It bears repeating that vaccines are essential for protection against the deadly coronavirus. We've seen how the virus spares no one and targets the most vulnerable people, including those who have pre-existing health conditions or comorbidities. Unfortunately, the vaccines for Covid-19 that came out last year have remained out of reach for another group of "vulnerable" population—i.e. the billions of inhabitants living in developing countries. It has been over seven months since the coronavirus vaccine was first administered in the UK, and while more than 3 billion people have received at least one shot since then, a meagre percentage of them are in low-income countries. The haunting prospect of "vaccine apartheid" has raised its ugly head now. The question is, how do we prevent this from festering?

Amartya Sen, the Nobel-prize winning economist, had warned more than three decades ago that famines don't happen because of shortages of food, rather due to institutional and structural weaknesses. If we were to apply his Entitlement theory in case of vaccine inequities, we can see some parallels. The sole responsibility for vaccine apartheid cannot be placed on the rich countries and drug manufacturers; some of the blame also lies with the governments of poorer countries. To use Sen's logic, an abundance of supply does not guarantee access, or what is known as "effective demand". If the goal of vaccination is to reach the arms that need them, we must find a pathway to get doses of vaccines from point A to point B. In this instance, point A is the production facility, and B is the outstretched arm of the recipient. 

In my preliminary research on the topic of vaccine apartheid, I discovered three facts.

First: The term "apartheid" has been used very loosely since its origin in South Africa. If one goes back to the first use of this label in the context of the practice of discrimination against non-whites in that country, one cannot ignore the fact that apartheid implies some degree of intentional segregation. In South Africa, the word "apartheid" means "apartness" in Afrikaans, and was used to describe the unique oppression and wrongdoing inflicted on its own people. According to some activists, weaponising this word for political purposes ought to be avoided.  The main reasons for maldistribution of vaccines are cost, lack of infrastructure, and absence of planning.

Second: There is sufficient data to show that there is indeed vaccine inequality. Higher and upper-middle income countries have secured 6 billion out of the 8.2 billion doses available as of March 2021. In an analysis from the Global Health Innovation Center at Duke University in Durham, the researchers aggregated publicly announced forecasts from vaccine makers, which add up to around 12 billion doses by the end of the year. Once again, more than 80 percent of these are destined for wealthier nations.

Third: African countries have had the worse of the deal. They are poor, have a rickety healthcare system, and suffer from bad governance. The third wave of the pandemic comes at a perilous time. "Medical supplies have been depleted, doctors are physically and mentally exhausted, and in some cases, unpaid, and hospitals are turning patients away for lack of beds and oxygen," according to a report in The Wall Street Journal. The Delta variant has been identified in at least 13 of the continent's 54 countries.

Thus, it is abundantly clear that the distribution of Covid vaccines is unequal and African countries are getting the short end of the stick, but the use of the term "apartheid" does not enhance the cause of the "vaccine have-nots". What is needed is a global effort to strengthen the vaccine distribution network to launch a glitch-free operation to deliver the jabs where they are most needed, in Africa, Latin America and South Asia.

Vaccine roadblocks

Global vaccine distribution has already hit several roadblocks. COVAX announced on June 24 that it now projects it can supply less than 1.9 billion doses this year, down from the original target of 2 billion. The shortfall comes because the Serum Institute of India has redirected its production to domestic customers. So far, COVAX has only contributed about 90 million doses, far short of its original plans.

Previously, Gavi officials were optimistic that in the midst of global shortage, there was excess supply in a few countries, and they announced that "rich countries like the USA are expected to help fill the gap". Unfortunately, all this is easier said than done. The richer countries have kept the surplus for emergency purposes, including a new wave of infections, the Delta Plus variant, booster shots, etc.

Health experts point out that campaigns that have been most successful in delivering doses are in countries—such as Angola—that have been best prepared by mapping vulnerable populations, screening people and scheduling appointments in advance. This is lacking in most developing countries.

These are bad omens for other poor countries, from Africa to Latin America, Asia and the Caribbean, where the same issues have been replicated. On top of not finding enough doses, there have been logistical difficulties with delivery, problems involving healthcare infrastructure and, in some countries, public hesitancy towards vaccines. Andrea Taylor, who led a research team at Duke University, adds, "Supply chains could break down and countries could threaten to block vaccine exports." And all this is already happening, with India and the European Union having announced restrictions on vaccine exports.

It was well-known from the onset of the Covid vaccine rollout programme that distribution would be iniquitous. Since the government of the USA and a few other rich countries funded the research and deployment of the vaccine, there was an understanding that once vaccines were ready, a handful of countries would initially be the beneficiary of the campaign. Poorer countries would get the leftovers.

However, as the vaccination programme rolled out, the scenario has turned rather grim. Once the Delta variant spread from India across the globe, the developing countries who were waiting for the generosity of richer countries, or the altruistic instincts of pharmaceutical companies, now found that "their economy would remain stuck in the muck for at least another two years if not more, and the vaccine diplomacy would turn into another version of the new cold war".

A plan for the future: global and local actions

The WHO chief noted that vaccine inequity could be resolved by sharing financial resources to fully fund the Access to Covid-19 Tools (ACT) Accelerator, sharing doses with COVAX, and sharing technology to scale up the manufacturing of vaccines. The advantages of putting vaccine manufacturing in the hands of the Global South would save lives, prevent vaccine-resistant, more lethal variants, and give people control over their own destiny rather than making them beg multinational corporations and elite philanthropists for their very lives. A case in point: US officials said that while the US-produced doses are ready, deliveries have been delayed due to US and the recipient countries' legal, logistical and regulatory requirements. "What we've found to be the biggest challenge is not actually the supply—we have plenty of doses to share with the world—but this is a Herculean logistical challenge,'' said White House press secretary Jen Psaki.

The British PM Boris Johnson recently promised to vaccinate the world by the end of 2022. But here's the rub. The total requirement of vaccines is 11 billion doses, which also means USD 16 billion more is needed this year, and upward of USD 30 billion in 2022.

To reach the goal set by the British PM requires a ramping up of manufacturing, allocation, and distribution of vaccines. Apart from the scale and complexity of the task, another risk is corruption. The United Nations Office on Drugs and Crime (UNODC) has identified several weak points in the distribution chain in developing countries and sent out an alarm to the governments to take necessary actions.

In addition, to prevent major hiccups during the vaccination process as experienced by India, governments could take the following initiatives: 1) Create a specialised committee to oversee emergency funds and vaccine deployment; 2) Have a transparent and accountable public emergency procurement process during the pandemic, which can be fostered through open contracting and e-procurement; 3) Maintain storage and distribution systems to mitigate corruption risks; 4) Develop transparent criteria for priority vaccine recipients and provide public information about vaccine programmes; 5) Conduct corruption risk assessments; and 6) Strengthen civil society participation and protect journalists and whistleblowers. 

Dr Abdullah Shibli is an economist, currently serving as a Senior Research Fellow at the International Sustainable Development Institute (ISDI), a think-tank based in Boston, USA.