SCIENCE sciencemag.orgPHOTO: WILLY KURNIAWAN/REUTERS VIA NEWSCOM
T
he World Health Organization (WHO)
this week announced advances in
its effort to ensure the entire world,
not just wealthy countries, will ben-
efit from successful COVID-19 vac-
cines. It reported that 156 countries
have joined its plan to buy and distribute
the vaccines. It also unveiled a mechanism
through which it plans to allocate vaccine
doses, aiming “to end the acute phase of the
pandemic by the end of 2021.”
“It is a huge success to have the equiva-
lent of 64% of the world’s population signed
up,” says Alexandra Phelan, a global health
specialist at Georgetown University. But
China, Russia, and the United States are ab-
sent from the list of partners in WHO’s plan,
known as the COVID-19 Vaccines Global
Access (COVAX) Facility. Their absence re-
flects “the deeply unequal power dynam-
ics in global health,” Phelan says. It poses
financial challenges for the plan and raises
fears that some high-income countries will
hoard early vaccine supplies for their own
populations. WHO is also grappling with
how to fairly share what, at first, is sure to
be an inadequate supply of vaccine.
“As of today, 64 higher income countries,
including 29 economies operating as Team
Europe, have submitted legally bindingcommitments to join the COVAX Facility,”
Seth Berkley, head of GAVI, the Vaccine
Alliance, said at a 21 September press con-
ference. Those countries, which include
Canada, Japan, and New Zealand, will pay
for their vaccine doses. Another 38 higher
income countries are expected to sign on.
“The fact that the U.S. is not part of this
conversation at all, as far as I can tell, is
incredibly distressing,” says Ashish Jha,
dean of Brown University’s School of Public
Health. Berkley said COVAX hopes to work
with every country.
Many questions remain about how much
COVAX will achieve. So far, donors have
committed just $700 million of the $2 bil-
lion COVAX hopes to raise this year to pay
for vaccine doses for its 92 participating
lower income countries. And it is not clear
how the deals many wealthy countries have
already made with vaccine manufacturers
will impact WHO’s plans. The deals, says
Alex Harris of the Wellcome Trust, could
mean countries “won’t need COVAX so
much themselves, and therefore might not
provide sufficient financing for the non–
self-financing countries.”
Such bilateral deals pose a threat to the
plan, WHO’s Mariângela Simão concedes, but
negotiations on many of them were under-
way when COVAX was being set up.
WHO’s “fair allocation mechanism” pro-poses distributing vaccine purchased by
COVAX in two phases. In the first phase, all
participating countries would receive vac-
cine doses proportional to their population:
initially, enough vaccine to immunize 3% of
their people, with the first doses intended
for frontline health care and social care
workers. Then, doses would be delivered to
all countries until 20% of their population
was covered. WHO expects those doses to go
to people at highest risk from COVID-19: el-
derly people and those with comorbidities.
The plan’s second phase would favor
specific countries, which would receive
vaccine based on urgency of need. WHO
suggests two criteria for deciding priority:
how fast the virus is spreading and whether
other pathogens, such as influenza or mea-
sles, are spreading at the same time; and
how vulnerable a country’s health system
is, based on metrics such as occupancy of
beds in hospitals.
Ezekiel Emanuel, a bioethicist at the Uni-
versity of Pennsylvania, criticizes WHO’s ap-
proach to the first phase, saying countries
with the highest need should top the list from
the start. He compares the situation to a doc-
tor facing an overflowing emergency room.
“The doctor doesn’t go out into the waiting
room and say: ‘I’m giving 3 minutes to every-
body sitting in the waiting room.’ The doctor
says: ‘All right, who’s got the most serious
illness? ... I’m going to attend to you first.’”
At the moment, he says, sending vaccine to
South Korea, New Zealand, or many African
countries with low case rates would not do
much to reduce deaths from COVID-19.
But WHO’s Bruce Aylward notes that new
outbreaks can suddenly pop up: “Remem-
ber, we are dealing with a ubiquitous threat
(the virus) and ubiquitous vulnerability
(highly susceptible high-risk populations)!”
Allocating some vaccine to every par-
ticipating country may have been neces-
sary politically, Jha says. “I think [WHO is]
probably balancing between trying to get
enough people protected and trying to cre-
ate enough of a sense of buy-in that people
are going to be willing to chip in.” Emanuel
says he understands WHO’s position, “but
we shouldn’t confuse politics with ethics.”
For now, though, politics is crucial. “The
real question is: When the first vaccine
comes online, who will get those doses?”
Harris says. “COVAX now needs to secure
deals for their member countries that will
work alongside other countries’ existing bi-
lateral deals so that all countries get some
early vaccine doses, rather than some coun-
tries getting all.” jDespite obstacles, WHO unveils
plan to distribute vaccine
Nations with nearly two-thirds of world’s population have
joined, but not the United States, Russia, or China
Health care workers like these, in Jakarta, Indonesia,
would be first to get a vaccine under a World Health
Organization arrangement.By Kai KupferschmidtCOVID 1925 SEPTEMBER 2020 • VOL 369 ISSUE 6511 1553