Two years into the COVID-19 pandemic, it feels like we are stuck in an endless cycle. When a new variant like omicron pops up, the world reacts by enforcing questionable travel bans and lockdowns and expediting third or even fourth doses of the vaccine.
While it's likely that COVID will stay with us in one form or another, vaccines remain our biggest hope for protection of the vulnerable against hospitalization and death, especially for individuals at increased risk of severe COVID-19 due to conditions like diabetes, high blood pressure and obesity, or simply their age. Once those at highest risk everywhere are protected from severe disease — and if no other vaccine-evasive variant emerges — COVID will hopefully join the ranks of the other cold and flu viruses with which we live.
Yet governments – especially those in high-income nations – continue to hoard vaccines, leaving many individuals elsewhere vulnerable to the virus. Although more than 60% of the world's population has received at least one dose of vaccine, most who are protected live in rich countries. In fact, just 10.1% of the people on the African continent are vaccinated, according to the World Health Organization.
So how do we get vaccines to everyone? The good news is that we already have the resources, knowledge and systems to make and distribute vaccines around the globe. Here are five steps that world leaders must take to make this happen.
Step 1: Produce billions more vaccines
First, we need to make more vaccines. Insufficient vaccine supply and hoarding by rich countries has plagued the global effort to get shots into arms in low-income countries, where supply remains a major constraint.
While President Biden announced plans to produce 1 billion doses per year to give to poor nations, this is not nearly enough. A January report by a group of public health advocates and scientists estimated that in order to ensure every person has access to mRNA vaccines – the type of vaccine that currently appears to be most effective – the world needs to produce 15 billion more doses than the 7 billion doses currently planned for 2022.
While this may sound like a tall order, the U.S. has the capability to expand its vaccine manufacturing – quickly and at a reasonable cost. The production facility for the Moderna-NIH vaccine in New Hampshire, for example, was set up in just 4 months, suggesting we could do the same for other facilities if desired.
At the current production cost of the Moderna-NIH vaccine, it would cost $12 billion to produce 15 billion doses of vaccine, without even accounting for savings from economies of scale. This is just a drop in the ocean compared to the lives saved, COVID restrictions averted and trillions of dollars of economic productivity gained from achieving vaccine equity.
The Biden Administration could also speed up production by immediately implementing a government-owned, contractor-operated model. If the government hires manufacturers to produce the vaccine, those manufacturers would not have to repeat some of the clinical trials that were completed by the original vaccine manufacturers, saving months of time and accelerating the production timeline.
The U.S. can help other nations make vaccines, too – by waiving intellectual property protections for coronavirus vaccines that prevent other manufacturers from using the recipe. In May 2021, the Biden Administration announced its support for such a plan, but despite this early rhetorical support, they failed to deliver.
In contrast, Russian and Chinese manufacturers have not only shared their technologies, but have provided essential ingredients, supervised the manufacturing process and even built factories in other countries.
Step 2: Fund 'last mile' delivery
As vaccine supply increases, high-income countries and global institutions must help low-income nations get vaccines through their "last mile" – the final steps in the supply chain to get vaccines from shipping containers to medical facilities and into people's arms.
But transporting and storing vaccines requires money and logistics. Africa, for example, needs $1.3 billion in operational costs to deliver COVID vaccines, according to WHO.
These funds will go toward transport costs, staff – including truck drivers, distribution coordinators and community health workers – as well as syringes and fridges and commodities necessary for a cold-chain. The global experience rolling out a temperature-controlled supply chain for the pneumococcal vaccine in Africa over 10 years ago highlights that challenging environments are no excuse for inaction.
Without the necessary logistical supports, we cannot ensure that the vaccines will get to the people who need them.
Step 3: Set bold global vaccination goals
Once the world has a plan to make vaccines and get them to people, the next priority is to set an ambitious vaccination target so that we can hold national leaders and multilateral institutions to account. Setting goals – as the global community has done with HIV, smallpox and polio – helps to advocate for funding, track progress and drive political commitment.
Sadly, the aspirations set by global agencies for low-income countries have been disappointingly low. At the same time that wealthier nations, including the U.S., set their vaccine coverage goals at 70%, COVAX, the global COVID vaccine-sharing program, aimed to vaccinate just 20% of each country's population. This is not enough to protect those susceptible to severe disease.
We need more ambitious goals if we want to achieve vaccine equity and protect individuals at high risk. For example, 39% of people in the world are challenged by overweight and obesity, 32% have high blood pressure, and 9.3% have diabetes. Ensuring vaccines for individuals with these conditions — along with their caregivers and close family members — would likely require a coverage rate of closer to 70%, the same goal set by high-income countries.
While COVAX updated its goal to 40% of each country's population by the end of 2021, only six African countries managed to achieve this, largely due to vaccine supply shortages and logistical issues.
Step 4: Build more trust in vaccines
Now, we must convince more people who can benefit from vaccines to get vaccinated.
Historically, vaccines have been one of the most impactful global health interventions, yet significant numbers of people in the world are distrustful of them. Some of that reluctance stems from lack of faith in the government or the health-care system. Some fear the vaccine will harm them. Others are confused by conflicting sources of information and cannot make a well-informed decision.
One way to address this is to reach out to under-vaccinated communities to help them better understand the vaccine's safety and benefits. Last year, for example, the advocacy group Health Care for All ran a door-knocking campaign to improve vaccine uptake in 20 marginalized communities in Massachusetts. The group deployed trained, trusted community members to go house to house and talk to local residents about the COVID vaccine. The volunteers listened to and addressed their queries – some were concerned that getting vaccinated would compromise their citizenship status – provided information about the vaccine and explained how to make a vaccination appointment.
The program showed an impressive increase in immunization, especially among Black and Hispanic communities. Imagine if we could adapt this community-led approach in different parts of the world. Trust in vaccine has to be built from the ground up, one neighborhood at a time.
Step 5: Ensure vaccines benefit people, not just companies
Vaccine equity isn't just about getting doses to everyone who needs them. It's also about ensuring that we are making ethical decisions about who can benefit from them – that is, basing vaccine policy on the best available, highest-quality scientific evidence and not simply on the desire of the industry to maximize their returns.
Some companies, which have already reaped billions of dollars in profits, have made the cycle of booster shots part of their business plans. In April 2021, Moderna told investors they expected to reap the benefits of a robust "variant booster" market months before the there was any evidence that supported the use of boosters and before the delta strain became widespread. In December 2021, despite the absence of any data and just 12 days after omicron emerged, Pfizer CEO Albert Bourla said "I think we will need a fourth dose."
Doling out endless booster shots for all in high-income countries may be good for the pharmaceutical industry, but it leaves us stuck in a revolving door of variants and boosters. Angela Rasmussen, a virologist at the Vaccine and Infectious Disease Organization at the University of Saskatchewan, characterized it as "variant whack-a-mole" in The Washington Post.
The only way to be sure that the benefits of subsequent doses outweigh any risks for those most vulnerable to COVID-19 is to run clinical trials that look at real-world outcomes — like hospitalizations, intensive care admissions and deaths — rather than on data solely generated from studies done in laboratory test tubes. Although they are useful to inform early decision-making, laboratory-based data sometimes do not reflect the results we see in humans.
In order to provide people the best and most durable protection against COVID, we also need to invest in research on novel vaccines – such as those that target multiple variants of COVID-19 – as well as vaccines that can be easily scaled up and produced at a low cost in other parts of the world. One example of a scalable, patent-free vaccine is CORBEVAX, recently developed by the Baylor College of Medicine, whose final efficacy results are still pending.
If we can get these five steps right, we can protect the vulnerable and end the constant state of pandemic.
Any COVID-related death in 2022 represents the world's moral, economic and political failure to ensure that the tools at our disposal to combat COVID are fairly distributed across the world.
Scientists have played their role in developing powerful vaccines, now global leaders must prioritize the seemingly more challenging task of getting vaccines into the arms of those who need them.
Dr. Edward Cliff and Dr. Isaac Chan are resident physicians currently based at the Harvard T. H. Chan School of Public Health. Dr. Salmaan Keshavjee is a professor of global health and social medicine at Harvard Medical School and director of the Center for Global Health Delivery.