The Downside of Imperial Collapse
When Empires or Great Powers Fall, Chaos and War Rise
Since the United States began COVID-19 immunizations in December, more than 297 million vaccine doses have been administered nationwide. As of this writing, 41 percent of U.S. residents are fully vaccinated and returning mask free to businesses, bars, and ballparks. They’re not alone: in a handful of wealthier countries with high vaccination rates, including the United Kingdom (39 percent), Israel (57 percent), and the United Arab Emirates (63 percent), life is steadily returning to normal.
But vast swaths of the world remain unvaccinated, and the emergence of dangerous new coronavirus strains has exposed dramatic inequities in global access to vaccines. In India, where just over three percent of the population is fully vaccinated against COVID-19, the virulent B.1.617 variant has been devastating, leaving funeral pyres afire 24 hours a day in many Indian cities. Similar deadly scenarios now threaten to play out in other developing countries with low vaccination rates, including Brazil (11 percent), Colombia (seven percent), and Nepal (three percent).
There is wide agreement that vaccinating the world is the only way to end the pandemic. But no one has yet operationalized a plan or marshaled the support to achieve it. The result is a world divided into two parts: one vaccinated and the rest threatened by COVID-19 for years to come. Past initiatives make it clear that vaccinating the world is possible—but doing so will require more of every country, including the United States. By leveraging global buying power and improving production capacity in different countries, world leaders can in the weeks and months ahead not only set the course to end this pandemic but promote public health for years to come.
Vaccinating the world against COVID-19, and keeping it vaccinated, is no small task. In order to achieve sufficient immunity, an estimated 70 percent of any given population must have been vaccinated or developed antibodies to the virus. While nearly two billion shots have been delivered thus far, many billions more will be required, including for boosters. Only 1.2 percent of the population in Africa, 4.8 percent of the population in Asia, and 14 percent of the population in South America have been vaccinated so far.
With COVAX, the global initiative to vaccinate just 27 percent of the populations of 92 low- and middle-income countries this year, drastically underfunded and short supplied, the world needs to reimagine its vaccination efforts. Nearly 20 years ago, I was a part of the team that helped create the International Finance Facility for Immunisation, a key component of Gavi, the Vaccine Alliance, which is supporting COVAX. That experience and other recent vaccination initiatives make clear that a successful COVID-19 global vaccination plan must address three main obstacles: supply, delivery, and financing.
The world must first focus on how to develop the billions of doses of effective vaccines (particularly since variants have already challenged the efficacy of some) necessary to keep the world vaccinated. Thus far, supply has been determined by contracts with—and production by—vaccine makers, including Pfizer, Moderna, and others. Countries, including the United States, have donated some of their own surplus. U.S. President Joe Biden has committed to sending 80 million doses abroad by the end of June, and Europe plans to send another 100 million. Yesterday, the White House promised that an initial allotment of 25 million vaccines would be shipped "as quickly as we can logistically get those out the door.”
Global leaders can boost supply by helping buyers to obtain contracts to purchase effective vaccines
Such contributions, while unlikely to present a sustainable or sufficient path to enhancing global supply at the scale required, should be encouraged, especially in the short term. As is now clear, achieving sufficient levels of inoculation will require a certain degree of efficacy. Donations must do no harm: the vaccines must be safe and effective enough to meet World Health Organization guidelines, and the contributions themselves must avoid earmarking and favoritism that will sow additional inequity or stoke nationalism.
In addition, by supporting COVAX, global leaders can boost supply by helping buyers—whether individual nations, blocs of nations, or multilateral institutions—to obtain contracts to purchase effective vaccines. As existing producers see declining demand for vaccines from the United States and Europe, they will have more capacity to fulfill orders from developing countries and multilateral organizations. Supporting would-be buyers with connections and resources will encourage manufacturers to increase their production.
Global support can also decrease the cost of vaccines. Already, there is variability in pricing: some richer countries have paid $30 per dose, whereas nations in Africa are paying between $3 and $10. The more countries pool their purchasing power through initiatives such as COVAX, the lower that price can be driven. In addition, producers should be able to reduce marginal cost as orders grow. Such low prices should be sustainable given how well vaccine makers have been compensated already by sales to richer countries.
Boosting supply will also require responsible technology transfer, so that developing nations can begin manufacturing vaccines themselves. As the Biden administration’s recent decision to support a patent waiver demonstrates, the regulatory work required to expand manufacturing has already begun, but it is currently progressing too slowly to significantly boost the global supply of vaccines by the end of next year.
Beyond waivers, global leaders need to urgently encourage producers of safe, effective COVID-19 vaccines to license and transfer technology to proven partners in developing economies. Such arrangements are nothing new: pharmaceutical companies have made similar agreements for treatments for COVID-19, hepatitis C, and other maladies. To promote these sorts of initiatives, richer countries could agree to pay licensing fees through COVAX or some other mechanism. And to make these agreements successful, these same countries can help enhance coordination and capacity in the supply chain for vaccine ingredients, equipment, and manufacturing supplies.
Although there has been a great deal of global concern about producing vaccines, less attention has been paid to delivering vaccinations into the arms of the people who need them. Delivering COVID-19 vaccines is likely to prove far more challenging in low-income countries than it has been in rich ones. In India, for example, health-care workers have struggled to deliver vaccines in rural areas with little reliable electricity, while their counterparts in Brazil must devise vaccination campaigns for favelas where government authority is limited. Two-dose regimes and cold-storage requirements further complicate the logistics and increase the expense.
Fortunately, the world has seen how the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), the Global Fund, and other partners massively expanded the delivery of HIV/AIDS medication without detracting attention and resources from other needed health programs. Rich nations, along with Gavi, the Vaccine Alliance and other partners, must help middle-income and lower-income health authorities expand vaccination infrastructure while meeting other health commitments. Such support will include hiring, training, and paying additional health workers, building out cold-chain and other infrastructure, and establishing ways to track progress and certify immunizations.
Delivering COVID-19 vaccines is likely to be more challenging in poor countries than it has been in rich ones.
While the infrastructure in low-income countries is more limited, vaccine campaigns in advanced economies also offer useful lessons about increasing access and minimizing resistance. In the United States and elsewhere, political leaders have taken an active, visible role in promoting and managing vaccination campaigns. Taking the vaccines directly to homes and workplaces—as well as places where people congregate, such as beaches and bars—has also proved effective in wealthy countries. Developing nations should consider similarly unorthodox delivery methods.
Vaccinating the world enough to end the pandemic will require greater resources than are currently available. Until this week, COVAX was billions of dollars short of the funds needed this year to vaccinate 27 percent of the population in lower-income countries. Thankfully, at a June 2 meeting in Japan, donor nations, philanthropies and multilateral institutions committed much of what was required for 2021; but this investment is still far short of what's needed to reach sufficient immunity.
At next week's G-7 meetings in the United Kingdom, leaders must look beyond this year and take the steps—and find $25 to 50 billion in additional resources—to vaccinate around 70 percent of populations around the world in 2022. This is a great deal of money, but it is a relative steal compared with the trillions of dollars countries have already spent responding to COVID-19 and restarting their economies. It’s an even greater bargain compared to the $9.2 trillion one estimate predicts the world will lose this year without adequate vaccine access in developing economies.
At the G-7, leaders will need to get creative to finance not just the manufacturing of billions of doses but also the vaccination campaigns and health infrastructure, including production capacity, necessary to keep the world healthy for years to come. In a new report on what’s required to finance and operationalize a global vaccination campaign, my organization the Rockefeller Foundation outlines several options, including the International Monetary Fund’s international reserve asset Special Drawing Rights. The IMF executive directors have already voiced support for a new allocation of SDRs this year, which could produce $650 billion, and the matter is on the agenda for a meeting this month. If agreed upon, rich countries could find creative means to recycle at least $100 billion of the resulting liquidity from high- to low-income countries to fill the pandemic-response funding gap, including vaccines, and to meet other economic recovery needs.
None of this will be easy. Vaccinating enough of the world to control the pandemic by the end of 2022 will require legions of actors, billions of dollars, and herculean levels of coordination. Still, even if the scope and sweep of this initiative is without historical precedent, the world knows how to meet this moment: it has both the vaccines and the experience with global inoculation and broader health initiatives. But the world has also learned that the success of any plan is in its implementation.
At the G-7 next week and in the months ahead, President Biden and other leaders can make the commitments necessary to vaccinate the world. That will require doing more—and doing it longer—than any nation has yet to muster in combating the pandemic beyond its own borders. If today’s leaders take these steps, the benefits will be greater than even the pandemic’s end. The experience of rolling up a sleeve and getting a COVID-19 shot will become universal, shared by billions. Vaccinating the world will unite it in a way few things ever have.
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