Financial, epidemiological, and moral arguments should push policy makers to move away from nation centric vaccine policies and move towards global vaccine equity.

In 1955, when Jonas Salk was asked who owned the polio vaccine, he famously remarked “Could you patent the sun?” Where is that sense of communal servitude today? Covid-19 vaccine manufacturing and global access has been limited by vaccine nationalism and patent restrictions. Globally, approximately 2.7 billion doses of covid-19 vaccines have been administered. The Duke Global Health Speedometer estimates that as of June 2021, high and upper-middle income countries have secured over 8.1 billion doses of all covid-19 vaccines, while low- and lower-middle-income nations, where the majority of the world’s population reside, have secured 2.1 billion doses. Canada leads vaccine acquisition, with 10.45 doses per inhabitant, while India, which was recently hit with a devastating second wave, has access to 0.83 doses per inhabitant. This inequality is emblematic of the global vaccine inequities.

During crises, difficult choices are made to allocate scarce resources. How the global community makes these choices reflects our values, morals, and priorities. The Director General of the World Health Organization (WHO), Tedros Adhanom Ghebreyesus, recently suggested that a nationalistic stance is counterproductive and immoral. The National Academy and WHO outlined ethical frameworks for equitable and evidence-based allocation of vaccines, leading to the recommendation to vaccinate frontline workers and older populations first. This framework supported equitable global vaccine allocation; however, “rich countries” hold stockpiles in excess to their needs as they move to vaccinate low-risk groups. The call for equity went unheeded. 

High-income countries (HICs) procuring excess doses hampered supply for COVAX, the vaccine sharing coalition. Tasked with accelerated manufacturing, acquisition of vaccinations, and equitable distribution across low-income countries, COVAX has been slowed down by vaccine nationalism and monopolies, suffering a deficit of over 100 million doses, delivering ~65 million doses across 120 countries. 

While the pharmaceutical industry needs incentives to innovate and recuperate research and development costs, the degree of profit prioritization has been disheartening. Within the first three months, Pfizer made $3.5 billion in profits. Opaque pricing, skewed price differentials (for instance, South Africa is paying twice the EU cost for the Oxford vaccine), and allegations of “secret vaccine deals” between governments and corporate entities has further accentuated these inequities.

The case for global vaccine equity is not just based on an ethical or moral argument. There are epidemiological, as well as financial arguments to support vaccine equity. SARS-CoV-2, like any other virus, mutates. Higher community transmission, ineffective treatment strategies and growing case burdens, as witnessed in South Asia, create selection pressure for further vaccine escape variants, prolonging the threat globally.

An analysis commissioned by the International Chamber of Commerce Research Foundation estimated that if HICs were to fully fund the COVAX initiative, it would cost $27 billion. By comparison, a failure to rollout the vaccine globally would result in an estimated global loss of $9.2 trillion, half of which would be borne by HICs. Further, countries like India, where the second wave of the pandemic caused widespread production and supply chain disruptions, are the leading manufacturers of vaccines, and pharmaceuticals for global distribution, including to the United States. India shipped out more than 60 million doses this year, including donations, before halting vaccine exports to strengthen local response. A further collapse in production will have downstream consequences affecting HICs as well.

The recent response has also been constrained by a failure to learn from past successes. In the 1990s, when antiviral medications for HIV/AIDS were developed, 95% of the world’s population did not have access to them. Through collective action and activism, institutions such as PEPFAR and the Global Fund were born and resulted in global financial structures to support access to HIV medications, averting loss of life and human suffering. Compared to HIV, SARS-CoV-2 kills faster, spreads by air, is harder to contain, and will result in multiple waves of pain and suffering, both in terms of human and financial capital. This makes it even more vital to rapidly invest in international efforts to ensure global access to covid-19 vaccines. 

In the short term, continued donations of vaccines and funding to COVAX by both HICs and pharmaceutical companies is necessary, however this is a stop-gap solution. In the long haul, global vaccination policies must move away from a “zero sum game.” Vaccination in HICs need not come at the expense of global vaccine access. Given the existing manufacturing limits, it is necessary to ramp up production infrastructure globally, supported by waivers of intellectual property and patent rights, steady pipelines of raw materials and technology transfer agreements to augment production and supply. We need to draw inspiration from previous successes, such as the global partnerships and technology transfer, which led to the development and licensure of a safe, effective, and cheap oral cholera vaccine.

The cliche, “no one is safe, until everyone is safe,” rings hollow in the face of such gross inequities. A pandemic is a global problem, the cure should be a global public good. It is time to see each other as global citizens, versus members of single nations, and frame policies taking the long-haul view into consideration. Ending the pandemic should be a universal goal, driven by collaboration over capitalism, science over ideology, and people over nations. 

Bhavna Seth is a Fellow, Pulmonary Critical Care Medicine, at Johns Hopkins, with an interest in Global Health and Health Systems research. Twitter: @seth_bhavna

Abhi Kole is a Hospitalist, at Grady/Emory University, and graduate of the HEAL Fellowship focused on Health Equity Action Leadership. Twitter: @drdrabhikole

Aakriti Pandita is an Infectious Disease specialist at University of Colorado and a COVID-19 and TB advocate. Twitter: @aakritipandita

Pranab Chatterjee is a doctoral student at the Department of International Health, Johns Hopkins Bloomberg School of Public Health. Twitter: @scepticemia

Competing interests: none declared.