Pandemic of inequality

If vaccines promise the end of Covid-19, their unequal rollout is fueling a two-tier pandemic that is leaving the developing world behind. As affluent nations secure more doses than they need, the scale of vaccine inequity and absence of a viable plan to address the crisis has shaken healthcare systems and experts alike.

In a tell-all interview with The Express Tribune, Special Envoy of WHO Director General on Covid-19 Dr Maha El Rabbat discussed the efforts and challenges to combat the pandemic and why no nation will beat the coronavirus alone.

ET: WHO is calling for a halt on Covid-19 vaccine boosters until at least the end of September. Do you think this will help reduce the vaccination gap between rich and poor countries?

MER: That is the intention, yes. It represents yet another call by WHO for the global solidarity needed to achieve vaccine equity and the coverage we need to get the world out of this crisis as rapidly as possible.

The call for a moratorium was made in the context of high-income countries having administered almost 100 doses for every 100 people and low-income countries only being able to administer 1.5 doses for the same number due to lack of supply. We need an urgent reversal, from the majority of vaccines going to high-income countries to the majority going to low-income countries. Accordingly, WHO issued a call of global solidarity for a moratorium on boosters until at least the end of September, to enable at least 10% of the population of every country to be vaccinated.

We must focus on those who are most vulnerable – the most at risk of severe disease and death – to get their first and second doses, and then we can move on to advance programmes as evidence gets stronger and supply is assured.

ET: Vaccine inequality leaves people in low-income countries more vulnerable to the virus and the world more exposed to new variants. What does WHO have to say about it?

MER: The smaller number of doses we administer the more exposed we are to the possibilities of new variants. We are witnessing this with the new variants that have surfaced, and how they are spreading with increased transmissibility. This represents a tragic moral catastrophe.

The accessibility to vaccines must be addressed immediately. If not, we will only have more and more people at risk and this will allow the virus to circulate, threatening the gains we have made against the pandemic. Let’s not forget, this trend also threatens countries with higher vaccination coverage.

We can prevent this from happening only if countries that have the production capacity start sharing doses with those that haven't been able to manufacture the vaccine locally. This can be done easily through the Covax distribution model.

The global failure to share doses is fueling the pandemic. As Dr Tedros mentioned, we're fueling a two-track pandemic. Many countries still face an extremely dangerous situation, while some of those with the highest vaccination rates are starting to talk about ending restrictions.

Inequitable vaccination is a threat to all nations. Unequal distribution of vaccines will only allow the virus to spread, thus increasing odds of a variant emerging that could render existing treatment options ineffective. We need to support countries with limited resources and vulnerable groups. While some countries with resources are aiming to cover 70% or 80% of their population, others can't even vaccinate their health workforce or vulnerable groups.

No one is safe until everyone is safe but vaccination alone is not the only open window for ending the virus. It requires investment in public health measures and social and community engagement, and in the responsiveness of the health system.

ET: What are the hurdles in achieving vaccine equity targets. What challenges are preventing the eradication of Covid-19?

MER: The issue of vaccination can be divided into several parts. Apart from distribution, it also involves funding, production, and intellectual property rights. WHO is pushing for transfer of technology to make the vaccine more available and accessible. By doing this, we can easily ensure that the production and distribution of vaccines is not under the control of richer countries. There should definitely be intellectual property rights but the need of the hour must outweigh them during global emergency.

Inconsistent adherence to health protocols in many countries has also emerged as a hurdle. Preparedness, readiness, testing, tracing and diagnostics need to be strengthened globally.

What we need is a uniform response to the pandemic. Some countries, due to their fragile status, may not be able to respond. That's not just their weakness, it's our collective weakness.

As to whether WHO is satisfied with the progress, I will tell you that much progress has been made. Diagnostics and treatments to fight the virus in record time have been developed as result of amazing collaboration, but we need to do more. We need to share the doses, resources, technologies and data, and we need to be open and transparent about progress. We need to address the issue of vaccine nationalism.

Other hurdles include: patent protection, emergence of new variants, increasing transmissibility and decreasing protection. Vaccine hesitancy of people or countries that are unable to make proper and timely diagnosis, countries that fail in following the proper public health measures are also creating new challenges. Community fatigue and resistance are a major hurdle. Resources have also been exhausted.

ET: WHO says the virus has outpaced vaccine efforts. G7 has been criticised for doing too little too late. What are your views in this area?

MER: Clearly, the Covid-19 virus is moving faster than the vaccines. More people are infected than those vaccinated. Disparities in jab access need to be reduced at a faster rate. It is a dangerous trend and it does delay our ability to recover from this pandemic.

ET: How successful has Covax been and what are the challenges?

MER: The programme, despite its challenges, has moved as fast as possible. In five months, it has delivered millions of doses across the world. It is a global scheme for equitable access and distribution of vaccines. It is a mechanism that provides equity. But at the same time, the distribution has not matched the pace WHO is expecting.

This is due to several reasons. There are supply disruptions, production related issues and logistics. We need to speed this up to maintain vaccine equity but global supply constraints and vaccine nationalism have provided additional challenges. Covax is short of its target of delivering two billion doses by the end of the year but it does expect a big increase in supplies by early 2022. It has raised nearly $10 billion, above its target for this year, and has begun receiving some surplus doses from rich nations.

ET: How can vaccines be delivered fairly and how can WHO ensure that?

MER: WHO has been talking about vaccine equity since the doses were rolled out. We cannot ensure equity without the support of countries and their leaders, and solidarity.

Several factors play into this situation. You must note that financing is important, waiving of intellectual property rights is very important, increasing the production is very important, and the donation of extra doses is important. The pandemic preparedness and response treaty that many countries and WHO are advocating addresses this issue very well.

WHO has mentioned that the world needs more than triple its production of vaccines just to deliver the number of Covid-19 vaccines needed. We need to expand production sites globally. In order to reduce dependence on technologies concentrated in high income countries, we need to transfer the technology and ability to produce the vaccines. This will strengthen access to vaccines, diagnostics, treatments and essential health needs.

The pandemic is hitting low-income nations harder as they struggle with access to vaccines, the rapid spread of new variants and heavily burdened healthcare systems. The director-general has already described the inequity in his remarks. The persistent global inequity qualifies as “vaccine apartheid” and a “catastrophic moral failure” that has resulted in a “two-track pandemic.” And as the director-general said: More than 10,000 people are dying every day. These communities need vaccines, and they need them now, not next year. To make the supplies fairer and more accessible, we need to ensure production and distribution is localized.

ET: Is the world prepared for the next pandemic?

MER: This is a very tricky question. The slogan at the last World Health Assembly was: how can we prepare for the next pandemic?

WHO along with international organisations and with the support of governments around the world is not only trying to end this epidemic, but also trying in every way possible to prepare for future pandemics, that all of us know can happen anytime and perhaps. The aim is to prepare a plan at global, regional, and national levels to be prepared for such a situation in the future.

So, as much as there is global solidarity in finding out solutions to end this pandemic, we also need to strengthen all actions needed to prepare for the upcoming health crises with solid measures like readiness, preparedness, and response, that will not put the whole word into what has happened with the Covid-19.

Several leaders have already accepted and acceded to the global treaty, and they will be discussing it over the next few months to find out how to implement it globally. There is a global consensus on the role of WHO, and it comes at a very important and opportune time. Because now we know that no one is safe until everyone is safe, and that no one can do it alone, or on their own.

ET: So, would you say that we are already prepared, or are we preparing for it?

MER: It is being prepared for. The treaty which has been proposed should foster improved sharing, trust, solidarity leadership, accountability and provide solid foundations for building mechanisms for global health security. Leaders all over the world are talking about securing global health and making public health a priority.

ET: What have we learned from this pandemic?

MER: We have learned a lot of lessons and one of them is that we were not prepared for the arrival of this pandemic. There were many concerns in the past decades about a pandemic that would happen at any time and how countries should invest in preparedness and possible solutions to a major crisis. But when this pandemic struck, particularly in higher socio-economic nations, it turned out that most of them were not prepared for a health crisis of this nature.
There hasn't been proper investment in public health measures or in international health regulations. There hasn't been any investment to prepare countries, systems and communities for pandemics. We haven't invested in how governments should respond to such a health crisis.

We have learned that the health workforce is a treasure that every country should invest in. We have learned that solidarity is the pathway to overcome pandemics, and that no one can do it alone. We learned all of it the hard way.

But we now know that things can work and should work to be able to face outbreaks in the future. Scientifically, we have learned so many things that could pave the pathway for more measured actions and responses in the future. We have learned that when the global efforts are focused or when the entire world sets its mind to something, they can produce innovations in research, vaccines, treatments, and diagnostics, etc. Countries came together and within one year, they produced vaccines and diagnostics.

With all that we have managed to learn, we could do better in the future. This pandemic has exposed inequities across the world like no other outbreak has ever done before. They have been huge not just due to economic disruption but from lack of preparedness, fragility of health systems and ability to recover as well. We need to rethink our future, and how we can build a secure health system accessible to everyone.

ET: Before Covid, there was Ebola. Why didn't the world prepare for this pandemic?

MER: Because, in my opinion, Ebola affected some countries and not the entire world. While those countries have their own strengths and weaknesses, they still have some mechanism to deal with such a situation. They have the know-how to contain outbreaks or epidemics like Ebola.

Although it's a different virus, the Ebola crisis is a good example. These countries developed the knowledge and expertise to contain the virus. To deal with the crisis, these countries were able to create public health measures, and engage and empower communities. They were successful with the help of international organisations and global support, and now know how to use their own resources.

ET: Where are we on this pandemic’s timeline right now? Are we close to recovery or far from the finish line?

MER: We certainly have a long way to go. We can’t say far or near, but we can say progress has been made, knowledge has been built, innovations have been produced and countries are responding. But we are also besieged by inequalities that surfaced during this crisis. The manner in which some countries are acting, politicising the situation will not help. Display of nationalism by certain leaders will lead to new variants surfacing in several countries.

If we say 2.2 billion doses have been administered worldwide, less than 1% have been administered in low-income countries. We are certainly not safe until each one of us is safe. So that should tell you how far we are as a global community.

To defeat this pandemic, we need to exercise a package of actions that include vaccination and implementation of public health measures and health protocols. Without all that, it won't be possible to defeat the virus or prevent it from spreading. It is everyone’s responsibility.

We also need to admit that countries, governments and people are fatigued. They are fatigued with the inequities of vaccine distribution and with the inequities of health systems.

If you're asking me, ‘are we near the end’, I will tell you, let us define what is needed to end the pandemic, and then we would know how far we are from ending it. There are actions that are being undertaken. Heads of the International Monetary Fund, the World Bank Group, WHO are taking initiatives for financing efforts that will help end this pandemic. We know we need $50 billion investment in the effort to fight this pandemic.

But we also know that there are four factors that together can be a dangerous combination. The world is now dealing with the increased transmissibility of the new variants, increased social mixing, and relaxing of public health and social measures. All those factors really affect the progress of this outbreak and countries must continue to carefully calibrate how they apply and ease public health measures.

We must understand there are numerous challenges the world faces. When it comes to defeating Covid, we must understand the inconsistency in adherence in many countries to proven public health measures needed to control the virus and to prevent the occurrence of new variants of concern. We are also dealing with poor access to diagnostics, treatment, and oxygen. These issues collectively jeopardise our chances of recovering. Last but not the least, when we speak about vaccines, we're leaving millions of vulnerable people worldwide exposed due to lack of doses.

ET: How do you view the collective performance of the global community to deal with this pandemic? Has the world done a good job, or do we need to do more?

MER: So much progress has been made, and solidarity and leadership has been marked and can be seen across the board. All international organisations including the G7, G20, WHO and IMF are playing their part. Certain countries have remained focused on their own situation, and we hope they will expand their focus in the future. The pandemic is a common enemy and must be fought by each one of us regardless of national identity or origin. It must be fought in unison with a global approach. Tackling it at national levels will never be sufficient.

While it is normal to place your citizens on top of the priority list, continuing to place their citizens first will prolong this pandemic and even pave the way for future pandemics. If you ask me, yes, we need to do more.

ET: You mention nationalism and politicians playing a certain role to prevent vaccination or the sharing of vaccines with other countries. Former US president Donald Trump threatened to defund WHO. How much damage did he do to the world?

MER: I don't want to comment on countries that prevent the global effort. Now let us focus on the future, not on the past. Under the Biden administration, the US has emerged as a very strong partner of WHO and that is what is important to deal with the pandemic. So many partnerships have been achieved to end the pandemic. There is more collective guidance, coordination, and action, everywhere and from everyone.

ET: You spoke about a total package approach to pandemic response that includes investment in healthcare, social programmes and frontline workers. What if we’re diverting all our resources from that right now and a new pandemic emerges?

MER: The right investment in public health, health security, surveillance, data collection and sharing, and frontline workers will prepare for any outbreak. This pandemic will force elected leaders all over the world to reprioritise their spending. They will have to reconsider the health budget because we have been shown how public health can overshadow every aspect of the economy.

ET: What message would you like to give to the global leaders?

MER: It is solidarity and solidarity. Honestly, this pandemic is going to be with us for the foreseeable future. But at the same time, our collective approach will lead to its ultimate defeat. As my WHO colleagues say: If the virus is the problem, the people are the solution. We need to encourage, engage, and empower people and the communities.

And we must ensure that the health systems are functioning well. We need to prioritize those who are vulnerable. We need a global response to COVID-19 and not a regional response or a country specific response.

We need to dramatically scale up investment in global preparedness. We need to ensure that all countries can respond rapidly when the alarm bell starts to ring. The public officials need to demonstrate enlightened leadership by engaging in constructive cooperation. We must intensify international cooperation to develop and deliver the vaccines, diagnostics, and treatments that are necessary for achieving universal health coverage. And above all, there is an urgent need to reset the response to this crisis.