Ending the vaccine divide
History suggests we have reached a “tipping point” where it makes sense on medical, economic and moral grounds to redistribute surplus vaccines to poorer nations, thereby making everyone safer.
With the possible exception of antibiotics, no medical procedure has saved more lives than vaccines. Yet getting vaccines into the arms of those most at risk of disease, debility and death has rarely been straightforward or easy.
Take the video that went viral in early August showing six Peruvian health workers ascending a sheer mountain trail in the Andes with a cold storage box packed with coronavirus vaccines.
To judge by the grainy images, the box is too large to be hoisted onto their shoulders and in this precipitous mist-shrouded region airlifts are clearly out of the question. Instead, they are shown crouching under the strain of their life-saving cargo, as they inch the crate slowly up a treacherous, rock-strewn path. It takes 15 hours for them to reach their destination high in the Ayacucho region of the Andes, after which they must descend to the foot of the mountain and start the process all over again.
In a striking historical coincidence, British botanists in the 1860s, sponsored by the India Office, journeyed along similar Andean trails in search of “Peruvian bark” - for centuries the only source of the valuable anti-malarial quinine.
Motivated by the humanitarian desire to supply the world with a cure for the mosquito-borne disease, by 1872 the India Office had four million bark trees under cultivation in British India and was a manufacturing a cheap malaria treatment that retailed for just a rupee an ounce (I tell the story in more detail in my book, The Fever Trail).
Today, the world is desperately in need of a similar philanthropic effort to end the vaccine divide that has seen populations in the global south – such as the indigenous descendants of the Inca in Peru – struggling to obtain life-saving coronavirus vaccines, while countries in the global north sit on stockpiles that are nearing their expiry date or which, because of stubborn pockets of vaccine resistance, may never be utilised.
This is not only a problem for Peru but for the world. Eighty percent of Covid-19 infections in Peru are due to the Lambda variant, which, studies suggest, may be as infectious as Delta. Worse, a recent pre-print from researchers at the University of Tokyo indicates that Lambda may also be capable of evading neutralising antibodies induced by Coronavac, a vaccine manufactured by the Chinese company Sinovac that has been widely distributed in Latin America.
So far, there is no evidence that Coronavac or other vaccines are seriously ineffective against the Lambda or other variants, but in a recent assessment, SAGE, the scientific body that advises the UK government, said it was “almost certain” that the accumulation of genetic changes in circulating viruses would eventually lead to a case of vaccine escape – hence the importance of distributing sufficient vaccines to immunise everyone in the world as rapidly as possible.
Yet while the World Health Organization estimates that 11 billion jabs are needed to vaccinate everyone on the globe, the G7 has so far pledged just one billion to low- and middle-income countries. Bear in mind that 13 countries, including the US and the UK, have already ordered sufficient doses to vaccinate their entire populations, plus all of the world's vulnerable groups combined.
The choice is stark. According to a report by the Global Health Security Consortium, if Britain and other “vaccine-rich” countries were to share their doses more equitably, eliminate hoarding and scale up the measures required to deliver these vaccines to hard-to-reach populations, then all the world’s priority adults could be fully vaccinated by the end of 2021.
This is not only the philanthropic thing to do; it is manifestly in our self-interest.
Based on the reproduction number of the original coronavirus, it used to be thought that herd immunity would kick in when in excess of 70 percent of a population had been fully immunised. According to the Financial Times’s Covid-19 vaccine tracker, several countries, including Malta and Singapore, have reached or are close to that threshold. But because Delta, currently the dominant variant in most of the world, is five to six times more infectious than the original version of the virus, it is probable that in excess of 80 percent of a population will now need to be vaccinated in order to reach the Elysian fields of herd immunity.
Let us go a step further: if the coronavirus were to mutate so as to become as infectious as measles - which has a reproduction number of 12 – then in excess of 95 percent would need to be vaccinated. And please note: this does not take into account the extent to which vaccination is a barrier against transmissibility, or whether the new variants can be passed on by individuals who have received both jabs but do not themselves suffer symptoms. What of herd immunity in those circumstances?
The nightmare scenario, however, is the emergence of a strain resistant to current vaccines, or one with a similar fatality rate to MERS, the coronavirus first identified in Saudi Arabia in 2012 and which is deadly in around a third of cases. Given that the coronavirus currently has an infection fatality ratio of around 1 percent, some geneticists consider that scenario “extraordinarily implausible”. The coronavirus could just as easily mutate to become less virulent, like the common cold, they say. Nonetheless, the nightmare scenario cannot be ruled out. Nor can we be sure of being able to safely resume foreign travel until everyone in the world enjoys similar immunisation levels to the Maltese.
Unfortunately, despite Joe Biden’s appeal to world leaders in September “to go big” by scaling up donations of coronavirus vaccines to low- and middle- income countries, critics fear it will not be enough. Just one billion additional doses were pledged at the UN summit in New York - well short of the five billion needed by the end of 2021. Meanwhile, the UK, which has purchased over seven doses for every inhabitant, is sitting on a surplus of 210 million vaccines – and that’s allowing for the boosters being administered this autumn!
Little wonder that the UN secretary general Antonio Guterres has described vaccine inequality as an “obscenity” and “a moral indictment of the state of our world”.
The “politics of life”
This vaccine imbalance will come as no surprise to anthropologists who have long argued that humanitarian interventions entail what the French sociologist Didier Fassin calls a “politics of life”. Although the stated object of such interventions is to save lives, in practice it is not possible to treat all lives equally. Instead, all such initiatives invariably involve “making a selection of which existences it is possible or legitimate to save”.
Though all global efforts to contain or eradicate infectious diseases naturally draw on the rhetoric of medical humanitarianism – and in the past, the Rockefeller, Gates and other philanthropic organisations have funded the elimination of hookworm, yellow fever, malaria and polio - the historical record suggests that, on the whole, such campaigns only succeed where disease control coincides with the economic and strategic interests of wealthy nations.
The classic example is smallpox. Ever since the English physician Edward Jenner discovered in 1796 that he could induce immunity against smallpox by injecting individuals with material from the related cowpox virus, it has been known that vaccination could eradicate the disease. This is because, unlike the coronavirus, there is no animal reservoir for smallpox - so once it has been eradicated in humans it has been eradicated everywhere. This milestone was reached in 1977 when, after a decade-long campaign, the WHO announced it had identified the last naturally occurring case of smallpox in Somalia (three years later, the WHO officially announced it had eradicated the disease).
However, eradication was never a forgone conclusion, largely because smallpox vaccination was itself controversial and, as with the coronavirus today, some sections of the population resisted being vaccinated. This was not only the case in Bangladesh, where WHO vaccination teams employed strong-arm tactics to hunt down and vaccinate individuals suspected of the harbouring smallpox, but in cities in developed countries. For instance, in the 1880s, Leicester became a hotbed of anti-vax sentiment and the site of rioting as parents rebelled against legislation that sought to compel them to vaccinate their children. The US was even more resistant to the practice, and, by the 1920s, vaccination rates in some rural areas were as low as ten percent.
Even so, thanks to a combination of vaccination, better sanitation, and the isolation and quarantining of suspected cases and their contacts – a method pioneered in Leicester precisely because of the strong opposition to vaccination there and later exported worldwide – the incidence of smallpox by the late 1940s had declined to such an extent in Europe and North America that the leading industrial nations were engaged in essentially defensive policies of trying to keep smallpox out by policing their borders. In 1947, however, the fragility of this approach was starkly exposed when a man travelling from Mexico City to New York fell ill and died in hospital - sparking a rush by New Yorkers to get vaccinated.
By the 1950s the US was spending $15-20 million a year on defence against a disease that had not afflicted the country for a decade and a half and had reached what the historian of science Nancy Leys Stepan rightly calls “a tipping point”. The US grasped that, rather than continually vaccinating its own population, it would be cheaper and more effective to try to eradicate smallpox outside its borders and agreed to fund the global battle against the disease.
Thus, it was that, between 1967 and 1979, the US stumped up $32million for the WHO’s global anti-smallpox drive, with international donors providing a further $98 million under an international burden-sharing arrangement.
Some global health experts, such as Jeremy Farrar, the director of the Wellcome Trust and a member of SAGE, and the UK’s former Prime Minister Gordon Brown, think that a similar burden-sharing formula is exactly what is needed now.
“The richest countries [should be] paying the most”, writes Farrar in his book Spike: The Virus Versus the People (co-authored with Anjana Ahuja), “not only because they have the broadest shoulders but also because they will benefit most when trade and travel resume”.
In this spirit, the 2014-2016 Ebola epidemic prompted the United Nations to take charge of the international humanitarian and medical relief effort, with the US Congress agreeing emergency aid of $5.4 billion for the five worst-hit countries in West Africa. Compare and contrast the response in 2019, when the whole world was faced with the far graver crisis of a coronavirus pandemic. Only $8 billion was forthcoming in pledges for the WHO’s vaccine-purchasing facility COVAX - $2 billion of which has yet to be received.
And even the full amount is only sufficient to immunise one fifth of the populations of low- and middle-income countries. To purchase enough vaccines to immunise 70 percent of those populations – and have a chance of reaching herd immunity – around $50 billion is needed.
As Farrar puts it: “Crumbs from the table will not cut it in an era of pandemics”.
We should be mindful of the lessons of history. In 2019, the last year for which figures are available, there were 229 million cases of malaria worldwide and an estimated 409,000 deaths. Yet we have known about the curative powers of Peruvian bark since the seventeenth century, and the cheap quinine substitute, chloroquine, has been widely available since 1950. Unfortunately, however, many strains of the malaria parasite are now resistant to these drugs.
There’s more bad news when it comes to a vaccine. To date, only one malaria vaccine has been licensed for use in children and only one, still in the trial stage, has demonstrated in excess of 75 percent efficacy – a requirement for licensure under the WHO’s Malaria Vaccine Technology Roadmap. But every year nearly 20 million children go without already licensed vaccines for diseases such as diphtheria, tetanus, pertussis and measles. And of course, they and their parents and older siblings are also as susceptible to Covid as anyone else. Where should they come in the calculus of humanitarian interventions?
Clearly, we cannot afford to treat all the world’s ills; inevitably, choices and selections will have to be made. But, even with that caveat, it is surely in our interests to ensure that the indigenous peoples of the Andes have access to the same coronavirus vaccines as populations in the global north. And what is true of Latin America is even more true of sub-Saharan Africa where the prevalence of HIV and other diseases seriously increases the risk of Covid mutations in immune-compromised individuals – mutations that may result in vaccine-resistant variants.
Unlike smallpox, it is impossible to eradicate the coronavirus – it could re-emerge from a bat or some other animal reservoir at any time. But, as in the 1950s, we are now at a tipping point where it makes more sense, on medical and economic grounds, for wealthy countries to redistribute surplus doses to those in the world most in need of protection - and to do so with all possible urgency.
That this also happens to be most compassionate and humanitarian course of action should only strengthen that sense of mission.
An earlier version of this essay was first published in Tortoise on August 17, 2021.