An international system to share anti-COVID-19 vaccines supposed to guarantee that low and middle-income countries could get doses without being last in line and at the mercy of unreliable donations has not worked out that way.
In late June alone, the initiative known as COVAX sent some 530,000 doses to Britain – more than double the amount sent that month to the entire continent of Africa.
Under COVAX, countries were supposed to give money so vaccines could be set aside, both as donations to poor countries and as an insurance policy for richer ones to buy doses if theirs fell through. Some rich countries, including those in the European Union, calculated that they had more than enough doses available through bilateral deals and ceded their allocated COVAX doses to poorer countries.
But others, including Britain, tapped into the meagre supply of COVAX doses themselves, despite being among the countries that had reserved most of the world's available vaccines. In the meantime, billions of people in poor countries have yet to receive a single dose.
The result is that poorer countries have landed in exactly the predicament COVAX was supposed to avoid: dependent on the whims and politics of rich countries for donations, just as they have been so often in the past. And in many cases, rich countries don't want to donate significant amounts before they finish vaccinating all their citizens who could possibly want a dose, a process that is still playing out.
"If we had tried to withhold vaccines from parts of the world, could we have made it any worse than it is today?" asked Dr Bruce Aylward, a senior advisor at the World Health Organization, during a public session on vaccine equity.
Other wealthy nations that recently received paid doses through COVAX include Qatar, Bahrain and Saudi Arabia, all of which have relatively high immunization rates and other means of acquiring vaccines. Qatar has promised to donate 1.4 million doses of vaccines and already shipped out more than the 74,000 doses it received from COVAX.
The US never got any doses through COVAX, although Canada, Australia and New Zealand did. Canada got so much criticism for taking COVAX shipments that it said it would not request additional ones.
In the meantime, Venezuela has yet to receive any of its doses allocated by COVAX. Haiti has received less than half of what it was allocated, Syria about a 10th. In some cases, officials say, doses weren't sent because countries didn't have a plan to distribute them.
British officials confirmed the UK received about 539,000 vaccine doses in late June and that it has options to buy another 27 million shots through COVAX.
"The government is a strong champion of COVAX," the UK said, describing the initiative as a mechanism for all countries to obtain vaccines, not just those in need of donations. It declined to explain why it chose to receive those doses despite private deals that have reserved eight injections for every UK resident.
Brook Baker, a Northwestern University law professor who specializes in access to medicines, said it was unconscionable that rich countries would dip into COVAX vaccine supplies when more than 90 developing countries had no access. COVAX's biggest supplier, the Serum Institute of India, stopped sharing vaccines in April to deal with a surge of cases on the subcontinent.
Although the number of vaccines being bought by rich countries like Britain through COVAX is relatively small, the extremely limited global supply means those purchases result in fewer shots for poor countries. So far, the initiative has delivered less than 10% of the doses it promised.
COVAX is run by the World Health Organization, the vaccine alliance Gavi and the Coalition for Epidemic Preparedness Innovations, a group launched in 2017 to develop vaccines to stop outbreaks. The program is now trying to regain credibility by getting rich countries to distribute their donated vaccines through its own system, Baker said. But even this effort is not entirely successful because some countries are making their own deals to curry favourable publicity and political clout.
"Rich countries are trying to garner geopolitical benefits from bilateral dose-sharing," Baker noted.
So far, with the exception of China, donations are coming in tiny fractions of what was pledged, an Associated Press tally of vaccines promised and delivered has found.
Dr. Christian Happi, an infectious diseases expert at Nigeria's Redeemer's University, said donations from rich countries are both insufficient and unreliable, especially as they have not only taken most of the world's supplies but are moving on to vaccinate children and considering administering booster shots.
Happi called on Africa, where 1.5 per cent of the population is fully vaccinated, to increase its own vaccine manufacturing rather than rely on COVAX.
"We cannot just wait for them to come up with a solution," he said.
COVAX is well aware of the problem. During its last board meeting in late June, health officials conceded they had failed to achieve equitable distribution. But they still decided against blocking donor countries from buying up supplies themselves.
At a subsequent meeting with partners, Gavi CEO Dr Seth Berkley said COVAX intended to honour the agreements it had made with rich countries but would ask them in the future to "adjust" their allocated doses to request fewer vaccines, according to a meeting participant who spoke about the confidential call on condition of anonymity.
Among the reasons Berkley cited for Gavi's reluctance to break or renegotiate contracts signed with rich countries was the potential risk to its balance sheet. In the last year, Britain alone has given more than $860 million to COVAX.
Meeting notes from June show that Gavi revised COVAX's initial plan to split vaccines evenly between rich and poor countries and proposed that poor countries would receive about 75% of COVID-19 doses in the future. Without rich countries' involvement in COVAX, Gavi said "it would be difficult to secure deals with some manufacturers."
In response to an AP request for comment, Gavi said the initiative is aiming to deliver more than 2 billion doses by the beginning of 2022 and described COVAX as "an unprecedented global effort."
"The vast majority of the COVAX supply will go to low- and middle-income countries," Gavi said in an email about its latest supply forecast. For many countries, it said, "COVAX is the main, if not the only source of COVID-19 vaccine supply."
Spain's donation to four countries in Latin America – it's first via COVAX – reflects how even rich countries with a lot of vaccines are donating a minimum. Spain, which has injected 57 million doses into its own residents, shipped 654,000 the first week in August. The delivery totals 3% of the 22.5 million doses Spain has promised, eventually, to COVAX.
Gavi said COVAX now has enough money and pledged donations to one day cover 30% of the population of the world's poorest countries. But it has made big promises before.
In January, COVAX said it had "secured volumes" totalling 640 million doses to deliver by July 2021, all of them under signed agreements, not donations. But by last month, COVAX had only shipped 210 million doses, 40% of which were donated.
With COVAX sidelined, vaccine donations have become something of a political contest. China has already exported 770 million doses and last week announced its own goal of sending 2 billion doses to the rest of the world by the end of the year — exactly the same amount as COVAX's initial plan.
That's far ahead of the rest of the world, according to the AP tally of doses. Britain has delivered just 4.7 million, far short of the 30 million pledged, and the European Union has given 7.1 million and another 55 million through COVAX contracts.
"If the donors are not stepping forward, the people who continue to die are our people," Strive Masiyiwa, the African Union special envoy on COVID-19 vaccine procurement, said.
The United States has so far delivered 111 million doses, less than half of what was promised. Several U.S. lawmakers from both parties argued Wednesday that the government should seize the opportunity for diplomacy by more aggressively seeking credit for the doses it ships overseas.
"I think we should make vaccines available throughout the Middle East, but I also think we should have the American flag on every vial," said Rep. Juan Vargas, a Democrat from California, at a hearing on the state of the pandemic in the Middle East.
Even the European Union's foreign policy chief, Josep Borrell, recently decried Europe's lagging in donations in geopolitical terms as a loss to China. US President Joe Biden, in announcing the US donations that have finally come through, similarly described the doses as a way to counter "Russia and China influencing the world with vaccines." The White House said the United States has donated more than 110 million vaccine doses, some via COVAX.
In addition to its planned vaccine exports, China announced plans to donate $100 million to COVAX to buy more doses for developing countries.
"The key to strengthening vaccine cooperation and building the Great Wall of immunization is to ensure equitable access," said Wang Xiaolong of the Chinese Foreign Ministry, speaking Friday after China hosted an online forum on fair vaccine distribution.
The COVAX board has agreed to go back to its basic assumptions about vaccinating the world before the end of the year. High on its list: "An updated definition of fair and equitable access."
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