As successful as the COVID-19 vaccines have been in curbing the pandemic, their benefits haven’t been enjoyed equally by people around the globe. Throughout the pandemic—and even now—vaccine development and distribution has been undeniably lopsided, skewed in favor of developed countries with the resources to create, test, manufacture, and distribute shots when the need arises. In the third year of pandemic, while nearly 70% of people worldwide have received at least one COVID-19 vaccine dose, in low-income countries, only 24% have.
In its latest report on the global vaccine market, which includes an assessment of vaccines against COVID-19 and a variety of infectious diseases, the World Health Organization (WHO) calls upon both governments and companies to reshape the vaccine market to equalize these discrepancies. Pulling from the lessons learned from the global COVID-19 response, the report urges governments to invest more aggressively in the development and manufacturing of vaccines against infectious diseases—even in the absence of an existing public-health threat—focusing specifically on pursuing innovative technologies that could streamline and reduce the cost of shots. The idea is to build a more local network of scientists and manufacturers who can create and distribute a new vaccine during a crisis.
But governments can’t accomplish that alone. Companies should create new pathways for sharing intellectual property and opening doors that are currently closed by proprietary priorities, the report says. It asks companies to concentrate on developing vaccines for WHO’s priority diseases, targeting pathogens (such as coronaviruses) that are likely to cause outbreaks but may not be in line with business objectives, if these diseases only affect a relatively small percentage of the world’s population and don’t represent a major market. That’s a big ask, says Dr. Robert Murphy, executive director of the Havey institute for Global Health at Northwestern University’s Feinberg School of Medicine. “Big pharma is not going to do this,” he says. “There has to be more technology transfer.” Murphy points to efforts by vaccine maker AstraZeneca, which developed a COVID-19 vaccine based on research from Oxford University, and took steps to share its technology with countries who were willing to capitalize on that knowledge. The company worked with a Brazilian research institute to allow scientists in that country to produce the vaccine for its citizens. WHO has also designated that institute as a hub for making mRNA vaccines in Latin America.
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There are signs that the pharmaceutical industry is taking steps to follow WHO’s recommendations. Two of the largest COVID-19 vaccine makers for the developed world, Moderna and Pfizer-BioNTech (both of whom produce mRNA-based vaccines), have plans to manufacture the vaccines in Africa to more efficiently address vaccination needs on the continent. Pfizer-BioNTech announced a partnership in 2021 with a South African biopharmaceutical company, the Biovac Institute, to make and distribute COVID-19 vaccines in Africa, and Moderna said earlier this year that it would build a manufacturing facility in Kenya. Moderna has also pledged to not enforce its patent on its vaccine in certain low- and middle-income countries during the pandemic. But it remains to be seen how committed they are to these steps. It won’t be until at least 2023 when locally sourced vaccines from either company will be available on the African continent, and public-health groups Oxfam and Doctors Without Borders have criticized the vaccine makers for not doing more to fulfill the pandemic needs of the developing world.
Toward a ‘global vacine strategy’
Governments, too, are making progress. India and China have also built capacity for developing and manufacturing vaccines, and, despite early growing pains, are establishing an infrastructure for producing vaccines for their populations.
But making effective and safe vaccines remains a challenge for nascent industries. While China produced its own vaccines against COVID-19—which the WHO recommended, making it the most widely administered COVID-19 vaccine around the world—studies showed that the original 51% and 79% efficacy in protecting people against COVID-19 waned more quickly than protection from the mRNA shots, mainly because the vaccines made in China generated lower levels of virus-fighting antibodies.
“We have to not only produce vaccines, but produce vaccines that are validated and that work,” says Dr. Ian Lipkin, professor of epidemiology and director of the center for infection and immunity at Columbia Mailman School of Public Health. That could require more intentional coordination around another important part of the vaccine-making process: testing and validating their effectiveness. COVID-19 revealed how disjointed the regulatory system is around the world. While billions of doses of COVID-19 vaccines have been distributed and administered, a relatively low efficacy could promote new mutations and new variants that can escape the protection provided by vaccines. Lipkin would like to see a system that does not rely solely on different countries testing and validating vaccines, but rather a global one for evaluating these quickly and consistently. “There are so many advantages to adopting a global vaccine strategy. We will reduce mortality and morbidity in the developing world, reduce social and economic damage due to disruption of travel and trade, and expedite the validation of vaccines through international trials,” he says. Establishing some type of global FDA to run the trials and evaluate the results would streamline the process of bringing new vaccines to market.
Going forward, to ensure that vaccines are distributed more equitably, the WHO recommends prioritizing innovation around vaccine storage and delivery in favor of the least burdensome methods—unlike the ultra-cold temperatures required for the mRNA COVID-19 vaccines. Those conditions made it challenging to administer the vaccines in many parts of the world with minimal health infrastructure. And for those around the world who are needle-averse, having other modes of delivery, such as nasal, inhalable, or oral vaccines, is also a must. “We can come up with vaccines that cost pennies to deliver and that people are more likely to accept,” says Lipkin. “The more we get away from needing needles, syringes, and experts in vaccination, that would be enormously helpful.”
The state of global vaccination groups
While 15 billion doses of COVID-19 vaccines were distributed globally, the vast majority of these went to people in the developed world, with only 12% trickling through COVAX: a pandemic-era program created by the WHO, GAVI the Vaccine Alliance, the Coalition for Epidemic Preparedness Innovations, and UNICEF to pool resources and purchasing power to obtain and distribute vaccines to low- and middle-income nations. One problem is that only a couple of vaccine manufacturers make 80% of the world’s supply of COVID-19 vaccines. Most companies that manufacture any type of vaccine are based in Europe, Indonesia, Japan, or the U.S.—so many countries in Africa, for example, where nearly 17% of the world’s population lives, depend on getting 90% of their vaccines from outside the continent. To date, these African nations have received only 3% of all available COVID-19 vaccine doses.
To address the existing gap, COVAX began soliciting donations as the pandemic unfolded in 2020 from developed nations to fund pooled purchasing of vaccine doses, at significantly lower cost, for the developing world. While 180 countries have joined COVAX, either as donors or recipients, the WHO report found that a lack of coordination of supply and demand left many doses out of reach for countries that needed them. Public-health experts say the impact of COVAX is mixed so far. While it represented a step in the right direction in terms of creating more purchasing power for certain countries, it faced challenges in executing on its mission, as developed nations continued to receive priority when it came to vaccine doses.
“The impact was way more modest than [health experts] had anticipated, because they were such a new structure,” says Murphy. “COVAX was made for this pandemic, and they had to start basically from scratch to negotiate with more than 100 different countries. But the work was still important. While there was a learning curve, now all the players are in place, and hopefully the system is geared up so everything can happen more quickly and more money will continue to support the program.”
To sustain that momentum, the report concludes, a better balance is required between national interests and global ones, especially in a world that is increasingly connected. Even if a new virus such as SARS-CoV-2 is controlled with impressive vaccination campaigns in one part of the world, continued pockets of infections in any region can seed new outbreaks and provide fertile ground for mutant strains that can evade those vaccines. “If we had been much more efficient and faster to deliver vaccines globally, we might have deprived the virus of the opportunity to evolve as rapidly as it has,” says Lipkin.
As the virus continues to mutate, the inequitable vaccine market only widens the gap between those who are able to benefit from these innovations and those who aren’t. The next step in bridging this divide requires a more significant shift in how governments and companies perceive health threats. The WHO calls for heightened diplomacy between countries that would set binding obligations to distribute vaccines more equitably, especially during a crisis when supplies are scarce. That would require a change in culture at the political level, so leaders see investment in manufacturing as an insurance policy against future health threats, rather than a cost with little return. “We need to…strike a much better balance between serving national interests and global public health objectives,” the report concludes.
Already, some efforts to train scientists locally to learn about the latest vaccine-making techniques are starting to build a base of experts who can quickly adapt to producing new vaccines, even if the basic technology is provided from abroad. “It’s not just about building factories around the world,” says Murphy. “Those factories are highly regulated and sophisticated, so you’ve got to have a cadre of scientists who can put that together. Why can’t low-income countries also get into the game? They can do it.” Tapping into that potential may be the quickest way to protect against another pandemic in which an emerging virus maintains the upper hand.