Cecilia Lee

A group of Yale-affiliated researchers recently found that there are significant inequities in global COVID-19 vaccine distribution — specifically among countries that hosted vaccine trials, low- and middle-income nations received disproportionately fewer doses than high-income ones.

In the long term, these lower-income countries are less able to vaccinate their populations, ultimately resulting in a high disease burden and overstretched hospitals in economically disadvantaged regions, the researchers found. Among countries that hosted clinical trials, the high-income countries were able to vaccinate a median 51.7 percent of the population, whereas lower middle- and upper middle-income countries could only provide doses for 31 percent and 14.9 percent of the population, respectively. This result occurred despite similarly high rates of vaccine authorization and approval across countries, indicating that the wealth-based inequities in vaccine distribution are due to variations in vaccine delivery. 

“Registration wasn’t the barrier,” explained Reshma Ramachandran, lead author of the study and a research scholar at the Yale School of Medicine. “Basically over 90 percent of all the countries that tested the vaccines, regardless of income group, approved the vaccine for use in their populations. The disparities really existed in terms of delivery … vaccine manufacturers, because they’re the ones who have control of the supply, were prioritizing high-income country orders ahead of those from low- and middle-income countries.” 

One of the reasons for this, she elaborated, is that wealthier nations are able to pay higher premiums for the vaccine doses, often before research and development has even been completed. 

According to Ramachadran, the National Institute of Health, or NIH, initiated Operation Warp Speed, which contributed roughly $20 billion to the development, manufacturing and purchase of vaccines. In Canada and several European countries, similar programs were instituted, with the governments of these nations negotiating contracts with major pharmaceutical companies such as Pfizer, Moderna, BioNTech and Johnson & Johnson. 

Alka Menon, a medical sociologist and research fellow at the MacMillan Center for International and Area Studies at Yale, said the urgency of the COVID-19 pandemic also increased the speed at which the clinical trial process occurred, which is ultimately disadvantageous to low- and middle-income regions. 

“Countries with a lot of money could command a seat at the table faster and make a commitment up front of much more resources, and that’s exactly what the U.S. did,” Menon said. “The government made bets on several different manufacturers simultaneously, before middle-income countries even got a conversation with some pharmaceutical companies.”

Although the United States federal government, along with other high-income countries, has pledged to donate millions of vaccine doses to low-income countries, the follow-through has been far too slow, according to Ramachandran. In addition to getting priority access to vaccines, higher-income countries have also obtained doses or boosters in quantities greater than the needs of their own population. This means that the majority of the existing vaccine supply is concentrated in just a few countries. 

Professor of public health and epidemiology Albert Ko added that countries like Germany and the United States, who are worried about risks associated with finding which vaccines will work, prepaid each of these companies to buy a supply of doses for “sometimes multiple times the number of people in the population to get enough vaccines.”

During public health crises, countries generally aim to launch a coordinated effort in terms of both surveillance of the disease and the development of vaccines and treatments. The rapid spread of COVID-19, combined with a lack of preparedness for a pandemic of this scale, resulted in a gap in vaccine access between high- and low-income countries. 

The actions of the U.S. government are also to blame, according to Ramachandran. In contracts between the government and pharmaceutical companies, policymakers can implement certain provisions or stipulations requiring the vaccine manufacturers to share their technology with other biotechnology companies in order to facilitate widespread production of vaccines. However, Ramachandran emphasized that the government left vaccine distribution in the hands of private vaccine manufacturers and pharmaceutical companies. 

“Despite repeated asks from patient communities, nonprofit organizations and healthcare providers, [the government] decided to write them a blank check, instead of requiring access as a condition for these contracts [which is] … one of the biggest policy failures we’ve seen during this pandemic,” Ramachandran said. 

One of the most important next steps, especially with the recent emergence of new strains of COVID-19, is to find a way to promote more equitable access to vaccines across all countries, regardless of national income. Ramachandran suggested that President Joe Biden could extend the Defense Production Act, an emergency response clause that allows the nation’s leader to reallocate resources and facilities to promote national defense. Although the Biden and Trump administrations have both invoked this act to expand vaccine production, broadening its scale to require that vaccine manufacturers share the results of their clinical trials with other companies would likely reduce disparities in vaccine access. 

Jennifer Miller, an assistant professor at the Yale School of Medicine and founder of the nonprofit Bioethics International, highlighted the ethical issues surrounding these disparities. 

“Populations or communities that participate in clinical research should stand to benefit from that research,” Miller said. “It’s a basic principle of research ethics, and as a corollary of that, generally the benefits and burdens of research should be equitably shared among participants.” 

The outcome of a recent court battle, a dispute between Moderna and the NIH over whether NIH researchers were unfairly left off as co-inventors on a vaccine patent, also has the potential to improve the delivery of vaccines to lower-income nations. Winning this case could enable the NIH to “collect royalties and license the patent to manufacturers in other countries,” especially countries severely lacking in vaccine doses, according to Ramachandran.

Overall, both centralizing control of vaccine distribution under the umbrella of the World Health Organization and continuously working to improve upon its programs, like the COVAX initiative, could result in a more equitable distribution of vaccine doses. Menon further explained that developing more vaccine production facilities on every continent and dispersing them could potentially eliminate logistical difficulties in vaccine delivery.

All completed clinical vaccine trials in the study were identified using the WHO COVID-19 Vaccine Tracker.