People wait to receive a COVID-19 vaccine at a center in Soweto,...

People wait to receive a COVID-19 vaccine at a center in Soweto, South Africa, on Monday.  Credit: AP/Denis Farrell

How do we ensure that the world has access to the COVID-19 vaccines needed to prevent more variants like the latest omicron strain from emerging?

One disturbingly common response to calls from the World Health Organization and others to increase the availability of doses in emerging economies is to suggest supply isn’t really the problem, but demand. South Africa, where omicron was first identified, provides one data point in favor of this hypothesis. Despite the fact that barely 24% of the population has been fully vaccinated, the Department of Health last week asked Johnson & Johnson and Pfizer Inc. to suspend delivery of vaccines because its existing stockpile was more than enough at current lackluster rates of uptake.

To be clear, outside of the rich world demand is clearly not the main constraining factor on inoculations. All but 14 of the 51 nations with supply agreements sufficient to cover their entire populations are high-income countries, according to data collected by UNICEF.

Vaccine manufacturing capacity, which a database kept by Duke University puts at 11.435 billion doses this year, is simply insufficient to double-dose everyone on the planet. The rich nations where most shots have been developed have managed to hog the lion’s share of both first, second and third boosters so far.

Next year, though, that’s likely to change. UNICEF’s figures suggest that we’ll have capacity to produce about 23.53 billion doses, more than enough to put a needle in every person on the planet three times over. At that point, hesitancy in the unvaccinated world may become a real problem — and everything we’re doing now is likely to make it worse.

Tackling the reluctance of people to take action against epidemic disease isn’t a new problem. Indeed, from the heyday of smallpox eradication after World War II to the current campaign to snuff out the last vestiges of polio and Guinea worm, it’s at the heart of what groups like the WHO do year after year.

The lessons of that experience for lower-income nations are fairly straightforward. People need outside public health experts to show a genuine interest in the problems they face, from a lack of drinking water, sanitation and clean cooking facilities to more neglected and endemic diseases such as HIV, tuberculosis, malaria and diarrhea. Ideally, vaccines should form part of a package of measures to improve health, rather than be a one-time campaign parachuted into remote communities. If the motivations of those driving the push and the direct impacts on those receiving doses are unclear, that can lead to suspicion and conspiracy theories, especially among vulnerable populations.

Looked at that way, it’s clear why our current strategy is setting itself up for failure. By not ensuring sufficient doses for the world and hoarding those we do have, rich nations are sending a strong signal that vaccinations don’t really matter.

Sub-Saharan Africa in particular has reason to take outside advice with a pinch of salt. For reasons that are still unclear but probably relate to the youth of the population (around 1 in 20 Africans are over the age of 60, compared to about a quarter of Europeans and North Americans), mortality and severe sickness from COVID-19 has been far lower than other parts of the world. The comparatively affluent and old South Africa is a notable exception.

Unlike polio, which frequently causes prominent leg and spine deformities, the effects of COVID aren’t particularly visible, making vaccination a harder sell to skeptics. In asking Africans to take doses once they become available, we’re appealing to them to pull together for the sake of our own elder populations, while showing little evidence of solidarity in the other direction.

There are some advantages in this fight. Africa is already more urbanized than much of Asia, meaning there’s a smaller rural population disconnected from routine health information. Its public health systems, while starved of funding, are well set up to tackle COVID because communicable diseases have always been the main threat to local populations. That contrasts with richer countries, which direct resources more toward conditions of aging, such as cancer and heart disease. The long, bitter struggle to roll out polio vaccines, HIV antiretrovirals and tuberculosis antibiotics also means we have a head start in knowing what problems to address.

We have to heed those lessons and work fast. While the small size of Africa’s over-60 population might be protecting it from major outbreaks, the legacy of HIV and the prevalence of undernourishment mean there is an unusually large population with the weakened immune systems that are so conducive to cooking up new and concerning variants of COVID.

Richer countries may feel safe behind their walls of boosters and travel restrictions. Until the whole world is protected, though, those defenses will be under constant assault.


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