How do you go about vaccinating the world? More specifically, how do you go about vaccinating lower-middle and low-income countries that lack the resources of wealthier nations keen to hoard doses for their own populations?
This has been the challenge for the Covax scheme and its managing director, Aurélia Nguyen, over the past 18 months.
“As has often been said, viruses know no bounds,” she told me via video link from her home office in Geneva, Switzerland. Early on in the pandemic, it was clear to Nguyen that adopting “an approach of each country looking after their population only through vaccination was not going to be enough”. That was the argument for the foundation of Covax, an alliance co-led by the Coalition for Epidemic Preparedness Innovations (Cepi); the global vaccine initiative, Gavi; and the World Health Organisation (WHO).
With backing and support from major NGOs – including delivery support from the UN children’s agency, Unicef – the premise of Covax was simple: identify, buy and deliver vaccines to lower-middle and low-income countries that would otherwise struggle in a market free-for-all against wealthy (mainly Western) nations.
The need for vaccines in much of the developing world is clear. According to figures from Our World in Data, only 7 per cent of those in low-income countries have received a first dose of a coronavirus vaccine, compared with around 75 per cent of people in high-income countries.
With the emergence of the Omicron variant, first identified in southern Africa, we’re now dealing with the repercussions of letting the virus mutate among largely unvaccinated populations, Nguyen said. “Had we been able to get to high [global vaccine] coverage quickly, we would have had... much more [of a] fighting chance to avoid the emergence of new variants.
“Specifically for Omicron, we still need to [learn] more, but as long as large portions of populations are unvaccinated, we can expect variants to continue to appear,” she added. “We are creating favourable conditions for variants to continue to appear, and it is going to prolong the pandemic.”
The worry about future variants – perhaps ones that could evade existing vaccines – makes the job of Nguyen and Covax even more pressing.
So far, Covax has delivered over 635 million doses to 144 countries, and has allocated 1.6 billion doses, said Nguyen – but the total falls well short of the initial aim of giving out two billion doses by the end of the year. In addition, reports have surfaced of vaccines donated through Covax and going to waste, reaching their expiry date before they could be used. “As an ideal, [Covax was] an A+,” Lawrence Gostin, WHO adviser and professor of global health law at Georgetown University told Time. “In its implementation, a C.”
Covax’s chequered progress has led to critical articles in a number of news outlets branding the programme a failure. How does Nguyen respond? “Those who think that Covax is a failure need to look at the data,” she said.
“Covax has supplied over 50 per cent of all vaccines shipped to the... poorest countries that are supported by the Covax Advanced Market Commitment [AMC],” the financing mechanism for 92 low and middle-income countries (full list). “And we’ve secured access to enough doses to protect more than 40 per cent of the [AMC] countries’ populations… and we’ll get there by early next year.
“If Covax had not existed, these countries would have been left with literally nothing,” she added.
The current Covid vaccine portfolio has been around for just over a year. But a number of aggravating factors have hampered Covax from fulfilling its mission.
The biggest has undoubtedly been vaccine hoarding by wealthier countries in the Global North. At the peak of the vaccine monopoly, major players including the US, UK, EU and others had pre-ordered enough doses to vaccinate their populations several times over, leaving Covax to feed off the scraps. (There are now fears that Omicron may trigger another wave of hoarding.)
Vaccine manufacturers had no qualms about prioritising larger nations. In some cases they actively made it difficult for Covax – Pfizer even resisted a direct deal with the alliance earlier this year, the New York Times reported. Though countries have donated some excess doses to Covax in dribs and drabs, a lot of damage has already been done.
These were things Nguyen anticipated: “We’ve been quite vocal in calling out high-income countries for [the] hoarding of vaccines,” she said. “We’ve been vocal to the manufacturers for failing to prioritise Covax over their richer and more profitable customers. But that in itself is a failure of multilateralism, not of Covax specifically.”
But Covax has made some – honest and unforeseeable – missteps. It went big on the AstraZeneca vaccine, ordering hundreds of millions of doses from the Serum Institute of India, which had a licence to produce the AstraZeneca jab. At the time, India was coping with the pandemic relatively well. But by August 2021, the Delta variant was running rampant, and India imposed a vaccine export ban. The move was a “large contributor” to Covax falling short of its coverage targets, Nguyen admitted.
Contending with funding, delays and organising teams across different areas has been a lot to manage for Nguyen, who used to work in the finance team at UK-American multinational GlaxoSmithKline. She moved across to work in medical roles within the company before joining Gavi in 2011.
“I won’t hide from you – it’s been very, very hard,” Nguyen told me, noting the many late nights she and her team have been through. “But it’s also an extreme privilege to be part of a global response, and being able to get the support from the solidarity that we have seen.”
Supply challenges will continue into 2022, Nguyen believes.
But is it ethical for wealthier nations to be focusing on boosters while other countries struggle to get first doses?
“I don’t think it should be controversial to say that from an equity perspective, or from an epidemiological perspective, it makes more sense to give a first dose to an elderly person or a healthcare worker in Africa than it does to give a third dose to a healthy young person in Europe,” she said. But, “as we look forward, thankfully, global supply is going to be less constrained… we should be less in a place where it’s a trade-off of one against the others.”
In January, when the disparity in vaccine coverage between richer and poorer nations was at its starkest, the director-general of the WHO, Tedros Adhanom Ghebreyesus, described the West as having a “me-first” attitude.
More diplomatic in her response, Nguyen said “one can understand that it is the role of governments to look after and protect their citizens. But I think what wasn’t taken into account is that that cannot be done strictly within the confines of one’s borders.
“It’s taken a while to come to this realisation that, in fact, it really has to be a global effort with global protection to be able to have all countries safe at the same time.”
Alongside supply issues, medical infrastructure in various countries will need to be improved as well. “What we need to think about is learning the lessons from this past year and trying to avoid a vaccine nationalism 2.0-type scenario developing,” Nguyen said. “I think it’s going to be a bit of a game of two halves, in that sense, and the work that we’re doing is really to try to push on both those fronts going forward.”