Vaccine equity: The rollout that needs a booster shot

We are over a year into one of the most challenging rollouts of a global health technology product — the COVID-19 vaccines.

With almost half the world fully vaccinated against the pandemic, we can look at the glass as either half full or half empty — it depends on where you are and who you are. The lowest vaccination rates can be found in low-income or low-middle income countries, and among the most marginalized populations within nearly every country. So while COVID-19 vaccine development is a great example of scientific progress, its delivery reflects tragic inequity.

COVID-19 has shown us the fragility of our efforts to end diseases in places where poverty is entrenched. Programs that tackle tuberculosis (TB), for example, were sharply reduced, and the most recent World Health Organization (WHO) report showed an increase in TB deaths in 2020 for the first time in more than a decade. When the COVID-19 pandemic started, TB was the world’s most lethal infection, yet efforts to find and treat TB patients lost more than $500 million in funding. This cannot be a zero-sum game and TB should not be worse than when we left it back in February 2020. But TB remains vanquished only in the wealthier parts of the world. In 2020, the U.S. had over 7,100 cases of TB. But in the Democratic Republic of Congo, a much poorer country with roughly one-quarter of the U.S. population, researchers estimate there were 286,000 infections with almost one-third of these undiagnosed and untreated, providing a continuous source of transmission for this contagion.

Consider the PrEP pill for HIV prevention, a combination of two drugs that prevent HIV infections. It was approved by the U.S. Food and Drug Administration (FDA) in 2012, almost two full years after the first of several clinical trials proved its effectiveness. And it took until 2015 for the United Nations to fully embrace the medicine’s potential and adopt a goal for dissemination by 2020, one that we were failing to meet even before the COVID-19 pandemic.

We need to invest not just in research and development of new technologies, but also in the next “d” — delivery. We invest hundreds of millions in large trials but nothing similar on how to disseminate the results to achieve public health impact. This is not unique to any one disease: We have seen it in the lack of global vaccine equity in the COVID-19 response and we’ve seen it in TB and HIV.

We see it most starkly in income disparities. Ever since science began producing answers for the diseases plaguing humanity, wealthier countries have had faster access to new technologies.

Treatment for drug-resistant TB takes up to two years or more. That would be roughly the equivalent of how long the COVID-19 pandemic has lasted to date. A new treatment for highly drug-resistant TB, one that would shorten treatment time from up to two years to six months, has been approved and is being rolled out in more than 30 countries four years after a clinical trial proved its effectiveness. This can be hailed as a breakneck pace in the severely underresourced field of TB research.

In the U.S., the regimen is now available to treat patients in clinical practice, with results published and presented at major conferences. In Ukraine, the regimen was being used successfully to treat patients in a national research program — but now, with bombs regularly striking the country’s healthcare infrastructure, patients are facing horrors that are only compounded by the risk of treatment disruption in a period of mass displacement.

Science can make a difference. COVID-19 has shown us that we can compress timelines and new technologies can be developed, tested and distributed quickly and with urgency — for wealthier nations. The challenge is whether those technologies can reach impoverished regions and whether the same urgency can be found in tackling other pandemics like TB and AIDS when they disproportionately affect low- and middle-income countries and often marginalized populations.

But even — and especially — in the midst of war and continued health inequities, we cannot give up hope. Instead, we must look to the inspiring example of the late Dr. Paul Farmer, who devoted his life to the medical treatment of those in greatest need, including the millions who develop TB each year. His life and legacy remain the best example of what it means to lead with equity, empathy and human rights in addressing the ills of the individual and the society.

While the poorest are hit hardest, everyone who breathes is at risk. We are achieving breakthroughs in developing new medicines and vaccines, but we are failing to deliver them with equity and with impact. It is well past time to do better — to reduce the time from discovery to impact and to ensure that the impact is equitably distributed.

Mitchell Warren is executive director of AVAC, a global HIV organization, and also president of the TB Alliance Stakeholder Association.