As of 28 September 2021, in total, 6.18 billion doses of COVID-19 vaccines have been administered globally and 44.7% of the world population (in over 195 countries) have received at least one dose (https://ourworldindata.org/covid-vaccinations). At first glance, these numbers suggest that the world is on the right track in achieving the WHO's goal to vaccinate at least 10% of the population of every single country by this autumn. However, a closer examination of the status quo reveals an unconscionable reality, described by the World Health Organization (WHO) Director-General Tedros Adhanom Ghebreyesus as “vaccine apartheid” (World has entered stage of “vaccine apartheid” - WHO head https://www.reuters.com/business/healthcare-pharmaceuticals/world-has-entered-stage-vaccine-apartheid-who-head-2021-05-17/).

Even though 51 % of the world population (˜4 billion people) live in low-income or lower-middle-income countries (LMICs), their share of fully vaccinated populaces remains at 1.2 and 13%, respectively (Figure 1) and https://data.covid19taskforce.com/data/tables. We are clearly far from achieving WHO's goal to vaccinate at least 40% of the world's population by the end of this year. Almost 4 billion of our fellow humans living in the southern hemisphere see COVID-19 vaccines as a privilege earmarked only to the wealthy. The great divide in global wealth distribution is a mirror image of the current vaccine inequity. Disparity between wealth and access to vaccines nourished “vaccine nationalism” and high-income countries hoarded doses enough to vaccinate their adult population many times over. According to Airfinity, by the end of 2021, the G7 (Canada, France, Germany, Italy, Japan, UK and USA) and EU will collectively have 1 billion more vaccines than they actually need, 100 million of which are in danger of being wasted due to imminent expiry dates (COVID-19 vaccine expiry forecast for 2021 and 2022 – https://www.airfinity.com/insights/global-press-release-more-than-100-million-vaccines-are-set-to-expire-by-end-of-2021).

Total number of people fully vaccinated against COVID-19, divided by the total population. September 25, 2021.

Source: https://ourworldindata.org/grapher/share-people-fully-vaccinated-covid?tab=map&time=latest

Living on a planet where 3.4 billion people are forced to live on less than $5.50 a day while the world's richest 1% possess twice as much wealth as 6.9 billion people is, for want of a better word, dystopian. The COVID-19 pandemic did its worst to accelerate this divide. According to Oxfam and the International Labour Organization, from March 2020 to the beginning of 2021, global billionaire wealth increased by $3.9 trillion whereas global workers’ combined earnings decreased by $3.7 trillion. Inequality.org reports that one-third of U.S. billionaires’ wealth growth over the last 31 years occurred during the pandemic (Covid-19 and inequality – https://inequality.org/great-divide/updates-billionaire-pandemic/). To top it all, this year, one “ultra-high net worth individual” spent $5.5 billion to occupy space for just 4 minutes during which roughly five people were dying every minute on the planet surface due to COVID-19. We can only imagine how many lives could have been saved with a $5.5 billion donation to purchase vaccines for LMICs. To end poverty and reduce inequality, all countries need to urgently implement the 17 Sustainable Development Goals (SDGs) adopted by The United Nations 2030 Agenda for Sustainable Development – see https://sdgs.un.org/goals.

The development of highly effective vaccines against COVID-19 in under a year was one of the greatest achievements of this century in the field of medical research. Public funding for COVID-19 vaccine development played a crucial role in accelerating this process, with USA and Germany leading the countries that publicly invested (Figure 2A). The main recipients of such public funds were mostly private companies (Figure 2B) (Global Health Centre. 2021. COVID-19 Vaccines R&D Investments. Graduate Institute of International and Development Studies – https://www.knowledgeportalia.org/covid19-r-d-funding). The Global Health Centre at the Graduate Institute of International and Development Studies in Geneva estimated that if advance purchase deals were also included, public investment in Covid-19 vaccines amounts to more than $50 billion. Having received such unprecedented public funding, should these pharmaceutical companies have a moral obligation to support the WHO's efforts to guarantee worldwide equitable access to COVID-19 vaccines? Jannsen and AstraZeneca had committed that their COVID-19 vaccines would be not for profit during the pandemic. A recent report by Amnesty International (AI) (A double dose of inequality: Pharma companies and the Covid-19 vaccines crisis. September 22, 2021 – https://www.amnesty.org/en/documents/pol40/4621/2021/en/) forecasts that by the end of 2022, for-profit companies BioNTech, Moderna and Pfizer are set to earn $130 billion combined. However, little progress has been made towards vaccine equity. Here are some numbers from the AI report: The doses delivered by Pfizer/BioNTech to Sweden alone are nine times the collective dose sent to all low-income countries combined. So far, not even a single dose of the Moderna vaccine has reached a low-income country. Similarly, Moderna provided just 12% of its vaccines to lower-middle income countries (A double dose of inequality: Pharma companies and the Covid-19 vaccines crisis. September 22, 2021 – https://www.amnesty.org/en/documents/pol40/4621/2021/en/). Following the decision taken by some high-income countries to administer booster shots after two doses, Pfeizer and Moderna increased the price of their vaccines in their European Union supply contracts (Pfizer and Moderna raise prices for COVID-19 vaccines in EU- FT – https://www.reuters.com/business/healthcare-pharmaceuticals/pfizer-moderna-raises-prices-its-covid-19-vaccines-eu-ft-2021-08-01/).

Leading Countries that have provided public funding for COVID-19 vaccine R&D and major recipients of these funds. Source: Global Health Centre. 2021. COVID-19 Vaccines R&D Investments. Graduate Institute of International and Development Studies. Retrieved from: knowledgeportalia.org/covid19-r-d-funding.

https://www.knowledgeportalia.org/covid19-r-d-funding

The Covid-19 Vaccines Global Access (COVAX) alliance, co-led by Gavi, the Coalition for Epidemic Preparedness Innovations (CEPI), WHO, the Vaccines Alliance and UNICEF, function as an international pooled purchasing mechanism for COVID-19 vaccines (Gavi,“COVAX explained”. 3 September, 2020. – http://www.gavi.org/vaccineswork/covax-explained). COVAX was established in April 2020 to accelerate the development and production of COVID-19 vaccines, and to ensure equitable access to SARS-CoV-2 vaccines. COVAX pre-purchases large quantities of vaccines from major manufacturers to allow equitable distribution to all countries. The initiative originally pledged to vaccinate 20% of the vulnerable population in 92 low-income countries (∼ 2 billion doses) by the end of 2021. Yet, COVAX has so far delivered just 311 million COVID-19 vaccines to 143 countries (COVAX vaccine roll-out. 27 September, 2021. https://www.gavi.org/covax-vaccine-roll-out). Even though most of the doses went to LMICs, some high-income countries (UK, Canada, Australia and New Zealand) also received deliveries through COVAX (Rich nations dip into COVAX supply while poor wait for shots. AP news, August 14, 2021. (https://apnews.com/article/joe-biden-middle-east-africa-europe-coronavirus-pandemic-5e57879c6cb22d96b942cbc973b9296c). With the booster dose policies adopted by several high-income and upper-middle income countries, expecting an improvement in global vaccine inequity status only through COVAX looks quite bleak.

On 22 September 2021, at the Global COVID-19 Summit, the WHO Director-General announced that only 15% of the 1 billion vaccine donations promised by rich countries have materialized. He urged the countries and companies that control the global supply of vaccines to fulfil their dose-sharing pledges, to facilitate the immediate sharing of technology, know-how and intellectual property. In fact, the WHO had launched the COVID-19 Technology Access Pool (C-TAP) last May to establish a pool of intellectual property, knowledge, and data sharing hub so that a broader range of quality-assured manufacturers could contribute to licensed vaccine production (WHO, “COVID-19 Technology Access Pool” (accessed on 31 August 2021) – http://www.who.int/initiatives/covid-19-technology-access-pool). So far, none of the COVID-19 vaccine manufacturers have shared any patents or know-how through C-TAP. Similarly, WHO's initiative to establish mRNA-vaccine technology transfer hubs in low and middle-income countries, starting with one such hub in South Africa (WHO supporting South African consortium to establish first COVID mRNA vaccine technology transfer hub. 21 June 2021, https://www.who.int/news/item/21-06-2021-who-supporting-south-african-consortium-to-establish-first-covid-mrna-vaccine-technology-transfer-hub), was not reciprocated by any of the mRNA vaccine manufacturers. A proposal at the World Trade Organization (known as TRIPS waiver) (Waiver from Certain Provisions of the TRIPS Agreement for the Prevention, Containment and Treatment of COVID-19 (IP/C/W/669), Council for Trade-Related Aspects of Intellectual Property Rights (2020) – https://www.wto.org/english/news_e/news20_e/trip_10dec20_e.htm) to allow temporary lifting of intellectual property rights to produce COVID-19 vaccines was strongly opposed by the European Union (EU), Switzerland, Norway and the UK, despite the backing of over 100 countries, including the USA. Pharmaceutical companies and countries opposing the TRIPS waiver claim intellectual property rights are fundamental to innovation and waiving patent rights does not ensure a quality product. The proponents of the waiver rightfully point out that public funding and government support was pivotal in fueling innovation. They argue waivers are a necessary first step in ramping up global vaccine production. Global Economic Governance Initiative Brief-016 offers a solution not just for the current pandemic but for future challenges by defining the three pillars of vaccine equity (Three Pillars of Vaccine Equity. Triaging the Global Vaccination Challenge Gallogly-Swan, K., Thrasher, R. GEGI POLICY BRIEF 016, 09/2021. https://www.bu.edu/gdp/files/2021/09/GEGI_PB_016_FIN.pdf). Firstly, the TRIPS Waiver of intellectual property rights to enable new production, secondly, technology transfer to regionally distributed manufacturing hubs and finally financing to upgrade production facilities and improve global vaccine distribution. The only rule is to support these pillars robustly and simultaneously. The brief also very accurately identifies that the current inequity is not a vaccine problem, but a system problem.

Vaccine inequity is only one facet of the system problem. Unless we face this reality, can we hope to wake up to an equitable world? As WHO Director-General Dr. Tedros has previously said: “Will we swim or sink together?”.