Three inoculation assumptions for this year

Vaccinating the world against COVID-19 is one of humankind's most critical non-wartime efforts ever. Many countries have developed ambitious, politically sensitive and carefully sequenced vaccination plans, but executing them successfully will be a challenge. To succeed, policymakers should include three realistic assumptions into their vaccination planning for 2021 and beyond.

First, delays are inevitable. More than two months after the world's first COVID-19 vaccine injection on Dec 8, 2020, hopes of a rapid rollout are fading in many countries. Production hold-ups have prompted the European Union to threaten legal action and impose export restrictions. Yet there are several reasons to expect further delays.

For starters, the manufacturing constraints are daunting. Pharmaceutical companies must scale up or re-purpose their factories to produce billions of doses of vaccines annually, even as vaccine supply chains are still being built despite being stretched. For example, the Pfizer/BioNTech and CureVac vaccines use lipid nanoparticles manufactured by the same supplier.

Moreover, capacity expansion through technology transfer－say, from AstraZeneca to Thailand's Siam Biosciences－involves legal and technical hurdles. If novel coronavirus variants reduce the current vaccines' effectiveness, vertically integrating the research-to-manufacturing process may enable a faster and more agile response.

Other legal and regulatory obstacles, too, could cause delays. Many countries have signed bilateral advance purchase agreements (APAs) with vaccine manufacturers, most of which are subject to the vaccine gaining regulatory approval and involve phased delivery and a refundable deposit. But APAs may be difficult to enforce, and international law must evolve rapidly for dispute resolution to be effective.

The United Kingdom's regulator was the first to approve the Pfizer/BioNTech vaccine because it benefited from rolling data submissions from clinical trials－an opportunity that should be accorded to other regulators, regardless of market size or wealth. A new approval process may be needed for vaccine variations in response to novel coronavirus variants, perhaps modeled after the abbreviated approval pathway for seasonal variations in influenza vaccines.

Furthermore, a population-wide COVID-19 vaccination program poses formidable logistical challenges and will require an all-of-society effort. Governments may need to provide around-the-clock or drive-through vaccination facilities, with proper cold-chain support, while a robust adverse-event reporting system must accompany adequate indemnity protections. Wastage, sabotage and weaponized vaccine hesitancy may occur. But countries can mitigate these potential problems by planning properly and learning from one another.

The second assumption is that COVID-19 vaccines will aggravate global inequality in 2021. All Organization for Economic Cooperation and Development countries except Turkey have procured more doses of vaccines than their population needs. Canada, for example, has enough for nearly six times its population. This "vaccine apartheid", as UNAIDS Executive Director Winnie Byanyima calls it, means that rich countries will most likely achieve widespread vaccination coverage and economic recovery sooner, leaving poor countries far behind.

COVID-19 vaccination programs could also worsen inequalities within countries, just as the pandemic itself has already disproportionately affected ethnic minorities, women, immigrants and the poor. The World Health Organization recommends vaccinating front-line health workers and the elderly first, but some advocate giving priority to ethnic minorities or the poor. Indigenous communities, migrants and refugees could be marginalized further.

Besides, wealthy elites could secure early vaccinations through the private sector, the black market, or "vaccine tourism". Big businesses may purchase vaccines for their employees or lobby for them to be given priority as "essential workers"; Amazon and Uber are already doing so. And "vaccination passports", if implemented, could be discriminatory.

Mitigating this inequality risk will require a multi-layered approach. The UN General Assembly and Security Council must govern global public goods more actively, while the administration of US President Joe Biden needs to provide thoughtful and inclusive global leadership. Governments must sustain the financial and political support that the COVID-19 Vaccine Global Access (COVAX) Facility needs to make vaccines available everywhere in the world. The UN Human Rights Council's Universal Periodic Review process for all member states could be expanded to include country-level COVID-19 outcomes and vaccine equity. And citizens, civil-society groups, and media must remain vigilant to prevent unequal vaccine distribution.

Lastly, policymakers should assume that procurement decisions could become a proxy for the US-China rivalry. Geopolitics is already influencing public procurement, notably in some Western countries' decision to bar the Chinese telecommunications company Huawei from their 5G networks. When it comes to vaccines, geopolitics could encroach on decision-making criteria like data, quality, availability, value and cost.

Vaccines could also feature in the US-China competition over global standards, which already encompasses artificial intelligence, smart cities and lithium batteries. COVID-19 vaccines may require new standards for research methods, primary endpoints in trials, clinical outcomes, and production.

Competition is good if it gives countries a choice of cheap, cutting-edge vaccines. But it could turn ugly if superpowers weaponize vaccine supplies, prices, or patents, or use them as bargaining chips in "vaccine diplomacy".

If that happens－if choosing vaccines means choosing sides－small and medium-sized powers can adopt a hedging strategy or "vaccine portfolio" approach, as Australia, Malaysia and Singapore are doing already. But this could still leave countries caught in a bind if they are forced to choose whether to weight their portfolios toward the US or China. To escape the bind, such countries could use international mechanisms like COVAX, or band together for pooled procurement using models like the Pan American Health Organization's Revolving Fund or UNICEF's initiative to strengthen vaccine procurement.

COVID-19 vaccines offer a welcome glimmer of hope after a bleak first year of the pandemic. But translating this hope into effective action will require policymakers to be resourceful in mitigating delays, inequality, and geopolitical risk.

Project Syndicate

The views don't necessarily reflect those of China Daily.

The author, a Malaysian physician specializing in health policies and global health, holds fellowships at Chatham House, the United Nations University.

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