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How Equitable Is the Distribution of COVID-19 Vaccines?

SIS professor Maria De Jesus answers questions about global COVID-19 vaccine dose distributions.

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The fastest vaccines ever to have been developed are now being distributed to combat COVID-19. The global roll-out, however, is far from equitable. Wealthy countries have secured a lion’s share of coronavirus vaccine doses for their citizens, leaving fewer doses available to be distributed to low-income countries. In fact, it’s likely that it will take years for low-income countries, many in the Global South, to have widespread access to the doses.

To learn more about global COVID-19 vaccine dose distributions, the COVAX initiative, and vaccine hesitancy, we spoke with SIS professor Maria De Jesus.

What are the disparities between higher income countries and lower income countries when it comes to vaccine distribution, and what are the implications of such disparities?
If we look at a world map, we can observe that there are large disparities by country level. We see that high-income countries are much further along in their vaccination distribution programs compared to lower-middle and low-income countries. To give some figures taken from government sources by the Our World in Data project at the University of Oxford, as of March 7th, 2021, Israel is on top of the list, having vaccinated 101.09 vaccination doses per 100 people in the total population, which translates into 57.3 percent of Israelis who received at least one COVID-19 vaccine dose. The United Arab Emirates follows with 63.43 vaccination doses per 100 people, the United Kingdom with 34.37 doses per 100 people, Bahrain with 29.97 doses per 100 people, and the United States has administered 27.02 doses per 100 people.
Then we see major disparities with less wealthier countries that comprise the global majority being left behind in the vaccination roll-out, such as South Africa—the worst COVID-hit country in Africa and with COVID cases surging—which has administered less than 0.01 doses per 100 people. India and Indonesia have administered 0.07 doses, and Brazil has administered 0.16 doses per 100 people. The important takeaway message here is that the vaccine rollout is uneven and that countries in the Global South are being left behind. Therefore, there are large country-level disparities in being able to achieve herd immunity, and our efforts toward attaining global herd immunity are severely hampered.
COVAX is an initiative led by the Coalition for Epidemic Preparedness Innovations (CEPI); Gavi, the Vaccine Alliance; and the World Health Organization (WHO). It aims to provide participating countries, regardless of income levels, equal access to COVID-19 vaccines. Ghana became the first country to receive a shipment of the vaccine from the initiative, but, currently, the supply is just enough for one percent of the country’s population. Why has equitable global distribution of COVID-19 vaccines been so challenging?
As a global health researcher who focuses on inequities, one of the biggest challenges that I see to the equitable global distribution of COVID-19 vaccines is that there is a disconnect between how some countries are agreeing to do things in a way that shows global unity among leaders and the actual implementation of the agreement. A perfect example is the COVAX facility that you described. COVAX is a global initiative created to ensure rapid and equitable access to COVID-19 vaccines for all countries, regardless of income level. Low-income countries receive support from wealthier countries and other donors for vaccine purchases through the Advance Market Commitment (AMC) to ensure that these countries can access the new vaccines at the same time as the lower-middle, middle, upper-middle, and high-income countries. However, in practice we see something completely different, which is what WHO and public health advocates feared. Internationally, high income countries have adopted a competitive “fend for yourself” attitude, competing against others for access to supplies and commercial advantage in the COVID-19 vaccines.
Most supply of the leading vaccines was pre-ordered by wealthy nations even before the safety and efficacy data was made available. So, the nationalistic competition for the vaccines is a major factor contributing to the challenges we are facing in the equitable global distribution of the COVID-19 vaccines. These practices are contrary to global interest and are likely to harm countries and citizens of the Global South. Even in the situation with Ghana, which recently received 600,000 doses of the AztraZeneca/Oxford vaccine, we see that this is still too low of a supply to be able to achieve herd immunity. The global pattern we see is that the low-income countries with the least economic and political bargaining power have less access to the vaccines.
While the Trump administration opted out of COVAX, under the Biden administration, the US pledged $4 billion to the program. Though, like other wealthy countries, the US has yet to say anything about donating doses to participating countries. What else do you think needs to be done to ensure that the maximum number of people are vaccinated around the globe?
First, we need to adopt an attitude, an approach, and actions that reflect global fairness, solidarity, and equity for the timely vaccine distribution and immunization campaigns across the globe so that there is not a discrepancy between our words and actions. WHO director-general, Dr. Tedros Adhanom Ghebreyesus, stated it clearly in his opening speech of a WHO executive board meeting: “Not only does this me-first approach leave the world’s poorest and most vulnerable people at risk, it’s also self-defeating. Ultimately, these actions will only prolong the pandemic, prolong our pain, the restrictions needed to contain it, and human and economic suffering.” This recommendation also resonates with the idea that no one is safe until everyone is safe. With some of the current practices, we risk exacerbating more inequities in COVID-19 infection and mortality rates.
Second, we need local, national, regional, and international coordination of the vaccination roll out. We already have established a mechanism to do this known as the Access to COVID-19 Tools (ACT) Accelerator, a partnership launched by WHO and its partners to support this coordinated and global effort.
Third, we need both a top-down and bottom-up approach—that is, a strong commitment, cooperation, and implementation of plans among our scientific, industrial, and political leaders in conjunction with community mobilization at the local levels.
The important message driving my recommendations is this: given that the COVID-19 pandemic is having an impact on a global scale, we need a global response rather than a one-region-at-a-time or high-income-countries-before-all-others type of response to effectively control the pandemic.
Johnson & Johnson’s COVID-19 vaccine is one of the cheaper ones available, only requires one dose, and has less stringent freezer requirements. There’s been a perception that it’s less effective than other vaccines, which has led to people fearing its distribution will be a way to enact a two-tiered system, with wealthy and white people receiving the “better” vaccines and poorer communities of color and at-risk populations like the homeless receiving the “lesser” vaccine. What are the implications of such perceptions, and vaccine misinformation in general at the individual and community levels, when it comes to immunization efforts?
The important factor here to consider is that misperceptions that people have about the COVID-19 vaccines fuel vaccine hesitancy and these misperceptions, although false, are powerful barriers to vaccine uptake. Vaccine hesitancy encompasses a refusal to vaccinate, delaying vaccines, or using certain vaccines but not others. Interestingly, this trend was identified by the WHO as one of the top ten global health threats in 2019. Apart from misperceptions, vaccine misinformation whereby false information is spread, for example, by people in a particular community because they believe it to be true, also drives vaccine hesitancy. Another main driver of vaccine hesitancy is disinformation, which is different from misinformation because it refers to false or misleading information that is spread deliberately to deceive and in turn leads to skepticism and mistrust in the population.
A recent published paper by Lazarus et al. in Nature Medicine that surveyed almost 14K people in 19 countries found that about a third of the people in the cross-country sample were not likely to take a COVID-19 vaccine. Differences in acceptance rates ranged from almost 90 percent (in China) to less than 55 percent (in Russia), and an important barrier was mistrust. Respondents reporting lower levels of trust in information from government sources were less likely to accept a vaccine. In the US, a recent published paper by Malik et al. in The Lancet found that almost 30 percent of their sample of 672 participants in the would not accept a COVID-19 vaccine, with Black Americans, those unemployed, and those with low levels of education less likely to accept the vaccine compared to their counterparts. The KFF COVID-19 Vaccine Monitor, an ongoing research project, is tracking the public’s attitudes and experiences with COVID-19 vaccinations, including vaccine confidence and hesitancy.
Focusing on particular communities that are hesitant about vaccine uptake and understanding who these communities trust for reliable vaccine information will be critical for COVID-19 immunization efforts. I will draw from my own health communication research here related to the human papilloma virus (HPV) vaccine—when it first came to market in the US in 2006 for use among 9-26 year-old females. There was a lot of vaccine hesitancy, especially among Latinx and African communities. What my research showed was that there was a large discrepancy between actual and preferred sources of HPV information in these communities. They wanted the messengers to be trusted sources of health information—in this case it was a health provider rather than pharmaceutical and media campaigns. This type of community-specific information is critical as it informs the different health communication strategies needed when it comes to increasing trust levels in Johnson & Johnson’s COVID-19 vaccine. Public health experts also have a role in being more transparent in educating the public about the effectiveness of the Johnson & Johnson vaccine and in addressing the existing misperceptions and misinformation about the vaccine.