Back of the line

“RUSH VACCINE” read placards on the plastic-wrapped white boxes rolling off the tarmac at Johannesburg’s O.R. Tambo airport. An overnight flight from the Serum Institute of India brought to South Africa 1 million doses of the AstraZeneca COVID-19 vaccine. Their arrival Feb. 1 was not only the first to reach the country but the first million to reach Africa—a continent of 1.2 billion people.

The boxed vials received a hero’s welcome, with President Cyril Ramaphosa and Health Minister Zweli Mkhize on hand to meet them. Stickers on AstraZeneca boxes read: “May All Be Free From Disease.”

African leaders are in a race to free their countries from the coronavirus spread. South Africa leads the continent in confirmed cases and deaths, spiked in recent weeks by a new variant that’s more infectious and already has spread to the United States.

Worries about virus mutations, coupled with shortfalls in vaccine production, already are unleashing a vaccine war. While the disease itself knows no boundaries, poor nations face barriers when it comes to accessing vaccines. A European-led plan to create a “humanitarian buffer”—setting aside enough doses to launch vaccination programs in countries that otherwise cannot afford them—is so far failing to deliver.

Vaccines represent new hope everywhere as COVID-19 deaths top 2.2 million globally. That’s nowhere more true than in Africa, where healthcare workers for a year have battled to treat the worst cases of the virus without basic tools. On the best days they work amid fragile health systems where piped oxygen is a nearly unheard-of luxury. Their communities already may be compromised by high incidences of tuberculosis and AIDS.

At the peak of one surge in cases last fall, “my hospital neared its COVID ward capacity and prepared to turn away patients due to oxygen scarcity,” reported Jon Fielder, chief executive of African Mission Healthcare who works at two facilities in Kenya, including AIC Kijabi Hospital outside Nairobi.

Now, physicians like Fielder are watching from the sidelines as other parts of the world launch massive vaccination campaigns. “I don’t know where any meaningful amount of vaccine is going to come from for months or longer,” he said.

Workers at O.R. Tambo International Airport transfer the first shipment of COVID-19 vaccine to arrive in South Africa. Elmond Jiyane for GCIS/Handout

TWO MONTHS AFTER a British grandmother became the first person in the world to receive an approved vaccine, shortfalls are plaguing production and distribution facilities in Europe and North America. Production involves two steps: making the actual vaccine and placing it in vials. For the AstraZeneca vaccine—the vaccine of choice in places like Africa because it only requires refrigeration, not the sub-zero conditions necessary for others—each step can take up to 60 days. Company officials in Europe say they are struggling to complete the first step in quantity.

Forecasters continue to believe that most developed nations will reach mass COVID-19 immunization by the end of this year. But they have downgraded expectations for 84 poor countries, saying most will not achieve mass immunity until late 2022 or even 2023.

South Africa is paying $5.25 per dose—more than twice as much as EU countries reportedly paid AstraZeneca at $2.19 per dose.

That leaves exposed some of the most heavily populated parts of the world, and some of the most restive. Pakistan, Afghanistan, Iran, and Syria are countries likely waiting more than a year for vaccine doses.

In South America, only Argentina, Chile, and Brazil have vaccination programs underway. Bolivia, Peru, Colombia, and Ecuador could be a year or more away from vaccination coverage, yet are among the countries experiencing some of the highest COVID-19 death rates in the world.

In Africa, only five of 54 countries are likely to see vaccines this year: South Africa, Morocco, Seychelles, Egypt, and Guinea. Apart from clinical trials, only 25 people in all of sub-Saharan Africa had received a COVID-19 vaccine by Feb. 1, according to the World Health Organization (WHO).

Fearing production shortfalls for their own countries, European leaders in late January imposed export restrictions on the Serum Institute of India, the largest vaccine manufacturer in the world and maker of the vaccine developed jointly by AstraZeneca with Oxford University. At the same time, press reports revealed South Africa was paying $5.25 per dose—more than twice as much as EU countries reportedly paid AstraZeneca at $2.19 per dose. That’s after South Africa agreed last year to host clinical trials for the vaccine in a bid to bring down costs.

MONTHS INTO THE PANDEMIC last year, a consortium including the WHO and the European Commission (the European Union’s executive branch) launched COVAX, a platform to speed research for vaccines and prompt equitable distribution. The public-private initiative brought government and global health officials together with financiers, vaccine research firms, and manufacturers to share costs and benefits in the high-risk, fast-paced effort.

The 27-nation European Union and others would finance vaccine developers up front by entering advance purchase agreements, which earned them the right to buy a specified number of vaccine doses within a set time frame. The funding served as those nations’ down payments on the vaccines while at the same time covering the cost of additional vaccines for poor countries.

“This is all about geopolitical cooperation, not competition,” Ursula von der Leyen, president of the European Commission, said last year. “Vaccine nationalism—a ‘my country first’ approach to immunization—can only slow down the global fight against the virus.”

Airport employees unload the first shipment of Russia’s Sputnik V COVID-19 vaccine after it arrived in Bolivia. Juan Karita/AP

More than 170 countries joined COVAX by September, underwriting nine potential vaccine candidates, including Oxford-AstraZeneca’s and the Pfizer-BioNTech vaccine now widely used in the United States.

The Trump administration—having signaled its intent to withdraw from the WHO—did not enlist the United States in COVAX. Separately it helped fund clinical trials and entered purchase agreements with vaccine makers, expenditures totaling about $4 billion. The European Commission pledged to COVAX $600 million, and Britain pledged $750 million. Wealthier countries like Germany, Canada, and others joined COVAX and at the same time made bilateral agreements with vaccine makers for additional doses.

By mid-December, with record development of successful vaccines no doubt helped by the global effort, COVAX reported it had agreements in place to access nearly 2 billion doses aimed at distribution in the first half of 2021. Von der Leyen on behalf of the 27 EU countries announced purchases from six pharmaceuticals for the European vaccines, plus set-asides of 1.3 billion doses for low-income countries.

A Moroccan man receives a dose of the COVID-19 vaccine. Fadel Senna/ AFP via Getty Images

BUT AS SHORTFALLS and distribution issues have mounted, calls for equitable vaccine delivery instead turned to panic buying. In addition to the COVAX agreements, Western nations have ordered vaccines far exceeding their populations: Canada, for example, has purchased more than five times what it will need to vaccinate its adult population fully.

At the same time, COVAX lowered the number of expected doses available to member countries and for low-income countries, though it announced Feb. 4 that it aims to start shipping to Africa nearly 90 million doses this month.

Leaving low-income countries in the lurch could threaten vaccination efforts everywhere: Large, unvaccinated populations become breeding grounds for new mutations. Already, say researchers, four vaccines effective against the original virus are proving less successful against a new South African variant, which now makes up 90 percent of all cases in the country.

One week after its arrival, South Africa suspended the use of the AstraZeneca shot on Feb. 7 when a clinical trial showed it gave minimal protection against the new variant. The WHO said it would continue to monitor variants and the need for boosters or adjustments to vaccines—all underscoring the need for more rapid and widespread vaccinations.

Each nation has to invest in COVAX beyond their own need in order to create a stockpile, explained Deepmala Mahla, vice president of humanitarian affairs for CARE. The international NGO is partnering with UNICEF to distribute COVAX vaccines in underserved countries and places like the Rohingya refugee camps in Bangladesh. The humanitarian buffer, said Mahla, is key to reaching migrants, refugees, and those living in war zones and contested border areas. “But right now the humanitarian buffer is zero.”

News of new shipments is a step in the right direction, said Mahla, “but it still needs to be clarified how these allocations will turn into reality.”

Pledges may continue to run against the reality of slow vaccine rollouts. After German Chancellor Angela Merkel appeared ready to bolt from COVAX, AstraZeneca announced it would deliver 9 million additional doses to EU countries. For every 10 Americans vaccinated, only three Germans had received doses. At a Feb. 1 meeting with pharmaceutical executives and EU officials, Merkel called the rollout “a debacle” that could push Germany to go its own way.

For the European Commission, von der Leyen threatened legal action against AstraZeneca over the wording of purchase agreements. She and Merkel also sought an export ban on vaccines leaving Europe for the U.K. (Britain under Brexit reached a separate agreement with AstraZeneca months before the EU did) and on AstraZeneca shipments departing India.

Empty vials that contained the Pfizer-BioNTech COVID-19 vaccine. Esteban Felix/AP

All such tensions are likely to push the COVAX “humanitarian buffer” further off. That’s forced countries feeling left out to look elsewhere for vaccines. China will donate doses of its Sinovac vaccine to Pakistan and the Philippines.

Many countries are looking to Russia and its controversial Sputnik V vaccine. Its phase 3 clinical trials reported in February showed favorable efficacy, though it isn’t yet approved for use in North America or Europe, or authorized by the WHO.

In Africa, Mali and Malawi announced plans to purchase directly from AstraZeneca, putting them further back in line. South Africa will continue its prearranged plan to purchase nearly all its vaccines from India, taking only perhaps 10 percent via COVAX.

Despite the shortfalls and dustups, “COVAX is the world’s best and main route for delivering on international vaccine solidarity,” said Ana Pisonero, a spokesperson for the European Commission. She told me plans continue to “help secure 1.3 billion doses” of vaccine for low- and middle-income countries by the end of the year. But she and others wouldn’t comment on the current status of the humanitarian buffer.

THE COMPETITION among nations for vaccines has clouded the role of NGOs, community-based groups, and mission hospitals—though they are the backbone of healthcare in underdeveloped countries and conflict zones.

Mahla with CARE said the organization is prioritizing those outlets once it has vaccines to work with through UNICEF. “We see ourselves supporting others already in place, and we want to work with community groups, churches, and local NGOs.”

Medical missions organizations I contacted were in the dark about vaccination plans, though they have existing infrastructure and operations to mount campaigns, including in places otherwise hard to reach.

“There has been no news as to a vaccine for COVID being available in South Sudan any time soon,” said Daniel Stephens, a surgeon serving with MRDC International in Juba, South Sudan.

“At the moment we do not have vaccines in Zambia,” said Michelle Proctor, a nurse anesthetist with SIM working at Mukinge Mission Hospital in Kasempa. The hospital has seen a rise in COVID-19 cases in recent weeks, and Proctor expects it will be part of a vaccination program “when the government approves and we get vaccines.”

In Kenya, Dr. Fielder said news reports are his only source of information on the arrival of vaccines, though he’s been working much of the last year at two of the country’s largest mission hospitals treating COVID-19 patients: AIC Kijabe and Maua Methodist Hospital.

But Fielder sees silver linings in Africa’s lower-than-expected COVID-19 rate. Part of that may be due to inadequate testing and reporting, plus serious government lockdowns. Fielder also attrib­utes it to outdoor lifestyles in Africa and more youthful populations. Kenya’s median age is 20 years old, while the United States’ is 38.

Past epidemics and infectious diseases, such as Ebola and HIV/AIDS, have tempered seasoned medical workers in Africa like Fielder. For four years he ran a U.S.-funded HIV program serving 2,000 patients at Kijabe. He thinks reversing COVID-19 will take deep community-level engagement, and national and international programs.

“A significant community push—similar to the efforts around antiretroviral treatment for HIV—will be necessary to achieve high coverage in the population,” he said. “Just waiting for adults to come to the hospital won’t hit the target.”

While childhood vaccination rates across Africa are high, adult vaccination programs “are not routine.”

Another silver lining to waiting at the back of the line may be newer vaccines that could prove more effective. This month it became clear that Johnson & Johnson and Novavax vaccines under trial have performed well against the South African and U.K. variants.

That news will matter most when medical workers see vaccines rolling in boxes from planes and can jab them into their patients’ arms. “Supply is the biggest issue,” said Mahla. “If you ask me what keeps me up at night, that is the one.”

—Editor’s Note: WORLD has updated this story to correct the title of Deepmala Mahla, who is the vice president of humanitarian affairs for CARE.