The Hollow Order
Rebuilding an International System That Works
Africa is experiencing the world’s worst vaccine deficit. Only a minority of countries—mostly those where vaccines are manufactured—are approaching adequate levels of vaccination. But Africa is averaging even lower rates than other less affluent continents—less than one-tenth the percentage of South America and one-eighth that of Asia. Most African countries missed a recent goal of vaccinating ten percent of their populations. Overall, less than five percent of Africans are fully vaccinated.
This is a colossal global health failure. Considering the vaccine surplus found in developed economies, especially the United States, it is also a moral crisis. The United States has purchased 1.2 billion vaccine doses, enough to inoculate its entire population twice over, and may have as many as 500 million excess doses by the end of October and possibly one billion by December. Extra vaccines are beginning to accumulate so rapidly that growing numbers of doses are being destroyed.
COVAX—the global COVID vaccination partnership established by the World Health Organization (WHO), the Coalition for Epidemic Preparedness Innovations, and the GAVI Vaccine Alliance—was supposed to prevent such gross vaccine inequities. High- and low-income countries were encouraged to join, and each was supposed to receive dose shares based on population size, not wealth. But the world’s richest states sidestepped COVAX to secure priority access to more vaccines than they can use, putting themselves ahead of other countries in the manufacturing pipeline. India, the planet’s largest producer of vaccines and COVAX’s primary supplier, banned vaccine exports for five months as it weathered a devastating third wave of infections. China has largely shared its vaccines directly with other nations, sending very few through COVAX.
COVAX has still managed to ensure that no state got left entirely behind, and the United States and other high-income countries should continue to work with the initiative. But COVAX has struggled mightily, falling far short of its goals. Solving vaccine inequality and successfully inoculating the entire world is essential to ending the pandemic, and that means taking a new and different approach, with more targeted and impactful partnerships. In Africa, that means working with one organization in particular: the Africa Centres for Disease Control and Prevention.
Founded in the wake of the 2014 Ebola epidemic, the Africa CDC has a strong record of combating diseases. During the 2018–20 Ebola outbreak, for example, the organization supported contact tracing and laboratories that tested tens of thousands of samples, and it trained thousands of health-care workers. It has established effective new systems to share resources, such as the Africa Medical Supplies Platform; amplified best practices, including testing regimens; and responded to regional disease dynamics through Regional Collaborating Centers.
Until recently, vaccines bottled in Africa were going to Europe.
There are many reasons to partner with the Africa CDC in addition to COVAX. The smaller domain of the Africa CDC makes the organization more effective logistically than COVAX, which has struggled to keep up with the communications and mechanics of working with so many countries around the world. The Africa CDC directly engages heads of state, whereas COVAX deals primarily with health ministries, which often lack the staff and support needed to get vaccines distributed. And vaccine donations to COVAX are spread across the entire globe, whereas doses distributed by the Africa CDC target the countries with the most acute need. To promote global health equity, prevent the rise of dangerous new variants, and stop more of its doses from going to waste, the United States should give large shares of its surplus vaccines to this powerful institution. It is the organization best able to help Africa reach and, it is hoped, accelerate its ambitious goal of vaccinating 25 to 30 percent of residents by the end of 2021 and 60 percent as soon as possible.
Africa was never well positioned to inoculate its population without strong partners. Home to 17.8 percent of the world’s population, the continent houses less than 0.1 percent of global vaccine manufacturing, according to a WHO estimate. It is working to develop new capacity, but it will be many months before more factories come online. Reports indicate that a new facility in Senegal, for example, will likely not produce doses until the second half of 2022. As a result, the continent has been forced to rely almost entirely on overseas manufacturing. In fact, until recently, the relatively few doses bottled in Africa were being purchased by and exported to Europe, a misallocation of resources that is both unconscionable and epidemiologically unsound.
But despite these challenges, the Africa CDC has taken major steps to procure vaccines for the continent. The organization’s African Vaccine Acquisition Trust has contracted 400 million Johnson & Johnson doses, enough to partially inoculate roughly a third of the continent’s population. Yet the delivery of these doses to the trust has ramped up slowly and is expected to reach only 20 million per month in January. It is time for the United States and other wealthy nations to get out of the way. Rather than demanding that vaccine manufacturers complete their outstanding orders first, rich countries should heed the Africa CDC director John Nkengasong’s request to deprioritize their own contracts in favor of the Africa CDC’s purchases—an approach favored by the White House in leaked documents. States would still receive their doses, but the delay in delivery would fall on countries already benefiting from substantial vaccine coverage.
Vaccine-rich nations should also share their stockpiles and future commitments with Africa, and contributing through the Africa CDC has many advantages. Pandemics are driven by regional dynamics, and the Africa CDC has a strong understanding of the continent’s needs. Cross-border travel, seasonality, socioeconomic characteristics, and other factors mean that viruses have no respect for borders, and the intensive logistical investments required to vaccinate less populated areas would benefit from a regional approach that allows doses to be safely stored until they can be delivered. With its ongoing, direct engagement with heads of state, the Africa CDC has excellent visibility into epidemiologic trends and into national public health resources, making it well positioned to quarterback distribution. (In contrast, many national leaders have struggled to communicate with COVAX.) Gifting vaccines through the Africa CDC will also help limit the diplomatic fallout and national political clashes over vaccine allocation and management that would likely bedevil U.S. bilateral donations.
The Africa CDC has taken major steps to get vaccines for the continent.
As a trusted and authoritative health entity, the Africa CDC can help resolve thorny questions for the continent’s countries around such issues as delaying second doses or mixing different types of vaccines. In countries where national leaders have downplayed the pandemic or propagated vaccine misinformation, the Africa CDC can play a crucial certification role, confirming the vaccines’ safety and efficacy. The organization can address concerns from pharmaceutical companies around liability for vaccine-related injuries by helping draft a no-fault compensation agreement modeled after the one already used by COVAX, indemnifying manufacturers and administering a compensation fund that the United States should help endow.
Asking strained national public health systems to administer millions of vaccine doses will present extraordinary challenges, but African countries have demonstrated their ability to meet them. Rwanda administered nearly 350,000 doses of the Oxford-AstraZeneca vaccine in three weeks, and Ethiopia vaccinated 15 million children against measles despite the pandemic and a brutal civil war. The Africa CDC can help by using its granular data on the logistical capacity of the continent’s countries and its demonstrated ability to support supply chains during the pandemic through vehicles such as the Africa Medical Supplies Platform.
The Biden administration appears to understand the need to share vaccines with Africa, recently committing to delivering 17 million more Johnson & Johnson doses to the African Union (although this is not nearly enough). It is also beginning to understand how valuable the Africa CDC can be. In addition to backing the Africa CDC’s call for manufacturers to move the organization’s contracts to the front of the line, Biden recently announced plans to nominate Nkengasong to lead the President’s Emergency Plan for AIDS Relief (PEPFAR). Biden clearly has faith in the group’s management.
Nkengasong’s appointment has been met with somewhat mixed feelings by those who worry that his departure could undermine the work of a critical organization at a key moment in the pandemic. But in addition to being an excellent choice to lead the flagship U.S. global health intervention, the move may ultimately make the Africa CDC even more effective. PEPFAR is itself a pandemic response body, with expertise and experience in disease surveillance, public health communications, and clinical interventions, and one whose work has been primarily in Africa. PEPFAR could use its infrastructure—including its existing relationships with governments, nongovernmental organizations, and community organizations, as well as with clinics and public health staff—to support the Africa CDC in its fight against COVID-19. PEPFAR is already immensely successful and has been well received on the continent. Helping the Africa CDC fight the pandemic would build on its political legacy.
This could also be just the start of an even bigger partnership between the United States and the Africa CDC. The United States could and should help the organization become more self-sufficient by increasing vaccine manufacturing in Africa as quickly as possible. This is the only way that the continent will be able to fully fight not just COVID-19 but also the next pandemic. Vaccine manufacturing capacity on the continent would also be a game changer in Africa’s fight against diseases that have plagued the world for generations, such as malaria, for which the WHO just approved a vaccine.
Strengthening the Africa CDC won’t just benefit Africans. Multiple analyses indicate that effective global vaccination campaigns, both for COVID-19 and other illnesses, have immense economic returns that rebound across the planet. In the years to come, the strength of the Africa CDC will also be essential to responding to future pandemics and managing the effects of climate change by tracking alterations in disease prevalence and geography, coordinating regional responses, and mitigating the health impacts of displacement. In doing so, the organization will be critical to keeping the entire world safe. But building the Africa CDC’s capacity must start right now by helping it vaccinate the continent and end the pandemic, and that depends on a timely and robust partnership with the United States.