Stanford Politics

In late February 1954, Arsenal Elementary School in Pennsylvania gained nationwide fame for hosting the first injections of the polio vaccine, which neutered a disease that had paralyzed 50,000 Americans in the year prior. By 1957, American Polio cases were down to three per 100,000, and by 1963, U.S. polio cases were nearly zero.

But much of the world never heard about Arsenal Elementary School. Take Sudan, a northern African country with a population of roughly 41 million, a little bigger than the state of California. In 1980, nearly all American infants were vaccinated against polio and the United States’ polio case count was essentially zero. In the same year, 1 percent of Sudanese infants were vaccinated, and the polio case count reached 286 per 100,000. Sudan wouldn’t go on to claim eradication of Polio until 2004, nearly 50 years after the first inculcations took place at Arsenal Elementary School.

And Sudan wasn’t alone in their struggle to eradicate Polio. The majority of the world didn’t eradicate the disease until the 1990s, 17 countries eradicated in the 2000s, and three countries—Afghanistan, Pakistan, and Nigeria—still have ‘endemic’ status from the World Health Organization (WHO).

These days, Arsenal Elementary School is closed due to a Covid-19 outbreak, as is the rest of the Pittsburgh elementary school system. As of January 9^th, 2021, 92 of every 100,000 people in Allegheny County – the home of Arsenal Elementary – are dead of Covid-19. But, like in February of 1954, there is flicker of hope, as the first shots of a vaccine have been delivered, starting with a nurse named Sandra Lindsay. Lindsay, 52, immigrated to Long Island from Jamaica in 1990, and was the first American woman to receive a vaccination against Covid-19 on December 14^th.

Lindsay’s first words after receiving the vaccine were printed alongside her picture on the front page of the December 14^th New York Times issue, an inspiring message of resilience and hope for a nation in hellfire. And Americans have every reason to be hopeful. Most experts estimate that the 10 percent of Americans will be vaccinated by the end of January, with the entire American population fully vaccinated between April and August of 2021, as hundreds of millions prepare for mask-free summer. But optimistic forecasts and words of encouragements in American media mean little to citizens of developing countries like Sudan. On the day Sandra Lindsay received the Pfizer-BionTech vaccine, Sudan conservatively reported 263 new Covid-19 cases—as well as 15 new cases of Polio.

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Vaccinations are a notoriously difficult problem for developing economies, with an average 10 to 15-year lag for low-income nations. Steve Luby, Professor of Epidemiology and Infectious Diseases, explains that because of the high cost, poor governance, supply chain deficiencies, and other regional issues, poor nations often receive vaccinations a decade or more after their rich counterparts. “You look at Hep B, childhood vaccines, Hib, Pneumococcal, and despite our best efforts to accelerate that recently, there’s still a long gap.”

And Covid-19 poses challenges that no vaccine has met before. There’s simply no historical comparison to the distribution problems posed during a pandemic, Luby explains, joking that “[t]he only time preceding Sars-Cov-2 that we’ve ever developed a vaccine during a pandemic was on the set of the movie Contagion.”  But fortunately for those in rich countries, reality has begun to reflect Hollywood, with Pfizer and Moderna flying in with red capes to intercept the pandemic at its worst, as hospital beds around the country fill to capacity. But the future is murkier for the rest of the world. Billions of people in low-income countries like Sudan and Bangladesh remain unsure how and when the vaccine gets to them, and other countries worry that they’ll be left out entirely.

And if the world can’t figure how to share, people will die. As a healthy 20-year-old living in New York City, most estimates suggest that I’ll get my first-round vaccination around early April—meaning I’ll be vaccinated before the elderly in Bangladesh, first responders in Sri Lanka, and immuno-compromised people living in Nigeria. And while healthy people like me can feel protected from a disease with a sparse chance of killing me in the first place, at-risk people around the world will die unnecessarily.

One analysis published by The Gates Foundation imagined two scenarios: a cooperative scenario where the first 3 billion doses are distributed to countries based on population, and an uncooperative scenario, where 2 of those 3 billion vaccines are shelved exclusively by rich nations. The report found that in a cooperative scenario, 61 percent of all global deaths over the next year would be averted. But in an uncooperative scenario, only 33 percent of avoidable deaths will be avoided. With approximately 1.7 million deaths in 2020 and a conservative assumption that next year’s death count would be identical to this year’s in absence of a vaccine, the difference between a cooperative and an uncooperative distribution can be estimated at roughly 476,000 deaths globally. Few moral systems can justify killing three foreigners to save one of your own citizens, but unfortunately, this is precisely the ethical paradigm rich nations are operating under.  

But in their race to stockpile, Luby explains that rich nations are shooting themselves in the foot by hampering equitable distribution. The United States, simply put, isn’t alone in the world, and a raging pandemic anywhere is still a threat to the safety of vaccinated countries. “There’s a clear justice argument, but there’s also a case of enlightened self-interest, and the rich nations need to understand that the world is better off if this virus isn’t spreading wildly,” Luby said.

First, because no vaccine is 100 percent effective, and across polls, only two-thirds of Americans have expressed willingness to get vaccinated. With that, once masks become a historical vestige and travel resumes to normal, Covid-19 outbreaks in foreign countries can easily spark outbreaks back home, especially among the unvaccinated. Luby explained that it’s perfectly possibly that travel from the United States to poor nations with high tourism traffic like the Dominican Republic could lead to Covid-19 reappearing on U.S. shores. And while some have suggested that these poor nations can eventually come to rely on herd immunity, Luby countered that there’s no secure evidence of how long antibodies from infections even last, especially as new strains pop up all the time—meaning that herd immunity might end up being something of a folk tale.  

But even if the United States keeps its borders closed to travelers for the foreseeable future, those same outbreaks can distress the American economy without anybody getting on a plane. In an increasingly globalized economic world, where nearly all of our goods are manufactured abroad, economic lag in poor nations can have spillover damage to high-income economies. Even if Americans are back in schools and offices, if U.S. trading partners are still seeing business closures, full ICU beds, and hampered productivity, America can’t consider itself out of the woods. To quantify this, one RAND analysis found that unequal vaccine distribution could cost the global GDP roughly $1.4 trillion over the remaining life of Covid-19.

While the rest of the world sits and prays for the wealthy nations to divvy the pot up fairly, those same wealthy nations have spent their time doing the opposite. According to the Duke Global Health Innovation Center, with billions of dollars at their disposal, high- and upper-middle-income countries have collectively reserved nearly 5 billion vaccine doses, enough to vaccinate their entire populations multiple times over. The United States, for example, has entered into at least six of these bilateral deals, totaling more than 1 billion doses—more than enough to inoculate the entire American population. This leaves low- and middle-income countries like Sudan and Bangladesh, countries that house 86 percent of the world’s population, wondering when they can expect relief. Others, like those nations still struggling to battle polio, are left to fear that they’ll be left out entirely.

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To understand the difficulty in vaccinating the population of developing economies, it’s important to understand what the world’s plan was in the first place. Introduce COVAX. Developed as a partnership between the WHO, UNICEF, GAVI, The Gates Foundation, the Coalition for Epidemic Preparedness, 179 countries, and the World Bank, COVAX is a global partnership designed to ensure affordable vaccine access to poor nations. COVAX works in two parts:

1. The purchasing pool. The pool works like a group of friends investing in a raffle with plans to split the winnings equally. Instead of individual nations purchasing their own supplies, COVAX members pool money into a collective pot, which is used to purchase and then redistribute vaccines back to member states, commensurate to their population and strength of their Covid-19 outbreaks.
2. The Advanced Market Commitment (AMC). The AMC pools funds from nations and NGOs to subsidize vaccine procurement for poor nations. This serves as an advance cash commitment for pharma companies, and a lifeline for poor nations, likely the only shot these countries have at securing hundreds of millions of doses that sell for $30 each. Take PV13, the series of Pneumococcal vaccines developed in 1980 to protect against Streptococcus pneumoniae, a bacterium that can cause pneumonia, meningitis, and sepsis.Eight years after the pneumococcal vaccine was created, poor countries had near-zero access to the vaccine, mostly due to the $50-per-dose price tag. But in 2007, GAVI (Global Alliance for Vaccines) established an AMC. In less than a decade, 54 countries, from Afghanistan to Zimbabwe, were able to roll out the pneumococcal vaccine. Ultimately, an independent review by the Boston Consulting found that by 2015, the AMC deal had saved the lives of almost 300,000 children.

Thirteen years later, COVAX and its Advanced Market Commitment is the most promising outcome for low-income nations. In fact, COVAX is probably the only chance for these countries to access Covid-19 vaccines in a reasonable timeline. And COVAX is moving along in some very important ways. As of writing, COVAX’s AMC has just secured its 2020 funding goal of $2 billion, the Pfizer and Moderna vaccines were recently added to the COVAX portfolio, and private partnerships within GAVI have ensured that, if approved, 64 percent of the doses of the Oxford-AstraZeneca vaccine will flow to developing nations through COVAX. In sum, by the end of 2021, COVAX plans to deliver two billion doses of safe, effective vaccines that have passed regulatory approval and/or WHO prequalification. But here’s the rub: even if COVAX and AstraZeneca meet all of their stated goals, only 18 percent of the world’s population will be vaccinated by Christmas 2021.

And on paper, this seems to contradict the stated supply chain goals of the largest vaccine developers. Pfizer has stated capacity to produce 1.3 billion doses by the end of 2021, Moderna to produce 1 billion, and Oxford to produce 3 billion — not to mention any other vaccines that get approved in the next 12 months. So by next year, we’ll have over 5 billion doses of vaccine, enough to vaccinate two-thirds of the world, and yet all estimates suggest we won’t even vaccinate one fifth.

The reason for the gap is pre-purchases, a fancy term for vaccine hoarding, which highlights the first major challenge that COVAX will face in the mission to eradicate Covid-19. To understand pre-purchases, it’s important to understand how nations get vaccines in the first place. Right now, there are two major ways for a nation to get a vaccine on their shores. First, they can pool their money through COVAX and purchase a vaccine through the international market once it has gained WHO clearance, this being the choice of nearly every low-income nation. Or, instead of waiting for a vaccine to get regulatory clearance, a country can choose to pre-order doses of a vaccine as it awaits approval, orders which pharmaceutical companies are more than happy to fulfill. Most of these purchases have been of the Pfizer-BioNTech vaccine, the first to be approved by multiple western nations, a vaccine of which 82 percent of the first doses will flow to countries housing only 14 percent of the global population.

And in some sense, pre-purchases are a double-edged sword. While COVAX only promises to purchase vaccines once they’ve been approved, preorders from rich nations infused the initial capital necessary for vaccine manufactures before they could prove efficacy.

But what isn’t a double-edged sword is the harsh strain of isolationism that has struck the United States in the final stages of the pandemic. COVAX is currently membered by all of the world’s countries save eight. Five of those nations are island micro-states, and the remaining four tally Belarus, Russia, Kazakhstan, and the United States. Trump primarily shunned COVAX because of its ties to WHO, but as of January 9^th, President-Elect Joe Biden hasn’t yet made comment on whether he will join COVAX, although it has been reported that he has met with COVAX organizers about the possibility. So, in addition to hoarding vaccines through pre-purchases, the United States’ refusal to join COVAX could hobble it outright. For example, COVAX has expressed concern about meeting it’s $5 billion funding target for 2021, funding which serves as the linchpin of the plan to subsidize vaccinations for poor nations.

Even middle-income nations are playing keep away from poor nations. In early August, GAVI and the Bill & Melinda Gates Foundation announced a plan to outsource production of the Oxford-AstraZeneca vaccine to the Serum Institute of India (SII), with plans to make hundreds of millions of doses available through COVAX at just $3 per dose. But, in late November, as the approval path began to illuminate for the Oxford-AstraZeneca vaccine, SII changed its tone sharply. In a public statement, SII’s chief executive Adar Poonawalla took an ‘India first’ bent, saying “It’s very important we take care of our country first, then go on to Covax after that and then other bilateral deals with countries.”

Other countries face internal political issues, nations where Covid-19 has been politicized to the point of ruling parties ignoring the virus outright. In these countries, Luby explained, it will be difficult to persuade governing officials to allocate money to pay the steep prices these vaccines sell for, especially when most of these countries are already facing pandemic-induced recessions.

All of this comes in addition to the host of issues that have always plague vaccine deployment in poor countries. Refrigeration and power are severely lacking in many low-income nations. As one United Nation report points out, health systems serving two-thirds of the world’s population do not have adequate refrigeration facilities, and 30 to 40 percent of the health centers lack access to reliable electricity. And, of course, simply having a vaccine in shipping creates isn’t the same as having it in people’s bodies. “There are anti-vaxxers everywhere, and so a vaccine is necessary but not sufficient,” Luby explained, citing an example of a vaccine that took five years to reach saturation in India after being held up by anti-vaccine advocacy groups.

And even though every moment is crucial, with 8,000 dead globally each day, the exact timelines and mechanisms for the majority of the world are murky. We do know that, thanks to contributions from the Gates Foundation, roughly 10 to 18 percent of the developing world will be vaccinated by the end of 2021. Per public health estimates, this will be probably be sufficient to vaccinate health care workers and the most vulnerable populations in these countries. We also know that the AstraZeneca vaccine will sell for roughly $3 dose and can be stored at 2° to 8° C, temperatures you could reach in your household freezer, making it a far better candidate for developing nations than the Pfizer and Moderna vaccines that most Americans will receive. And, in all likelihood, whether the United States joins or not, COVAX will be responsible for the distribution most of those doses.

Overall, for middle- to low-income countries, which house the majority of the world’s population, the AstraZeneca vaccine should supply immediate relief in the coming year, but full safety for these populations is still years away. Especially since, as Luby explains, middle income countries face an especially difficult challenge: being too poor to purchase vaccines on the open market but too wealthy to receive the subsidies promised by COVAX’s subsidization. “For example,” he explained, “Thailand is a high-middle-income nation that still doesn’t have the Pneumococcal vaccine, and I suspect it will be a similar situation for the Covid vaccines.”

Yet still, the picture is bleakest for the lowest income countries. While 10 to 18 percent of the developing world will be vaccinated within 12 months, that’s only an average across countries, and that percentage could be near-zero for nations like Pakistan, in which poverty and civil conflict makes the penetration of any vaccine nearly impossible. Most of these poor nations lack even the supply chain for the AstraZeneca vaccine, with most estimates suggesting that these nations are one to two years away from having their most vulnerable populations inculcated, and three to four years away from a vaccine reaching their full population. And although miracles happen all the time, most poor countries will likely see no breakthrough until long after American stadiums are full and we begin treating Covid-19 as a pop culture relic.

Justin Portela is a gap-year junior studying Symbolic Systems and Creative Writing.