving doses. Because many lack the financial clout to secure contracts for Covid vaccines on their own, they depend for supplies largely on Covax, an initiative backed by groups including the World Health Organization that was designed to provide fair access to the shots for every country. And Covax has fallen short of its goals.

3. What happened with Covax? 

Covax uses funding provided by governments and donors such as the Bill & Melinda Gates Foundation to make its own contracts with vaccine manufacturers. But it has struggled to get hold of doses, especially after India -- home to the Serum Institute, the world’s biggest vaccine manufacturer -- pared back exports to supply the domestic market following a new wave of infections there in March. The original aim of Covax was to distribute at least 2 billion doses, two-thirds of them to lower-income nations, by the end of 2021. By Aug. 30, it had shipped just 11% of that.

4. Will countries with ample supplies share them?

China and Russia were early to export vaccines as a tool of diplomacy, and in August China pledged to dramatically expand exports to 2 billion doses this year. In June, leaders of the Group of Seven nations upped their commitments so that in all they’ve promised to provide 2.3 billion shots to developing nations by next year. So far the actual contributions have been paltry. Health advocates say that billions more doses are needed and stressed that the speed of donations is as important as the quantity. They also worried that the flow of supply to the neediest countries would be interrupted by decisions in high-income nations to offer booster shots to people who’ve already been fully inoculated and to younger children.

5. What’s at stake?

The coronavirus has flourished in some places where vaccines have been scarce. In addition to causing misery locally, that increases the risk of the emergence of additional, worrisome variants, which will inevitably make their way elsewhere and may not be neutralized by existing shots. Many countries short of vaccines are relying on continued lockdowns to suppress the virus, stifling economic activity, while wealthier countries have been opening up. It’s possible that sub-Saharan Africa, where doses are in shortest supply, will be spared the worst effects. Researchers noted in a paper published in July that Covid’s impact has been significantly lower in the region than elsewhere and argued that the main factors are the relative youth of the population and the low numbers of elderly living in long-term care facilities. Still, many African countries are struggling to combat Covid on top of a string of other health threats. And there’s no guarantee the next pandemic won’t target the young, making future vaccine rollouts a concern for African health specialists.

6. What are the proposals for expanding vaccine access?

A group of countries led by South Africa and India has called for the World Trade Organization to lift intellectual property protections for makers of Covid vaccines to enable additional plants to produce more shots. Vaccine companies argue that they are already expanding production and that the move would have little if any practical effect. Few countries have the trained personnel to produce Covid vaccines even if they had the formulas. Some advocates of the waiver say it can serve as leverage to push pharmaceutical companies to voluntarily share their expertise more broadly. The WHO proposes serving as a coordinator of technology transfers, facilitating training and helping countries organize the necessary investments in factories. Global health advocates argue that it’s vital not just for this pandemic but for the next one to expand vaccine production beyond the current concentration in the U.S., Europe, India and China. The African Union’s Centers for Disease Control and Prevention announced an ambitious plan in April to establish new vaccine factories with the aim of reducing the continent’s reliance on imports from 99% to 40% of supply by 2040. 

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