Mar 13, 2021 Volume 397 Number 10278 p941-1034, e8
Access to COVID-19 vaccines: looking beyond COVAX
Global health leaders have been in a congratulatory mood. On March 1, they celebrated the first vaccinations against COVID-19 in Africa delivered through COVAX—the scheme led by GAVI, CEPI, and WHO to support research and development, raise funding, and negotiate the bulk purchase and equitable global distribution of vaccines for COVID-19. As of March 9, 12 million doses have been shipped to 29 countries, marking the beginning of the largest vaccine roll-out in history. This is an unprecedented achievement. Yet COVAX is wholly unequipped to resolve many of the most pressing threats to its mission. Global vaccination is central to ending the pandemic, yet it has been dealt with at far too low a political level. Too many obstacles are going unchallenged. A high-level individual or group with political acumen, technical competency, and the ability to advocate for justice is needed to galvanise the effort.
There is a startling lack of solidarity between countries. As outlined in a Health Policy paper, the many bilateral deals struck between governments and vaccine manufacturers, independently of COVAX, threaten the supply of doses. Rich nations have given money to COVAX and paid lip service to the idea of vaccines for all while scrambling to buy up all the doses they can. Olivier Wouters and colleagues report that polities representing only 16% of the global population have secured 70% of the available doses for the five leading vaccines in 2021. As a result, dozens of countries have yet to administer a single dose, whereas others have already immunised large proportions of their populations. COVAX will continue to face competition for purchasing doses and risks being outbid; it can only bemoan such agreements. No one may be able to persuade countries to cease these deals entirely. But a well respected and dedicated former head of state with the ability to encourage and cajole prime ministers and presidents might have more success in encouraging countries to behave more equitably. It would be far better for countries that have made bilateral deals to donate a fixed proportion of their acquired doses to COVAX, for example, than simply promise to share their surpluses. An authoritative voice with moral credentials is needed to support global access to vaccines, to intervene when that goal is under threat, and to call out unfair practices.
Clearer leadership and oversight are also needed to bring greater cohesion to the complex patchwork of national governments, technical organisations (including GAVI, CEPI, WHO, UNICEF, and the World Bank), the private sector, and civil society that is aiming to ensure global access to vaccines. The list of well meaning but varied vaccination targets is growing. COVAX’s current conservative aim is to immunise 20% of people in each country, which it estimates is enough to cover high-risk groups and health workers. Most high-income countries seem set on a policy of mass vaccination. The African Union has set a target of 60% coverage, whereas Nigeria, for example, is aiming for 40%. Some order needs to be brought to these disparate goals.
A dedicated envoy or tsar could also help moderate disagreements between countries, which are hampering global COVID-19 vaccination. Last year, South Africa and India called on the World Trade Organization to waive intellectual property protections on COVID-19 drugs and vaccines to boost manufacturing. Despite support from the WHO Director-General, the proposal has languished under opposition from the UK, the USA, Canada, Norway, and the EU. Meanwhile, on March 4, the Italian Government blocked the export of 250 000 doses of the AstraZeneca–Oxford vaccine bound for Australia following disagreements between the manufacturer and the EU. These issues require political and diplomatic solutions. They cannot be solved by technical agencies.
Who should take on this role? If a UN Special Envoy, they must be more than a symbolic appointee, flying around the world to shake hands with political leaders and getting little done. Their tasks must be actionable. The Elders, a group of varied political leaders formed by Nelson Mandela to use public and private diplomacy to advance justice and human rights, have successfully championed causes such as universal health coverage, and have the requisite experience.
Whoever it is, they must above all be able to drive a worldwide movement. Although the roll-out of vaccines brings hope, case numbers are increasing again globally and there is a grave risk of complacency. Progress has been capricious and there are still many uncertainties about COVID-19, not least the impact of new variants. Global vaccination is essential to ending the pandemic but this fact has still not prompted the unity required to deliver it. Far more vision and ambition are needed. They must come from the highest political levels.