Vaccine Inequity Is Still Costing Lives and Money—With Implications for Future Pandemic Response

After three years of pandemic, 18 percent of low-income countries and 56 percent of lower-middle-income countries are vaccinated with two shots against COVID-19. Booster coverage is much lower, despite proven efficacy against hospitalization and death as well as recent CDC and WHO recommendations. Fifty-five out of every 100 people in high-income countries have received a booster, compared to just one in 100 in low-income countries.

Yet the vaccines are still important to protect and save lives, particularly for high-risk groups. We don’t have much real-world data on the coverage of these groups, but we can see low rates of coverage among the elderly in low-income and many lower middle-income countries, (also here, figure 6). While COVID-19 vaccine development and rollout has been the fastest in the history of response to infectious diseases, excess mortality and disease burden clearly illustrate a developing country pandemic (and here, here, here).

The economic consequences of leaving COVID-19 unmitigated are also evident; labor shortages and economic slowdown are underpinned by the costs and after-effects of widespread and repeated illness around the world. In a May 2022 article, David Cutler estimated direct earning losses of $50 billion annually in the US. The same analysis confirmed an earlier estimate of the full economic costs of long COVID at around $2.6 trillion in the US, though such analyses have not yet been undertaken in lower-income countries.

There remains a need, and a clinical and economic rationale, for vaccination, so then why is vaccine inequity so persistent over time? The reality is that many policymakers in low-income and lower-middle-income countries (LMICs) no longer prioritize the COVID-19 response. The same behavior can be seen in the US, and for many of the same reasons. Vaccine wastage is in the news and donated doses were refused earlier in 2022.

Yet the smarter approach is to speed up vaccines and other countermeasures to those that need them most, preparing for the worst to manage the long-term risks of COVID. Through their inattention, governments are missing opportunities to save lives, and, perhaps even more worryingly, creating an erroneous precedent for high-income country aid that could worsen vaccine inequity in the future.

Vaccines are now plentiful, but will they be used?

After a year of scarcity, COVID-19 vaccine supply constraints eased by the end of 2021; almost every country in the world bought or secured amounts sufficient to fully vaccinate high-risk groups and more. Among the total secured are 2.8 billion donated vaccine doses made available via COVAX—the vaccine arm of the Access to COVID-19 Tools Accelerator—which were lobbied for by civil society organizations and advocacy groups, requested by LMIC governments, and agreed amongst high-income countries. Rich countries bought doses, and lots of them, to meet the multilateral commitment to expanded access. The US itself committed to purchasing and donating 1.2 billion doses, of which 583 million have been delivered (to date) to 115 countries, with the remainder to be delivered between now and the end of 2022. But will these and other doses be used?

While there has been progress, multiple factors lie behind the still too slow rollout.

Lack of storage facilities and fridges for vaccines and shortages of staff and other supplies meant there was little foundation from which to vaccinate adults at scale. Though there was a surge of shipments from COVAX to LMICs at the end of 2021, the unpredictable arrival of donated vaccines on short notice was also an initial obstacle to delivery.

Financing for the actual delivery of vaccines in LMICs did not come until late and in insufficient amounts. There was some funding via COVAX and bilaterally, and small-scale efforts like the COVID-19 Vaccine Delivery Partnership. The Global COVID GAP Accountability Report lays out the state of play on fundraising, finding major shortfalls. USAID had proposed an initiative to meet delivery financing needs and tackle barriers, but the agency’s request for new funding failed to gain traction on Capitol Hill.

Within LMICs, government-run and routine immunization approaches have been dominant, despite experience suggesting that a whole-of-health-system approach including the private and NGO sectors and vaccination campaigns are more effective than relying on passive health clinic provision of vaccines. While this public-only and passive approach is beginning to shift, it is still a main channel for delivery. Vaccine hesitancy, stoked by misinformation, also plays a role.

High levels of exposure recorded in serosurveys continue to confer a false sense of security as well, even though immunity wanes and new variants can emerge with the potential to evade antibody responses and affect different populations differently. In the various potential scenarios for the future of COVID-19, the risk that vaccines provide only temporary or partial immunity is not insignificant. Further, individuals already at high risk—due to immunosuppression, age, or other factors—will be especially vulnerable to the risks posed by new variants and to waning immunity.

Finally, emerging crises—including conflict in Ukraine, public debt concerns, looming recession threats, and rising food insecurity—compete for leaders’ energy and attention.

Taken together, the effort to vaccinate the world struggles to maintain momentum.

The consequence: The risks of long(er) COVID

The failure to vaccinate promptly, widely, and equitably created the breeding ground for variants like Omicron. Each time the virus  mutates and spreads, progress is set back and the fight against COVID is prolonged. More people vaccinated, more asymptomatic, means less likely spread and less opportunity for evasion.

Further, the scope and impact of long COVID is an evolving but serious concern. In the US alone, it is estimated that nearly one in five adults who had been infected with COVID-19 in the past were still experiencing long COVID symptoms, including fatigue, shortness of breath, brain fog, or headaches. It is clear that there is a lower risk of severe COVID-19 complications for cases not admitted to the hospital in the first place, and that vaccines reduce this likelihood.

Leaders should do what is necessary to lessen that risk.

Diffuse accountability and dangerous precedents for next variants and future pandemics

With COVID-19 vaccination and delivery left to increasingly distracted leaders, accountability for getting the vaccination job done is spread thin across governments that are already overextended. August’s COVID Gap report (figure 8) finds a still slow pace of vaccination and relatively low levels of product utilization in COVAX support countries. If country governments do not have the resources or capacity to prioritize the ongoing COVID response amidst a slew of other challenges, they should at least authorize local not-for-profits and firms, or the UN and humanitarian groups to do so on behalf of their high-risk populations.

If the vaccines are wasted due to sluggish delivery, the arguments for future high-income country contributions (and indeed the ongoing response to COVID-19) are also weakened. Some policymakers might conclude that financing and purchasing on behalf of low- and middle-income countries was a mistake, and external support for regional manufacturing initiatives would almost certainly languish. The spectacle of the US, despite evident need, having to repurpose or destroy hundreds of millions of vaccines ordered at the request of lower-income countries and their advocates would be disastrous not only for the COVID-19 response but for US global health and aid more generally.

Finally, scientists are developing a pan-coronavirus vaccine for new variants of COVID-19 and new coronaviruses in the future (see here and here). If we can’t vaccinate now as a globe, will governments be ready to deploy a new vaccine ahead of a new, more dangerous variant? Are international or regional mechanisms ready and willing to procure a new vaccine if needed? Or will we simply drift again into a wave of preventable death and economic damages?

Updated 2022/08/16