We Are Not All In This Together: COVID-19 and the Vaccine Apartheid

Existing policies and power structures have granted Western Nations control over global vaccine supplies while populations in the Global South, particularly African nations, struggle to get their hands on doses. This inequity has led to the unnecessary loss of millions of lives and endangerment of the human right to health.


By Megan Ruoro | megan.ruoro@yale.edu

A few Sundays ago, Jackson Majoni received a phone call from a woman complaining about chest pain and a high temperature. As the local pharmacist, Majoni is used to providing medical advice to the residents of Eldoret, a town in western Kenya. However, this past year, his phone has become increasingly busy. Almost every minute it rings with another question from frightened locals. Majoni suspected that the woman had pneumonia thus advised her to seek further treatment. But fearing the desperately overcrowded hospital, she resolved to stay home and by Tuesday night, Majoni received another call. This time, it was from a family member notifying him that she had died. The police soon collected her body, which had been abandoned out of fear of contagion. And when the postmortem report returned, it declared the sorrow that has become Majoni’s daily reality: death by COVID-19.


This summer, the Western world has been reveling in a long-awaited “return to normalcy.” Finally, indoor dining can be enjoyed comfortably; sports stadiums are reopening; theatre is making a comeback. The loathed emblem of COVID-19, masks, is beginning to disappear. While the proliferating Delta variant threatens to ruin fall plans, the majority of people in the richest nations consider the worst of the pandemic to be behind them. This privilege is not afforded to the millions of people in the Global South, in particular African nations, who continue to battle skyrocketing infection numbers, devastating mortality rates, and an impending fourth wave.


This is a result of global inequitable access to COVID-19 vaccinations. According to UNAIDS, “rich nations including the United States and Europe are vaccinating one person every second while the majority of the poorest nations are yet to give a single dose.” At this current rate, researchers predict that nations such as Rwanda, Bangladesh, and Venezuela will not be fully vaccinated until 2023. The continent suffering from the lowest number of vaccines is Africa. Only one percent of Africa’s 1.3 billion people are fully vaccinated. Yet, according to ONE’s analysis, the world’s wealthiest nations would still have over 1.9 billion doses in surplus if they vaccinated their entire population.


While the pandemic began with international messages touting unity, solidarity rings hallow during what many activists are describing as the vaccine apartheid. The presumed Western champions of humanitarianism such as the U.S. are selfishly hoarding the doses and vital medical technology needed to end this pandemic. This crisis echoes the injustice suffered during the HIV or AIDs epidemic. Access to life-saving medical innovations such as a COVID-19 vaccine must be recognized as a human right that should be enjoyed by all. Until officials in wealthy nations utilize the legal and financial power at their disposal to address this issue, the pandemic will continue to rage on.


Understanding how this inequity could persist amid the global pandemic requires the exploration of many other questions tied to the crisis. In pursuit of answers, the Journal spoke to legal and medical experts about the causes, implications, and possible solutions to the vaccine apartheid.


How are vaccines being supplied?


Lacking the purchasing power to negotiate early deals with manufacturers, the vast majority of lower or middle-income nations are relying on a supply of vaccines from COVAX, an international initiative funded by the Gates Foundation. This joint venture, led by the World Health Organization and Gavi, was founded in April 2020 on the promise of providing equitable access to COVID-19 vaccines.


The initial goal set by COVAX was to vaccinate at least 20 percent of the world’s population by the end of this year. However, the organization’s current delivery rate is falling well below this modest target. Almost 550 million fewer doses than originally promised by COVAX were delivered internationally between January and June. The number of doses promised was then decreased by 405 million. COVAX officials predict that they will not be able to meet their goal of delivering more than 200 million doses to Africa by October. With this number, only seven percent of the continent’s population would be fully vaccinated. These distribution problems are a result of the organization’s failure to secure enough doses. Supply priority went to wealthy nations with the money and power to broker deals with manufacturers directly. These nations quickly bought up more than enough doses for their populations. Additional setbacks for COVAX occurred in March when its major supplier, the Serum Institute of India, halted vaccine exports to ensure the country had enough doses during its worst period of the pandemic.


Let down by unfulfilled promises, the 55 member states of the African Union have been forced to search for other options such as contracting directly with pharmaceutical companies. However, these nations lack the purchasing power held by the West thus find themselves at the very end of the line.


“It's not because of science or engineering that billions of people around the world lack vaccines,” explains Chris Morten, professor at Columbia Law School and Director of their forthcoming Science, Health, & Information Clinic. “It's because of policy failures– or they might not even be properly characterized as failures; we might just think of them as policy choices.” These choices have ensured that the governments of the United States, the European Union, Australia, and other wealthy nations hold control over vaccine production. Patents and intellectual property rights are barring African nations from producing vaccines to save their own people.


“It's not the simplest thing in the world to make a vaccine,” Morten says, “but there are manufacturers throughout the world, including many places in the Global South...with capacity and with scientific sophistication to make the vaccines, if they had the recipes– if they had instructions on how to make vaccines, we could have them such that today, vaccines would be flowing out of those factories, but we've chosen not to do that."


What are the implications of the lack of vaccine supply?


The lack of vaccines is resulting in catastrophic impacts on the lives of billions of people. In Kenya, Doctor Mbira Gikonyo, chairman of the nation’s COVID-19 task force and ENT surgeon, explains “the demand is much higher than the supply, and [vaccines] are not readily available. Most of the time, they are restricted to the elderly, and the healthcare workers. They are not available for the common person." Despite these rationing measures, those in most need of protection are still far behind young and healthy U.S. citizens who have received both doses months ago. In June, after receiving the AstraZeneca vaccine, 20 million African healthcare workers and elderly people were left without their second dose due to shortfalls in COVAX supplies. This has forced public health officials to rely on the enforcement of what Gikonyo describes as ‘non-pharmaceutical interventions.’ This includes masking, social distancing, and hand-washing. “Of course, vaccines work well,” Gikonyo explains, “but in practice in Subsaharan Africa less than two percent of people are vaccinated, so it’ll take many months to get to the sort of levels to have a public health impact.”


In a Scheer Intelligence episode centered on this issue, activist Achal Prabhala explains, “by only immunizing wealthy nations, the pharmaceutical companies in question are in effect engineering vaccine apartheid… and driving the proliferation of other variants of the coronavirus." African nations are bracing themselves for a devastating fourth wave of infections due to the increasing prominence of the Delta variant. Epidemiologists such as Alex Welte, a Research Professor at the South African Centre for Epidemiological Modelling and Analysis and Stellenbosch University, are concerned for what is to come. “[The lack of vaccines] leaves us more vulnerable”, Welte said. “We have one less important tool in the closet as we would like to have.” While this new threat is posing a risk for all nations, the severity of Delta’s predicted impact differs between the well-vaccinated and under-vaccinated. According to analysis done by Financial Times, countries such as Namibia, Tanzania, and South Africa are experiencing surging infection rates which mirror the trend in mortality. Cases are increasing in wealthy nations as well; however, vaccines have protected against a mirrored rise in deaths. For example, the United Kingdom’s death to cases ratio has fallen from 1 to 50 to 1 to 750 thanks to the availability of vaccines. In Namibia, where only 1.2 percent of the population is vaccinated, the death to cases ratio is 1 to 22.


“At the moment, the ICU facilities are overwhelmed”, Gikonyo said. “And on most days, one cannot get a critical care bed or ICU bed, meaning they cannot be ventilated. So this is a real challenge. We expect by the end of this month, to be at the point where even the outpatient departments will be overwhelmed."


“It’s getting worse”, Majoni responded when asked about the situation in Kenya. Recently, he had to face the challenging task of telling a neighbor that her husband succumbed to the virus after spending a week in the hospital. After revealing that she was experiencing symptoms as well, Majoni referred her to the hospital where she was put on an oxygen tank. The next day she died in that same hospital as her husband did. “Everybody’s afraid,” Jack said.


How can this be fixed?


There are several steps that the U.S. government could immediately take to address this urgent human rights concern. The first of which is to donate unused vaccines. Daily vaccination rates have slowed down in the United States leaving the nation with a surplus of doses. According to ONE’s analysis, rich countries are sitting on enough extra doses to vaccinate all of Africa. By the end of the summer, the vaccine supplies in the United States, Germany, Canada, Italy, France, and the United Kingdom will surpass demand. Donating unused vaccines to countries in need is the easiest action the Biden Administration can take; however, this alone will not sufficiently address the issue at hand.


To combat vaccine inequity, the president needs to recognize the Global South’s manufacturing capabilities. This involves waiving the World Trade Organization’s Trade-Related Aspects of Intellectual Property Agreement (TRIPS). Established in 1995, this agreement ensures the protection of intellectual property rights for medical innovations. Led by South Africa and India, over 100 countries have called on the WTO to issue a temporary waiver for certain parts of the agreement to allow countries to produce, import, and export COVID-19 medical products. However, opposition from powerful nations such as the United Kingdom and Germany has kept this action from happening. The Biden Administration has expressed support for a TRIPS waiver, yet has failed to take any steps towards its realization. Because of this, Morten describes the president’s endorsement as “actually pretty weak."


Morten is a proponent of the TRIPS waiver, which would remove some of the legal barriers keeping African nations from manufacturing locally. However, he notes that it cannot be the sole solution to vaccine inequity. “It's a necessary step and it's an important step,” said Morten, “but it is not a sufficient step in and of itself." The waiver alone does not ensure that pharmaceutical companies must equip countries with the technology and medical know-how needed to produce vaccines by themselves.

Thus further government intervention is needed. The Defense Production Act enables the president to command private companies to act in the name of national security. In “How to Vaccinate the World, Part 2,” Amy Kapczynski explains that “the risk of virus variants alone clearly makes global vaccination an issue of national security as defined by the Act." Provisions of the Act outline the government’s power to require Pfizer, Moderna, and Johnson and Johnson to facilitate the necessary transfer of technology and share their trade secrets, enabling the increase in global vaccine production. Recently, Public Citizen found that the Biden Administration possesses "unlimited rights" to share key contracted information about the development of the NIH-Moderna vaccine. Outlining the implications of this revelation via Twitter, Law & Policy Researcher Zain Rizvi explains that “based on public information, we can reach high-level conclusion: because Moderna learned how to commercially produce hundreds of millions of doses on the taxpayer’s dime, the govt appears to have unlimited rights in the recipe for commercial-scale mRNA vaccine production.”


Despite these legal powers at the president’s disposal, so far Biden has done very little to enable global access to the vaccine. Instead, the administration continues to uphold the pharmaceutical monopolies of the status quo. But as Morten explains, “the world is on fire, now's the time to break the glass and use the tool that's been sitting there waiting for us."


Why should you care?


The political realist’s answer is that the vaccine apartheid will affect everyone regardless of which country you reside in.


“The problem is that we live in a global village”, Gikonyo said. “The village in Africa eventually gets to America… A disease in Africa is a danger to America, a disease in America is a danger to Africa… vaccinating only your neighbors and yourself is meaningless and does not defend you." For as long as a part of the world remains unprotected, new variants will develop and spread from nation to nation prolonging this pandemic. No one is safe until everyone is safe.


However, advocating for this issue solely in the name of self-preservation will never lead to the destruction of the unjust systems of its cause. Instead, Welte says we should ask ourselves: “Is this really the kind of world I want to live in?”


“Without deeply being willing to reassess the basic structures of the world from a human rights point of view,” he explained. “The big questions are still being skillfully avoided rather than dealt with." Access to life-saving medical innovations including but not limited to the COVID-19 vaccine is a human right that should be enjoyed by all. The fact that young people in America are attending concerts while healthcare workers in Ghana remain unvaccinated due to existing policies and power structures is a grave injustice. This disease has proven to be indiscriminate, thus responses to it must account for all of humanity.


What can you do?


Check out the Universities Allied For Essential Medicines and the chapter at Yale. This organization is a global network of university students dedicated to accessible public health and medicines.


The People’s Vaccine is a global coalition of organizations taking significant steps towards the end of this issue. Easy actions to support their work can be found here.



Writer’s Reflection

After a year of isolation, this summer I along with the rest of the United States, celebrated the long-awaited “return to normalcy” thanks to the effectiveness of COVID-19 vaccinations. However, talking with my family living in Kenya, forced me to acknowledge that the human rights to health and dignity are not being protected for those in the Global South. Angered by this, I began my research in the search for answers to the stark lack of vaccine supplies, particularly in African countries. What I discovered was the shocking history of selfishness and apathy on the part of Western nations when it comes to the issue of global inequitable access to healthcare. This issue extends far beyond the time, location, and word count limitations imposed on my research. However, I hope this piece encourages students like myself to become educated and involved in the fight for life-saving medicines for all. I would like to give a special thanks to Doctor Gathaiya Jumbi, chairman of Surgery & Orthopedics at Kenyatta University School of Medicine, and Naomi Karoki for personally connecting me with valuable sources in Kenya. Thank you as well to Doctor Mbira Gikonyo, Chris Morten, Alex Welte, and Jackson Majoni for sharing their time and expertise with me.