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The Curious Case of Vaccine Distribution


In March 2021, the US had refused to give some of its doses which were due from AstraZeneca to the EU, which was battling a third wave at the time and was suffering from a shortage of vaccines. The US had several vaccine deals alongside AstraZeneca, through which they could vaccinate their whole population, and had no legitimate reason to refuse. Vaccines are the only way to stop this pandemic. They can protect citizens from severe infection and death, as well as reduce the strain on the healthcare system. They allow countries to reopen their economies and go back to a relatively normal state. It is estimated that to achieve herd immunity and thus end the COVID-19 pandemic, at least 70% of the total population must be vaccinated. However, only 27.8% have received at least one dose of the vaccine, and 14.2% are fully vaccinated as of 30 July 2021. According to My World in Data, only 1.1% of people in low income countries have received at least one dose.

Vaccine Nationalism, what does it mean?

Vaccine nationalism refers to countries prioritizing their domestic markets and pre-purchasing vaccine doses from pharmaceutical companies before the vaccines even get approved. Pre-purchasing leads to increased prices for vaccine doses, and a line for early access to vaccine doses. High income countries such as the United States of America, and some upper middle income countries, could afford to invest millions of dollars in companies developing vaccines such as AstraZeneca to speed up research and development. The US and UK made their first deals in May 2020, while low income countries made their first deals in January 2021, 8 months later. Thus, when these companies’ vaccines would pass clinical trials and prove to be effective, the US and UK would get the agreed first share of doses. The lower income countries didn't have the resources to order any doses before the vaccines were proved to be effective, and take the risk of these vaccines not even being approved. Hence, when they did finally order the vaccine doses, there was already a line of several countries before them. The lower income countries would also be unable to procure millions of vaccine doses like the higher income countries, which bought, in some cases, a billion of them.

High income countries are in blue, upper middle income countries are in green and lower middle income countries are in yellow. Red is the African Union. From the chart above the disparities in vaccine purchases are clearly depicted, the yellow line that is on top being India, which, despite having purchased 1,790,000,000 vaccine doses, can fully vaccinate only 65% of its population. However, now the richer countries have extra doses left over from these purchases. Canada bought enough vaccine doses to fully vaccinate its entire population 5 times, and the US bought enough vaccine doses to fully vaccinate its population 3 times. The UK has enough vaccine doses to fully vaccinate its population 4 times and the EU has bought enough to fully vaccinate its population 3 times. At the same time, there are countries such as Honduras that has bought vaccine doses that can only fully vaccinate 7.5% of its population. The higher income countries are reluctant to share their extra doses, citing concerns about shortages and the possible need for booster shots. However, purchases don't mean that the countries have gotten all of the doses they've bought. These statistics have been mentioned to articulate the differences between rich and poor countries. These differences are the main reason why there is inequitable distribution of vaccines, as well as nationalistic behaviour by countries.

In April 2020, in the beginning of the pandemic, 80 countries had placed export restrictions on face masks, protective gear, gloves and other such goods, according to the World Trade Organization, to alleviate shortages. The EU had considered passing a legislation near the end of March 2021, which would allow it to restrict vaccine exports over grounds such as the recipient country having a higher vaccination rate, or where the epidemiological situation is less serious as compared to them. This legislation would also encourage them to block exports to a country that did not export vaccines to the European Union. This legislation was made in response to a row between AstraZeneca and the EU, and the deadly third wave sweeping the bloc at the time. They were criticized for not hoarding vaccine inputs and vaccine doses like the US and UK, instead exporting millions of vaccines while supply was less back in the EU. The EU decided to continue with the vaccine export restrictions in place instead of the much stricter restrictions, and asked AstraZeneca to provide them with all of the purchased doses as soon as possible. The EU has, however, mostly exported vaccines to higher income countries, instead of lower income. Below is a map of the EU's vaccine exports.

The India Situation

A similar situation had occurred in India in April 2021, when the country was beginning to experience the second wave. The government had delayed in ordering the amount of vaccine doses they would need, and ordered less. When they did receive the vaccine doses, they decided to donate them to neighbouring countries as part of the Prime Minister's 'Vaccine Maitri' campaign in February 2021. The vaccination campaign was sluggish as polls revealed the public was hesitant in getting themselves vaccinated. Soon, the number of cases started increasing rapidly in late March 2021. Yet the government continued with political rallies and allowed a huge religious event named 'Kumbh Mela' to happen. These events led to a larger increase in daily infections, and soon, in May 2021, the country was setting the highest daily infection records in the world: 400,000 cases. Vaccine demand was high, but the government delayed in ordering more and thus, there was a delay in the orders of vaccines coming through, so several vaccination centers had closed due to shortages. There was a scarcity of beds and oxygen cylinders, and sport stadiums and hotels had been converted into makeshift hospitals. The government decided to restrict vaccine exports, and Serum Institute of India, one of the biggest manufacturers in the world, decided to redirect its vaccine doses to its own nation instead. These decisions impacted 91 countries, according to the WHO, especially the lower income ones that were depending on Serum Institute to manufacture vaccine doses for them, as part of the AstraZeneca licensing deal. India eventually did recover from the wave, with the help of oxygen and ventilators donated by other countries. This is still an example of vaccine nationalism. This was not unexpected, it had been foreseen that the peak of the second wave in India would be in May.

Vaccine diplomacy

Vaccine diplomacy is a policy China seems to be following, to increase its influence over other countries and establish its position as a global superpower. Vaccine diplomacy refers to countries donating or selling vaccines to other countries to increase their influence there and support and create allies. China has exported 42% of the vaccines it has produced, a number that all of the countries that can produce vaccines don’t even touch. China has mostly exported to countries already a part of its Belt and Road initiative, or those countries that are considering joining it. China has also exported to countries that have supported its ‘One China’ policy and their position on Xinjiang, such as Egypt, who had offered support to China on its position on Xinjiang and then received vaccine donations. Latin America has bought 361 million doses from China, and has received 1 million doses as donations, thus American influence over Latin America declining rapidly. India has been offering vaccine donations and selling them as well, trying to curb China’s influence over its neighbours as part of the ‘Vaccine Maitri’ campaign. They have mostly exported vaccines to middle income countries in hopes to create new allies, and supply as many as 60 middle and low income countries, since the vaccines manufactured by Serum Institute are affordable. An example of curbing Chinese influence and using their soft power is Paraguay, one of the countries that recognized Taiwan. Paraguay had been searching for vaccines, and China offered them, in exchange for supporting China’s position on Taiwan. Paraguay’s foreign minister appealed to India for vaccines, and India exported 200,000 doses, and was publicly thanked by the Taiwanese prime minister.

Russia has mostly been donating vaccines as samples to other countries considering buying the Sputnik V vaccine, while Israel mostly has been donating to countries that support its position on Palestine.

Effects of vaccine nationalism

Researchers at Northeastern University modeled the effectiveness of a global cooperative strategy versus a uncooperative nationalist approach to distributing vaccines. They found that the number of deaths was halved in the cooperative strategy model, as compared to the uncooperative strategy model (33% deaths avoided in uncooperative, 61% deaths avoided in cooperative). Another study has reported that higher income countries would be losing 119 billion dollars per year if they used the vaccine nationalism strategy. The Organization for Economic Cooperation and Development (OECD) has warned that leaving developing countries behind in the vaccine rollout could cost the global economy $9.2 trillion. An uneven vaccine rollout would also leave low income and several middle income countries at vulnerable positions, susceptible to future shockwaves in the global economy by issues such as climate change. Vaccine manufacturing is a complicated process. It requires infrastructure and materials found in various geographical locations, as well as specialised parts of the process. A nationalistic approach to this, potentially hoarding key inputs for the vaccine, would interrupt the global supply chain and disrupt production. The US had done this with syringes and needles. They had invoked a wartime power named the Defense Production Act in April 2021. This power forced private companies within the US to fulfill domestic contracts before any others’. This disturbed the global supply chain for vaccines, which depends on America for various materials such as syringes and needles. Several international manufacturers such as Serum Institute complained of not receiving the materials they needed to make vaccines and thus production was slowed. Vaccine nationalism will prolong the pandemic, and put people, vaccinated or unvaccinated, at risk of being infected with a variant that is much more transmissible and severe, and renders current vaccines useless against it. Pharmaceutical companies have said that they could tweak the vaccines if such a thing happens, but it would take time, something too precious to waste, especially in a pandemic. So, we need multilateralism and global cooperation, not bilateralism and a “my nation first” approach. As Seth Berkley, the CEO of Gavi, the Vaccine Alliance mentions in an interview with Vox, “Remember with the Ebola vaccine, we had every country trying their technology, and they all thought they were going to win. And what [vaccine] actually won? It was a Canadian vaccine, transferred to an American biotech, transferred to an American multilateral manufacturer in Germany. That’s the way science works. So imagine if everybody said, ‘I just want my vaccine, my manufacturing, my assays, my adjuvants. That’s it.’ You would not have the best science. You would not have the best possibility of success.” Countries have to realize that their main enemy here is the virus, not each other, so to end the pandemic, we would need to cooperate with others to help out underdeveloped and developing countries in vaccinating their population.

Solution - COVAX

There is a programme dedicated for the equitable distribution of vaccines, COVAX. Its aim, according to the Gavi webpage on it, is to accelerate the development and manufacture of COVID-19 vaccines, and to guarantee fair and equitable access for every country in the world. It is led by the WHO, Gavi, the Vaccine Alliance and the Coalition for Epidemic Preparedness Innovations (CEPI). COVAX will act as a platform for the research, development and manufacture of various vaccines, as well as negotiating its prices with manufacturers. All countries, should they choose to participate, would get equal access to the vaccines approved by COVAX, irrespective of their income levels. The initial aim is to have 2 billion vaccine doses ready by the end of 2021 to vaccinate the most vulnerable and frontline healthcare workers in every country. According to the Gavi website, COVAX has been created to maximise our chances of successfully developing COVID-19 vaccines and manufacture them in the quantities needed to end this crisis, and in doing so ensure that ability to pay does not become a barrier to accessing them. COVAX has built the largest and most diverse portfolio of vaccines, which is actively managed, to increase chances of success. The COVAX programme is divided into two parts: the Facility and the Advance Market Commitment. According to the Gavi COVAX explainer, the Facility allows self-financing countries and economies to request and pay for the amount of vaccine doses that would be required by 10%-50% of its populations. The Facility would act as an insurance for these economies, even if their bilateral deals fail, they would still have COVAX to rely on. They help COVAX as well, as they ‘increase the world’s chances of bringing about COVID-19 vaccines as quickly as possible and in the quantities we need’, to quote the COVAX explained article. These countries can opt for two options within the Facility - a Committed Purchase and an Optional Purchase Arrangement. The Advance Market Commitment’s primary focus, according to the Gavi COVAX explainer, is to ensure that the 92 middle- and lower-income countries that cannot fully afford to pay for COVID-19 vaccines themselves get equal access to COVID-19 vaccines as higher-income self-financing countries and at the same time. The funding for the AMC is separate from the Facility and is mostly funded by Official Development Assistance (ODA) as well as from private sectors and philanthropy. CEPI would be ramping up manufacturing in potential production sites, in exchange for doses for COVAX, while UNICEF is concerned with the delivery of these doses to various countries. The benefits of joining COVAX according to Gavi are:

  • ● Doses for at least 20% of countries' populations

  • ● Diverse and actively managed portfolio of vaccines

  • ● Vaccines delivered as soon as they are available

  • ● End the acute phase of the pandemic

  • ● Rebuild economies

Once any vaccine from COVAX’s portfolio has been proved to be effective and safe and is approved, all available doses will be allocated to each country proportional to their population. The higher income countries were at first reluctant to join the COVAX initiative, with the Trump administration in the US outright refusing to cooperate and going forward with their ‘America First’ campaign, a clear example of vaccine nationalism. However, the Biden administration had pledged US$4 billion to the initiative and hosted a fundraising event for them as well, to show their support for the initiative. The US has also pledged 60 million vaccine doses to donate to lower income countries, or countries where the epidemiological situation was terrible. 25 million vaccine doses are being sent to Africa by the US with the help of COVAX and the African Union. The UK has followed suit, pledging 100 million vaccine doses at last month's G7 summit, with the first 9 million doses already going out this week. India is COVAX's biggest manufacturer, and COVAX had been depending on India's Serum Institute to provide for 190 million doses, which it couldn't due to India's second wave. However, Serum Institute is now in talks with the government to allow exports again, and Gavi hopes that they will resume production again soon, especially considering the effect the Delta variant is now having over the rest of the world.

Conclusion In conclusion, the West is following a nationalistic approach that is incredibly shortsighted and does more harm than good to the country and the world, while the East is following a policy of vaccine diplomacy and donating vaccines on the basis of geopolitics, not epidemiology as it should be. What we need is global cooperation to end the pandemic, which does not care about borders. So please spread awareness about this, and get yourself vaccinated if you can. The pandemic isn't over until all of us are safe.

~ Kavya Pandey


Rakesh Pandita
Rakesh Pandita
Aug 13, 2021

Very well articulated and researched article, got to know lot of info behind ' vaccine diplomacy"


Aug 12, 2021

The article was very well structured. Kudos to the writer


Dr Prasun Mishra
Dr Prasun Mishra
Aug 12, 2021

amazing article .so much important info with truth

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