Plan of Action
The figures on COVID-19 are grim: 298 million confirmed cases and 5.47 million confirmed deaths. These numbers also do not account for deaths due to COVID-19-related complications, which could mean deaths are undercounted by as much as 36%. Most of the developing world remains without a first dose, while recent studies show the vaccines available have significantly reduced effectiveness after the first six months of being vaccinated, placing pressure on national governments in the developed world to deploy booster programs. With vaccine supply shortages projected to extend into the next several years, vaccinating and boosting those in the developed world is not feasible. Therefore, efforts must be focused on vaccinating the developing world.
The international medical community is in general agreement that reducing the spread of COVID-19 and preventing further catastrophic tolls in developing countries requires an immediate and concerted global vaccination effort. Developed countries must stop booster programs to focus on vaccinating the most poorly vaccinated developing countries in Africa.
This article will discuss how to achieve three aims with regard to the global vaccination effort to quickly achieve higher vaccination rates in developing African countries. The three aims are reducing the targets for domestic booster programs, expanding the multilateral charity called COVAX through which rich countries with large vaccine stocks transfer doses to low-income countries, and designing a pipeline for distribution of vaccines, one that includes manufacturing and distribution capabilities on the African continent.
Background
The threat of variants is a concern during any pandemic. The more lethal delta variant of COVID-19 that arose in India in December 2020 was quickly replaced by the more contagious omicron variant discovered in South Africa in November 2021. Without existing protection, these and other variants can spread quickly from the poorly vaccinated in developing countries in Africa. In urban Kinshasa, DRC, individuals tend to live in close quarters and will be at a higher risk, acting as incubators for variants. In Burkina Faso, only 2% of the population has received at least one dose of a COVID vaccine. Densely populated regions and unvaccinated regions allow the virus to mutate into a deadlier and/or more infectious strain.
Unfortunately for the effort to redistribute vaccines to developing countries in Africa, research shows that after about six months, vaccinated individuals lose most of the antibodies created to protect the body during reinfection. Coupled with the advancement of new variants like omicron, governments may not be keen on releasing vaccine doses while previously vaccinated citizens clamor for boosters. Nevertheless, subsequent doses may not protect against new variants that arise in countries with low vaccination rates. Omicron, for instance, has predominantly been documented in among fully vaccinated individuals
While most of the world is above the 10% threshold set by the WHO for 2021, of the 36 countries in the world that have yet to reach the threshold, 31 countries are developing countries in Africa. While it is clear to many international observers that immunizing the populations of developing African countries is a priority, most developing African nations have not mobilized resources to vaccinate their people. Many developing central governments in Africa have declared that they have much greater domestic public health priorities that demand their time and resources, given budgetary constraints. It is thus incumbent on international agencies in cooperation with wealthy nations to mobilize these vaccination efforts.
First Steps
The objective of getting vaccines from wealthy countries to developing African countries faces a significant obstacle as booster shots are becoming more popular in the developed world. After research showed that waning effectiveness of vaccines against new variants would inevitably lead to an increase in hospitalizations and deaths in the summer and fall of 2021, developed nations looked to provide booster shots for their populations. Canada and Israel were among the first to begin booster programs, citing a domestic necessity. The United States has followed suit, cutting back their promised supply of doses for international relief efforts. Tedros Adhanom Ghebreyesus, director of the World Health Organization, has called for a global ban on boosters with the goal of getting 10% of every nation’s population vaccinated by 2022.
Past interventions make clear that it is important to anticipate demand for vaccines and demand legislation to prioritize distribution of available vaccines to groups that are most at risk. We need to evaluate risk in different population groups (i.e. young people in wealth nations versus young people in poor nations). From the perspective of wealthy nations, the calculus is always the same: they developed the vaccines and invested heavily in their Research and Development of them, so they feel comfortable to continue to monopolize the supplies.
“Although there are other countries that have been affected, none have had as many deaths as the U.S.,” said public health expert Dr. Clifford Lo, Associate Professor of Pediatrics at Harvard Medical School and Director of the Harvard Human Nutrition Program in an interview with the HPR. “So, it’s understandable that if one developed the vaccine in the U.S., one should use it in a place where the most number of people are affected.” This is despite the clear ability of wealthy nations to provide adequate medical and hospital treatment for those who need it, and despite the fact that the cause of death in wealthy countries due to COVID-19 is not from a lack of access to vaccines, oxygen or a hospital bed but rather from vaccine hesitancy.
Historically, this disparity is nothing new, says infectious disease expert, Dr. Nicole De Nisco, Assistant Professor of Biological Sciences at the University of Texas at Dallas, in an interview with the HPR. “For instance, the ebola crisis in 2014 is an example of an extreme disparity in vaccine development and access to lifesaving therapies. Another example is poliovirus which was eradicated in the United States in 1979 but is still, more than 40 years later, endemic to Afghanistan and Pakistan.”
Dr. Evelyn Hammonds, Chair of the Department of the History of Science and the Barbara Gutmann Rosenkrantz Professor of the History of Science, and Professor of African and African-American Studies at Harvard University sees similar scenarios in her book on the New York epidemic of diphtheria. “The ability to enroll the best scientific minds and the ability to produce effective public health measures has really been lost in a cloud of politics in ways that I could never have imagined, having written my book on diphtheria 22 years ago,” she said in an interview with the HPR.
The best way to improve COVID-19 vaccination status in developed countries would be through addressing misinformation about the disease, like on social media. “Social media has played a very significant and complicated role in making the political situation so complex that public health institutions, and governments have been unable to stay in front of what’s been happening on social media. The spread of disinformation has crippled leadership in many ways, in my view.” In contrast, from a human rights perspective, the lack of beds, PPE, medical equipment, and supplies are the infrastructural reasons that people in developing countries are most at risk and should be society’s priority.
Manufacturing capacity also needs to be expanded in developing African countries to combat the pandemic. The continent has consumed 160 million of the world’s vaccines (2.5%). There are three areas that must be addressed in order to provide this equitable distribution: funding the vaccine, expanding manufacturing in developing African countries, and effective supply chains. We need to invest in delivery programs that ensure reliable vaccine delivery. Low-income countries cannot afford to fund the cost of a robust COVID-19 vaccination program. According to Hammonds, countries like Liberia just coming out of Ebola are particularly worrisome. “Their health infrastructure has already been pretty taxed…in countries on the African continent where they have still been fighting HIV, Ebola, other kinds of outbreaks…the health infrastructure is very under-resourced.” Thus developing nations need other, wealthier countries, to join in the fight to help. “There is a great deal of need for continuing shoring up institutions that could effectively respond to infectious disease outbreaks.”
Solutions
COVAX is a program started by the WHO that has so far delivered 190 million doses to developing African countries. The aims and objectives of COVAX were limited from the outset, as it only set out to vaccinate 20% of these populations by the end of 2021. Yet, even by those limited objectives, it’s nevertheless been hard to deliver on them because of new waves and vaccine supply chain issues.
We have identified key issues with local manufacturing and delivery capacity, but I want to make clear proposals of what the U.S. should be doing to support COVAX. First, the U.S. should allocate funds to manufacturing centers that provide the majority of vaccines to developing African nations, as well as manufacturing centers within developing Africa countries that facilitate developing African countries’ domestic efforts to vaccinate their own populations. The current centers that provide such vaccines include the Serum Institute of India which produces the Astra-Zeneca vaccine and has a manufacturing capacity of 2 billion doses annually. In fact, developing African nations will require nearly 2.8 billion doses for the majority of the population to be completely vaccinated.
Another important strategy is to incentivize U.S. vaccine companies to establish factories in developing African nations. President Biden is already seeking to expand health infrastructure in developing African nations like Kenya and Nigeria by cementing long-term trade agreements between American and African firms. Due to the lower cost of manufacturing in Africa, establishing vaccine manufacturing plants can have long-term positive effects in terms of creating stable and expandable vaccine access for both the U.S. and African nations.
So far, 12 COVID-19 vaccine production facilities have been established in developing Africa countries, which include manufacturers of the U.S. and Europe’s Johnson and Johnson, Pfizer, and AstraZeneca vaccines, as well as Russia’s Sputnik V and China’s Sinovac vaccines. Efforts are particularly impressive in South Africa, where the U.S. International Development Finance Corporation pledged $600 million dollars for Aspen Pharmacare which to date has produced 500 million Johnson & Johnson doses. In Senegal, the government, with European and American financial support, is building a $200 million manufacturing facility. Other manufacturing facilities have cropped up in Morocco, Egypt, Algeria, and Nigeria with combined planned vaccine capacities of over 1 billion annually. Yet, crucially, four of these plants are yet to be built and/or are under construction.
We must also track who is getting the vaccines, which is a crucial component of supply chain issues — for many low-income countries containing refugee or undocumented citizens, it is difficult to keep track of who has received the vaccines. Seth Berkley, CEO of Gavi, has thus proposed biometric digital IDs—an identification database based on physical features and personal information. This would, for example, allow for immunocompromised individuals to still receive boosters while making it inaccessible to the public. Undoubtedly, through a collaborative effort with GAVI, CEPI, and WHO, the most successful measure against COVID-19 is COVAX. It is important to re-examine the discussion between the FDA and CDC that led to their making a decision on implementing boosters.
Concluding Recommendation
Based on the cost-benefit analysis and expert testimony, the best plan is to move forward with a series of ideas modeled on President Bush Jr.’s “President’s Emergency Plan For AIDS Relief,” better known as PEPFAR. There are three principal aims: reducing the targets for domestic booster programs, establishing a multilateral charity through which rich countries with large vaccine stocks transfer doses now to low-income countries, and designing a pipeline for distribution of vaccines, one that includes manufacturing capabilities on the African continent.
With regard to the second aim, the COVAX approach needs to be expanded into a robust “pooling system” through which poor countries can pay overtime for access to doses. With regard to the third aim, it is important to encourage COVAX to fix supply chain issues and redistribution to be able to effectively distribute more vaccines to African countries. Yet, this is not enough. The U.S. must launch its own governmental initiative to address the global inequity in COVID vaccination. The implementation of this strategy is detailed below.
To design a pipeline for vaccine distribution that includes manufacturing capabilities in developing African nations, the United States Congress must designate departments and agencies to manage and oversee a program to accelerate the distribution of vaccines to African nations. To do so, the U.S. can model the program on PEPFAR and engage the same departments and agencies in many of the same capacities. PEPFAR has been one of the largest investments by the United States since 2003 in the prevention of a specific disease in the world. With a total investment of over $85 billion, the initiative has been responsible for creating health infrastructure and human resources to treat HIV. The majority of its efforts have been in Sub-Saharan Africa, where PEPFAR has helped establish thousands of laboratories, healthcare facilities, and trained 290,000 health care workers. The infrastructure established has since helped with outbreaks of ebola, avian flu, and cholera. What will be the specific consequences of achieving, even in part, the three aims outlined here? Achieving the first aim of reducing the targets of domestic booster programs will have the immediate consequence of freeing up more than 200 million doses and hundreds of millions more within the next several months. The second aim of expanding the existing COVAX network will expand developing countries’ access to seed money and donated vaccines. Finally, the third aim of designing an African vaccine distribution pipeline will help African nations secure vaccines through a stable financial and logistical commitment from the American government and easier implementation of future research and development of modified vaccines to combat future variants. These recommendations, executed successfully, may pave the way for a robust global vaccination program that succeeds in improving vaccination rates across Africa and bringing about an end to this pandemic.
