People are right to be upset about the inequity here. Vaccines make Covid-19 a largely preventable disease — and a survivable one in all but the rarest cases — and it is heartbreaking to know that people are dying of a disease not because it can’t be stopped but because they live in a low-income country.
The fact that routine childhood vaccines are reaching so many people is reason to believe Covid-19 vaccines can too.
At the same time, we can learn from the inequities that were so clear during this pandemic so we can do a better job of closing the gap during the next one. (Assuming there is a next pandemic. I think it is possible to prevent them altogether. But that’s a subject for another time.)
How could we achieve vaccine equity in a future pandemic? I see two ways:
Change how the world allocates doses
What would the optimal allocation look like? It’s not simply a matter of proportional representation, where if your county has X percent of the world’s population, you get X percent of the vaccines. There are two different benefits to consider, and both are important.
One benefit is to the individual who’s immunized; they get protection from the virus. The more likely you are to get infected — and the more likely you are to become seriously ill or die if you do get infected — the more benefit you get from a vaccine.
Second, when an individual is vaccinated, society gets the benefit of lowering the risk that the person will spread the disease to others. This is the core of the argument in favor of vaccinating health workers and people who work in elderly care facilities, since even when a lockdown is in place, they can transmit the virus to people at high risk.
When a virus is spreading, we should maximize both benefits — saving lives and stopping transmission. This means that, when supplies are short, we should prioritize vaccinating people who both have a high risk of death and live in the places where the virus is spreading fastest.
The gravest inequity, even more than vaccinating rich people before poor ones, is vaccinating young people in rich countries before older people in middle-income countries with bad epidemics, such as South Africa and most of South America.
Although sharing doses needs to be part of the solution, it will never be sufficient to solve the problem. For one thing, the number of doses won’t be high enough. And will future politicians always be willing to tell young voters they can’t be vaccinated because the doses are going to another country, at a time when schools are still closed and people — including a few young people — are still dying?
That’s why it’s so important to find ways to produce more doses in less time. The world should have the goal of being able to make and deliver enough vaccines for everyone on the planet within six months of detecting a potential pandemic. If we could do that, then the supply of doses would not be a limiting factor, and the way they were allocated would no longer be a matter of life and death.
Make more doses
As limited as the supply of Covid-19 vaccines has been, the situation could have been even worse.
You may have heard the argument that waiving intellectual property (or IP) restrictions would have made a difference. Unfortunately, that’s not true in this case. IP waivers and licensing are complicated issues, so I want to take some time to untangle it.
Unfortunately, IP licensing doesn’t work as well with vaccines. Here’s why.
Many drugs are made using chemical processes that are well-defined and measurable. If you mix the same ingredients in the right proportion and so on, you’ll get the same product every time, and you can check your work by looking at the chemical structure after the drug is made. Company A can give a recipe to company B, and company B will be able to make precisely the same drug consistently.
But many vaccines don’t work that way. Manufacturing them often involves living organisms — anything from bacteria to chicken eggs. Living things don’t necessarily act exactly the same way every time, which means that even if you follow the same process twice, you might not get the same product both times. Even an experienced vaccine maker might not be able to simply take another’s recipe and replicate it reliably.
Licensing IP — or having the rights to it waived — only guarantees that company A can’t sue company B. Second-source deals are far superior because they involve sharing not only the recipe but also knowledge about how to use it, as well as personnel, data and biological samples.
So how can the world make more doses faster next time?
First, decision-makers should get serious about expanding the world’s vaccine-making capacity.
In particular, governments and industry should make sure there’s enough capacity to quickly make huge volumes of mRNA vaccines; now that we know the mRNA platform works, it will allow new vaccines to be developed faster than any other approach. And if companies that have second-source deals now maintain their relationships with each other, they won’t have to start from square one in the next outbreak.
One longer-term step is for more countries to build the capacity to develop, manufacture, and approve vaccines themselves.
Historically, the companies that invent new vaccines have been based in higher-income countries. Because it costs so much to develop a new product, they try to recoup their costs as quickly as possible by selling doses at the higher prices that rich countries can afford. They have no financial incentive to try to lower their costs (by optimizing the production process, for example) so that the price can be cheap enough for lower-income countries.
What we’ve learned is that creating an entire vaccine-making ecosystem is a tough challenge. But the obstacles can be overcome.
One issue is the need for regulatory approvals. Vaccine factories are required to be approved by what’s known as a “gold-standard” regulator. India is the only developing country with a gold-standard regulator; factories in any other developing country have to be approved by their own government first, and then by the World Health Organization. It’s time-consuming.
Another challenge: If vaccine manufacturers don’t have other products to make between outbreaks, they’ll go out of business. Unfortunately, making existing vaccines isn’t a viable option, at least right now, because the market is already saturated with existing vaccines, and it would be hard for new entrants to compete on price with established low-cost / high-volume companies.
But new products are coming that would be ideal products for them. As vaccines become available for diseases like malaria, tuberculosis and HIV, they’ll create opportunities for producers in middle-income countries. In the meantime, countries can take on the fill and finish process — putting vaccines made elsewhere into vials and distributing them.