The Washington PostDemocracy Dies in Darkness

Why Covax, the best hope for vaccinating the world, was doomed to fall short

A health care worker in India holds a coronavirus vaccine in March 2021. (Anupam Nath/AP)
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It was, many experts thought, a noble and necessary effort.

The goal: to combat a deadly coronavirus that in early 2020 was already spreading around the world.

The idea: to coax wealthy and poor countries to pool their money to place advance orders for vaccine doses. Participating countries would then share doses equitably to protect their most vulnerable people first.

But just months into the effort, it should have been clear it was doomed to fall short.

The initiative’s backers badly misjudged the desperation and myopia of wealthier countries, which raced to manufacturers to snatch up doses for their own people. Covax — as the program became known — was also too slow to adapt its model even as countries declined to participate and infections and deaths soared, according to more than two dozen international health officials, diplomats and other top experts.

Clemens Auer, an Austrian politician who served as the European Union’s chief vaccine negotiator, put it bluntly: “We told them right away this wouldn’t fly.”

Two years into the pandemic, the world has seen more than 470 million confirmed covid-19 cases and at least 6 million deaths. Many wealthy nations are trying to move on, preoccupied with the Russian invasion of Ukraine or domestic economic problems such as inflation. Efforts to prepare for the next pandemic have faltered.

But just two months after the omicron variant led to an enormous global wave of coronavirus cases, case numbers have again risen sharply in East Asia and Western Europe.

Unlike many national governments, those behind Covax saw the risk presented by the coronavirus early. But the initiative has fallen well short of its aims. More than a third of the world is yet to have a vaccine dose. That has left a huge gap between rich and poor countries. Experts say the lack of vaccinations in poor countries is not only inequitable but also dangerous, exposing the world to a greater likelihood that more-virulent variants will emerge.

And the challenges for Covax continue. Covax has raised $11 billion in total, well short of the $18 billion it initially said it needs. Falling short of funding targets for the spring could cost 1.25 million lives, backers say.

“We are right now basically out of money,” said Seth Berkley, head of the Vaccine Alliance, or Gavi, one of the main organizations behind Covax, during a fundraising call in January.

The takeaway: The world cannot count on mere goodwill and cooperation to propel responsible public health measures in the future.

“They are right to say that the [Covax] model would work — if we were organized differently as a world,” said Andrea Taylor, a researcher at the Duke Global Health Institute. “It clearly didn’t work and doesn’t work in the world in which we do live.”

Made in Switzerland

The idea for what would become Covax arose in conversation between two towering figures in global health, over drinks at the Hard Rock Hotel bar in Davos in January 2020.

The encounter between Richard Hatchett, who runs the Coalition for Epidemic Preparedness Innovations, or CEPI, and Berkley, the head of Gavi, unfolded at a moment when others were downplaying the risks posed by the coronavirus, which had just begun to draw attention.

Then-President Donald Trump, gathered with other elites in the Swiss town for the World Economic Forum, was telling Americans everything was going to be “just fine.” But Hatchett and Berkley were almost certain that wasn’t true.

The conversation “didn’t seem like just a hypothetical party game,” said Hatchett, who worked on pandemic preparedness in the George W. Bush and Obama administrations.

They agreed that the most powerful tool to fight the coronavirus would be vaccination. Their solution, which Hatchett outlined in a white paper published that March: pooled purchases.

By acting together to buy doses, Hatchett wrote, rich and poor countries alike could benefit. Covax could not only ensure that doses were allocated fairly, but also help to give countries more leverage with manufacturers to reduce costs — and circumvent an inefficient system in which drug companies would have to hold complicated negotiations with multiple governments.

The creators of Covax were emphatic that countries should buy doses rather than seek donated ones. They did not want Covax to become a charity, which they saw as an unsustainable model. And they had another, even more radical stipulation: Doses would be doled out evenly, so that participating countries could reach roughly 20 percent immunization around the same time and vaccinate their most vulnerable first.

Without a cooperative model, Hatchett recalls thinking, “rich countries are going to buy up all the vaccines,” as they had during an influenza outbreak in 2010.

Gavi had helped poorer countries negotiate en masse before, for diphtheria vaccine doses and others, with success. But the coronavirus pandemic wasn’t just another outbreak contained to poor or remote areas, but one that hit hard and fast in some of the wealthiest countries. That changed everything.

Lack of leadership

In the early months, the alliance came together swiftly with the support of the World Health Organization. But it was missing what had proved instrumental in fighting other global scourges — leadership from a powerful country.

The United States played that role in the effort to control HIV/AIDS in Africa. The George W. Bush administration spearheaded the President’s Emergency Plan for AIDS Relief, or PEPFAR, which devoted billions of dollars to fight HIV/AIDS on the continent.

The success of PEPFAR “was driven by leadership at the head of state level, which is absolutely essential,” said Mark Dybul, who helped create the initiative.

Hatchett said the idea of an equivalent effort to fight covid met with “no receptivity from the Trump administration,” which eventually pulled funding from the WHO and opposed Covax. No other wealthy country stepped in to fill the void.

Covax’s missteps also hobbled the effort. A report by Doctors Without Borders found that the alliance held key early meetings that excluded officials from the developing world, but included McKinsey & Co., a U.S. consulting firm with close ties to pharmaceutical companies.

Discussions were “heavy on the donors,” said a participant who spoke on the condition of anonymity to discuss the topic freely, referring to wealthy nations and nonprofits such as the Bill & Melinda Gates Foundation, which funds Gavi and the CEPI. The lack of full engagement with poorer countries became a problem later, as governments struggled with deliveries and complained of poor communication from Covax.

Even governments that supported Covax began to cut deals with manufacturers to amass huge stockpiles for themselves, draining the number of doses available globally. Canada, a vocal backer of Covax, had secured enough doses to cover 300 percent of its population by October 2020.

The European Union ultimately decided to give money to Covax but not to buy doses through it. Auer, the E.U. negotiator, said the proposal to vaccinate roughly 20 percent of each country’s population first and the inability to choose which type of vaccine to receive were nonstarters.

And then there were the financial issues. Gavi, the organization negotiating with vaccine makers for lowest-price guarantees on behalf of Covax, was unable to finalize deals until it secured funding. That meant Covax was at the back of the line for purchases, competing with deep-pursed governments.

Developing counties trying to secure doses on the free market found in some cases that Covax itself was in the way.

“I remember trying to get access to AstraZeneca. I was calling England, trying to get doses,” Ghanaian Vice President Mahamudu Bawumia said in an interview. “And we’re told no, developing countries have to go through this special facility called Covax.”

Killing the messenger

In what would become another, but largely unforeseen, stumble, Covax snubbed messenger RNA (mRNA) vaccines, a new technology used by the U.S. drug companies Pfizer and Moderna, because of “limited resources,” according to Hatchett.

In an internal document distributed to member states in November 2020, shared with The Post by a Covax partner, the organization said that mRNA vaccines cost as much as 10 times more per dose than traditional vaccines and warned that they would face additional hurdles for authorization.

Despite their price, mRNA vaccines received emergency-use authorization quickly and have since become the most sought-after thanks to their effectiveness.

“They basically bad-mouthed mRNA and said we shouldn’t even bother,” said one official in a government that backs Covax, speaking on the condition of anonymity because he was not authorized to comment. “That turned out to be a big mistake.”

Instead, Covax focused on cheaper — and ultimately less effective or otherwise problematic — vaccines. By the start of 2021, the alliance cut enormous deals with AstraZeneca and Novavax for vaccines made using older technology. The Serum Institute of India, a huge vaccine producer, was set to make 1.1 billion doses.

But Novavax did not receive WHO emergency-use approval until the final days of 2021, while AstraZeneca faced production issues. As India battled a wave of cases amid the rise of the deadly delta variant, the country slammed the door on vaccine exports. Between June and October, Covax was not able to deliver any doses made by Serum.

Those weren’t the only supply issues. Covax signed a deal with the U.S. manufacturer Johnson & Johnson for 200 million doses of the company’s single-shot vaccine in May 2021 that arrived almost six months later, while some wealthy countries received deliveries in the interim. J&J later paused manufacturing of its coronavirus vaccine without telling Covax.

Vaccine makers may have broken “contractual obligations” to Covax, a document released by a WHO committee in December suggested. “We’ve had delays with manufacturers, all of them,” Berkley said in an interview, suggesting they put wealthy countries that could pay top dollar ahead of Covax.

But many governments waiting for doses have blamed Covax, not its suppliers. In August, Botswana’s President Mokgweetsi Masisi said Covax was “just a scam” that had overpromised and underdelivered. African countries turned to a new procurement plan formed by the African Union, as did countries in Latin America under the Pan American Health Organization.

“Covax has disappointed Africa,” said Winnie Byanyima, executive director of UNAIDS.

In recent months, Covax’s supply issues have begun to improve. But with countries including Israel and Chile already administering fourth doses and as Pfizer and Moderna promise new, variant-specific vaccines, the availability of doses remains a shifting equation.

“Time and time again in this pandemic, people have said that supply constraints are in the rearview window,” said Thomas Bollyky, director of the global health program at the Council on Foreign Relations. “And time and time again, they’ve been wrong.”

Donated, then destroyed

Even as the alliance was watching its original model collapse, in the summer of 2020 it spurned an early offer of extra doses expected to be left over from the European Union’s vaccination drive, said Auer, the E.U. negotiator.

The response, by his telling, was prideful: “We don’t take what you, the rich European Union, is not using.”

Over the next year, Covax had to concede that it would need to begin accepting donations after all — despite legitimate concerns about taking free doses rejected by wealthy countries rather than purchased in partnership. Roughly 60 percent of doses administered by Covax in 2021 were donated. But it was late to the realization that it needed to accept donated doses, experts say.

And while donations have saved Covax from truly disastrous shortfalls in supply, many of the fears about them have come true.

Sultani Matendechero, head of the Kenya National Public Health Institute, said he now receives vaccine doses with “very short expiry dates” donated by wealthy nations. While Kenya is able to use these doses, Matendechero said, others cannot.

Internal documents shared with The Post by a Covax partner show that in October and November 2021, roughly 1 in 5 AstraZeneca doses donated by wealthy nations through Covax ended up being rejected by the receiving government, more than half of the time because they were close to expiration.

In a statement to The Post, UNICEF, which handles logistics for Covax, said that 80 million doses were rejected by countries in December, mostly because of short shelf life and “limited capacity on the ground.” Three million of these doses, almost all donated, had to be destroyed.

Kate O’Brien, the WHO vaccine director, argued that compared with national programs, Covax wastage has been “extremely low.” The monitoring group Airfinity estimated in January that 240 million vaccine doses could expire in wealthy nations alone by mid-March. A UNICEF official, speaking on the condition of anonymity to discuss Covax candidly, said some recipients had also become pickier about what they would accept.

Less effective vaccines made with an inactivated version of the virus, such as those available from the Chinese Covax suppliers Sinopharm and Sinovac, are “lower down the pecking order,” they said.

Yap Boum, a regional representative for the medical research body Epicenter in Cameroon, said the donation of doses of vaccines linked to side effects, such as AstraZeneca, had deepened vaccine hesitancy.

“The message being sent is a lack of respect,” Boum said. “I send you what I no longer want and I’m doing it as if I’m protecting you.”

Coronavirus cases spiked globally in the first weeks of 2022, despite record-high vaccination rates. Here’s how the omicron variant took off. (Video: Jackie Lay, John Farrell/The Washington Post)

The next pandemic

Many wealthy countries are lifting coronavirus restrictions, in large part because of the remarkable effectiveness of vaccines in preventing serious illness and death. Across high- and middle-income countries, the speed of the development and rollout of vaccines during the pandemic was unprecedented.

But according to an analysis published last month by the Center for Global Development, the picture was sharply different in the low-income countries that needed Covax the most.

Oxfam in March released an estimate suggesting that the toll of covid has been four times higher in lower-income countries than in rich ones.

And Covax is still scrounging for the money to meet its promises. According to Gavi documents, as of the beginning of March, the initiative had raised only $195 million of the $5.2 billion it asked for in a fundraising round in January. The organization’s backers say that they need the money not because of immediate supply concerns, but to aid with delivery and to establish a “pandemic pool” of 600 million doses for future surges.

Countries have the money, but they also have other priorities. The Biden administration in March asked Congress to authorize $5 billion to bolster global vaccination efforts, half the amount requested in response to the Ukraine crisis.

Despite appeals from the White House, that money was stripped out of the funding package for virus aid after disputes of how to pay for it. Even if it eventually goes through, only some of it will go to Covax.

Even if Covax can get the money, experts and officials have begun to agree that the alliance’s overall approach won’t be enough in the long term.

“This drip, drip, drip of donations through Covax will never solve the problem of the pandemic,” said Byanyima, with UNAIDS. “The pandemic is winning.”

Covax’s emphasis on pooled purchasing came at the expense of a focus on increasing supply, some argue. The organization’s backers have faced criticism for not putting their weight behind intellectual property waivers, which major backers including Bill Gates have dismissed. Many experts say technology sharing could have accelerated efforts to build vaccine manufacturing capacity in the developing world.

Purchasing doses, or distributing donated ones, rather than ramping up production is “like ordering takeout to solve a famine,” said James Krellenstein, co-founder of PrEP4All, an HIV-care nonprofit.

Some governments, including the European Union, South Africa, India and the United States, recently reached a compromise on the proposal, but advocacy groups have largely been disappointed with the result, with Washington-based Knowledge Ecology International calling it a “limited and narrow agreement” that would be welcomed by big drug companies.

Across Latin America and Africa, numerous vaccine-manufacturing efforts are underway, some with the support of a WHO-backed mRNA vaccine technology-transfer hub in South Africa. A big question is whether they can succeed without sustained support from wealthy nations and pharmaceutical companies.

At “some point, donation mechanisms just delay access,” said Colombian Health Minister Fernando Ruiz. His country is shifting to bilateral vaccine agreements and starting projects to develop its own vaccines.

Almost everyone agrees there is one major problem that needs to be fixed: paltry funding.

The WHO is seeking increased, reliable backing from governments. The United States has proposed a different plan: a $10 billion fund for pandemic preparedness, potentially housed at the World Bank — to the outrage of allies who think it would undermine existing structures, including the WHO.

“We discovered the limits of what could be accomplished,” said Orin Levine, director of vaccine delivery at the Gates Foundation, “with the leadership we were in, with the structures that we were in.”

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