The making of yet another global divide

The current narrative regarding the Covid-19 vaccine in rich countries is predominantly nationalistic in actions and global in rhetoric. They are primarily counting on vaccines to build sufficient immunity in their own populations so that the virus is not able to infect susceptible people in their neighborhoods. Current and anticipated vaccine supply shortfall has fueled vaccine nationalism at the political and hoarding at the strategic level.

Rationing under uncertainty

The US, EU, England, Canada, other rich countries, and India are struggling to get their own populations vaccinated. China and Russia have already begun distributing their own state-backed vaccines for domestic use. Many of the vaccines, and the ongoing trials for potential alternatives, have benefited from huge levels of government investment from wealthy countries determined to secure their spot at the front of the line when the vaccines are ready. Billions of doses were reserved before any were approved for use, with many countries claiming enough to inoculate their population several times over.

There is a supply constraint. Both the EU and the US have recently been hit with unexpected news about manufacturing setbacks. The EU has restricted domestic manufacturers from exporting until they meet their contractual obligations. The need for rationing when supply is order of magnitude shorter than demand, notwithstanding vaccine hesitancy, has crowded out moral imperatives and political correctness. Attempts to monopolise the initial supply is driven primarily by the rich country electorates who believe sharing doses with poor countries will affect their own ability to get vaccinated.

The International Chamber of Commerce has argued that helping poor nations will benefit the wealthy economies in the long run but vaccinating a quarter of the population of every country, as COVAX proposes, would delay returning to normal in the US and other developed countries beyond this year. The emergence of new virus variants has made vaccination even more a race against the clock. People may need yearly boosters against emerging strains. Helping the world is important but fending for one's own comes first.

This incentivises building up a safety stock of vaccines in the pipeline as precaution against shorter than expected duration of immunity in the first round. According to the Duke Global Health Innovation Center, high- and upper-middle-income countries have collectively reserved nearly five billion vaccine doses, largely through bilateral deals between governments and vaccine makers (known as Advance Market Commitments). They paid upfront in exchange for priority access once the vaccine is approved.

Near term supply constraints and uncertainty over what will work explains the excess buying. The bilateral deals made by the US is more than enough to inoculate its entire population. The European Union, Britain, and Canada have potentially secured enough doses to cover their populations two, four, and six times over, respectively. Their governments are ensuring that if one or more of the vaccine trials fail, they will still have plenty to fall back on. Even with increased manufacturing capacity, it may take a while before there are enough doses to meet global demand. So far, vaccine manufacturers are prioritising which countries get them first on a first come, first served basis. When high-income countries take a large slice of that pie, there is less for everyone else.

The whole smaller than the parts

The vaccine globalists argue that this go-it-alone approach risks perpetuating harm to public health and the global economy. According to a Northeastern University study, proportional distribution of vaccines could avert nearly twice as many deaths as a vaccine distribution limited to only high-income countries. "Vaccine nationalism could cost the global economy up to US$9.2 trillion", says the Director General of the WHO. The post pandemic reconstruction of the globe cannot take place if some countries remain virus transmission vectors.   

Enduring unilateralism in the global efforts to equalise vaccine distribution is a major drag in the evolution of a "new normal" globally. Public-health experts warn the pandemic could become endemic for years in such a state of play, bringing with it even more death and economic collapse. Economic-epidemiological models estimate that up to 49% of the global economic costs of the pandemic in 2021 could be borne by the advanced economies even if they achieve universal vaccination in their own countries.

Vaccination is a global public good with a difference. A 'global public good' is typically non-excludable and non-rivalrous in consumption globally. Non-excludability means that the cost of keeping nonpayers from the benefit of the good is prohibitive. In case of vaccine, it is the difference between life and death. However, vaccines are not non-rivalrous. One more vaccine inoculated overseas means one less nationally. Nevertheless, ultimately, no matter where one resides in a "flat" world, one more person vaccinated will marginally mitigate the chance of infecting one more person nationally. Vaccines are both excludable and rivalrous in consumption, but vaccination is not.

Excludability is not immutable. Societal and political decisions also determine whether a good is non-excludable. The call to make vaccines affordable and available to everyone, everywhere is embedded in the idea of universal health coverage. As argued by the WHO Chief, "...it is essential to vaccinate some people in all countries, rather than all people in some countries." This is the fastest possible path to return to open trade, travel, and investment. Border guards and travel restrictions can never be enduring protections against pathogens.

The illusive quest for national herd Immunity

Herd immunity occurs when a large part of the population of an "area" is immune to a specific disease. While not every single individual may be immune, the "group" has protection because there are fewer high-risk people overall. Based on different reproductivity numbers, studies estimate the percent of the population to be vaccinated to have immunity either by recovering from an infection or through vaccination. Mass inoculations may have a more powerful effect because vaccines appear to elicit stronger and more durable protection than a prior infection.

The key question in herd immunity pertains to the denominator—percent of which population, national or global? This virus persists in bats and infects minks, cats, gorillas, and other animals. Wiping out the virus would require banishing it from every susceptible species. During an outbreak of a new infection across continents, sustaining elimination of any infectious disease nationwide is nearly impossible because of the threat of the virus re-entering the country from infected international traders and travelers.  This suggests that the denominator should be the global population.

The extent of vaccination required for a defined population depends on efficacy and the average duration of vaccine protection. For a vaccine with 100% efficacy that gives life-long protection, the level of herd immunity as a proportion of the population, given reproductivity rate between 2·5 to 3·5, is about 60–72%. For lower efficacies and higher reproductivity, the entire population would have to be immunised.

Calculations of the proportion of the population that will need to be immunised year by year with a vaccine of defined properties involves additionally the rate at which people are immunised. The percentage of the population that must be vaccinated in year one is much larger than the percentage that must be vaccinated once the system has stabilised after a few years with a high proportion already immunised. When efficacy is satisfactory but duration of protection is short, a large proportion of the total population would need to be vaccinated everywhere if there is to be any chance of getting herd immunity globally.

When this number cannot be attained fast enough, the second-best solution is to vaccinate the population at risk across the globe first while maintaining masking and social distancing until global herd immunity is achieved.  This would save both lives and livelihoods. Analysts suggest inoculating one third of such a global population this year combined with those who have already had the virus (including asymptomatic rates) can bring the virus count down to zero by the end of 2021.

Smelling the coffee

No, countries do not view herd immunity from a global perspective. Pandemic experience shows that national governments tend to focus on their own population instead of pursuing a more globally coordinated approach. In previous pandemics, such as an H1N1 outbreak in 2009, wealthier nations bought up the first batches leaving no supply for poor nations. Presently, the high-income countries buying up limited doses of vaccines are not looking at the cooperative solutions. They are also neglecting solutions that might enable quicker manufacture of more vaccine doses through cooperation, production offshoring, and technology transfer.