Africa Without Vaccines: Inequity Sets the World on Course for a Great Divide

Covid-19

Africa Without Vaccines: Inequity Sets the World on Course for a Great Divide

Paper
Posted on: 4th November 2021
By Multiple Authors
Liya Temeselew Mamo
Associate
Hayley Andersen
Associate
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    Introduction

    Introduction

    The scientific development of multiple vaccines to defeat Covid-19 has been an enormous success. Seven vaccines have so far been approved for emergency use by the World Health Organisation (WHO) given their ability to significantly reduce the risk of severe illness, hospitalisation and death from the virus. Vaccines are saving lives and allowing for safe re-engagement in economic and social activities. They represent an end to the pandemic phase of Covid-19 and a return to normalcy.

    However, the equitable allocation of these life-saving vaccines has been an enormous failure. While 63 per cent of the population of high-income countries are fully vaccinated, just 1.4 per cent of low-income countries are. Though lower-income countries face greater challenges related to their capacity to implement mass-vaccination campaigns, this disparity is mostly driven by unequal access to the limited global supply of vaccines.

    The pandemic has already had a devastating impact in Africa. Covid-19 has taken tens of thousands of lives, if not more, and disrupted essential health services, reversing years of progress in fighting diseases like malaria and HIV. The economic downturn driven by lockdowns and restrictions on travel in 2020 has given way to a sluggish recovery in 2021. Africa needs vaccines.

    But the current gap in global vaccine access does not look likely to close in the coming year. In fact, Africa is on track to be left behind.

    Based on the current trajectory, the world is not expected to achieve a threshold high enough for global population immunity – which some experts now say is as much as 90 per cent given the transmissibility of the Delta variant. This means Covid-19 may become an endemic disease globally.

    However, high- and middle-income countries with ample access to vaccine supply, including booster doses for their populations, will be able to protect large swathes of people from illness. Further bolstered by substantial fiscal support, these countries are on course to safely re-engage in economic and social activity in 2022, returning to a pre-pandemic normalcy in which Covid-19 might be managed like the seasonal flu.

    Equally desperate to get back on track, African countries will also be opening up to economic and social activity. However, without the same access to vaccines, Covid-19 will continue to circulate much more widely. To protect health systems from becoming overwhelmed, outbreaks will need to be contained through re-implementation of lockdowns and stricter public-health measures. Countries with low vaccination coverage that continue to experience waves of transmission may be restricted from global travel lists. These public-health and travel policies will continue to weigh on Africa’s recovery, impacting the short- and long-term economic and social outlooks for the continent.

    This is the “Great Divide” emerging on the path to recovery between high-income nations and low-income nations, particularly those in Africa. The International Monetary Fund (IMF)’s latest economic outlook predicts that advanced economies will be the only income group to return to pre-pandemic trends by 2022.

    Without sufficient vaccination coverage in Africa, millions more will continue to fall ill from the virus, impacting health systems, mortality rates and productivity. Continuity of routine immunisation services are at great risk, with growing concerns around the widespread resurgence of diseases like measles and polio. Economic forecasts for the continent are troubling. The Economist Intelligence Unit predicts that countries unable to achieve at least 60 per cent vaccination coverage by mid-2022 will suffer $2.3 trillion in GDP losses by 2025, with sub-Saharan Africa experiencing the highest losses in terms of share of GDP.

    It’s clear that global vaccine inequity will severely undermine progress in wellbeing improvements and prosperity in Africa. At best, years of investment in economic and human-capital development will be forfeited. At worst, slow growth will become entrenched, resulting in a lost decade – or more.

    The consequences of such a divergent recovery will not only impact Africa, but the global community.

    With Covid-19 continuing to spread among unvaccinated populations, there will be a constant risk of potentially more potent variants developing. The emergence of such new variants poses a threat to vaccination efforts everywhere. And sustained health and economic insecurity in Africa could heighten domestic unrest, increase opportunities for extremism and possibly even drive new waves of migration.

    Furthermore, a Great Divide is likely to deepen gaps between wealthy and poor countries, increasing global instability, generating economic uncertainty and sowing geopolitical tensions. With this outcome, the world will be even more ill-equipped to address other pressing existential issues, such as the climate crisis or another pandemic.

    There is time to change course and avoid this Great Divide, but action must be taken immediately. Both high-income countries and African governments have roles to play.

    Key Recommendations

    • Changing course starts with equitable vaccine access. Countries must urgently fulfil their commitment to sharing excess doses and step aside in the supply queue so that COVAX can be prioritised.
    • Countries need to remove export restrictions and other trade barriers on Covid-19 vaccines and inputs involved in their production.
    • Travel restrictions that are not founded on scientific evidence and that perpetuate discrimination need to be lifted.
    • The G7 and the G20 should endorse a comprehensive financial-assistance package for Africa and allow governments on the continent to decide how this money is best deployed.
    • Governments of high-income countries need to scale up support for vaccine manufacturing in Africa and strengthen vertical and horizontal linkages. In addition to setting up new plants, policymakers need to explore how to support existing African facilities to participate in the production of Covid-19 vaccines by creating incentives for the sector and seeking to integrate the capabilities of different countries into the global production chain.
    • Countries must build up institutional strength for vaccine rollout and crisis response, including agile government systems, structures and skills.

    All of this requires a strategic response at the global level. Countries must approach this crisis as a transnational issue in need of globally orchestrated solutions.

    2021: The Impact of Covid-19 in Africa To Date

    Impact of Covid-19 in Africa To Date

    The first 18 months of the pandemic have had an acute impact on Africa’s economic and human-capital development. The virus has overwhelmed health systems, strained fiscal coffers and diverted resources away from essential development projects and routine health services.

    Health Impact

    Both Covid-19 and policy measures enforced to combat the virus have had long-lasting consequences on health services in Africa. The continent has so far recorded more than 8.3 million Covid-19 cases and more than 200,000 deaths, although these numbers are likely to be a substantial underestimate of the true figures due to low testing rates.1 https://africacdc.netlify.app/ While the number of people who have died from Covid-19 is high globally, the impact on African and other low-income countries is more intense because the virus has weakened already frail health systems, hindered them from providing essential health services and hampered their abilities to respond to a future crisis.

    The direct impact of Covid-19 on health care have been evident from the start. Oxygen and bed shortages have combined with an overall lack of surge capacity in African hospitals. Despite mortality rates being lower in Africa compared to the rest of the world, studies have shown that Africans are more likely to die after being admitted to hospitals on the continent. In Africa, nearly half of Covid-19 patients died if they required intensive care while the global average is one-third.2 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)00576-6/fulltext#figures Ethiopia, Nigeria, Ghana, Benin, Togo, Côte d’Ivoire and Somalia are among the African countries that continue to face dangerous oxygen shortages.3 https://healthpolicy-watch.news/several-african-countries-face-dire-oxygen-shortages-highlighting-need-for-investment-in-oxygen-infrastructure/

    To add to such resource shortages, health-care staff have been overwhelmed with the unmanageable crisis and forced to take dire measures. In August this year, about 19,000 doctors across Nigeria went on strike for the fourth time since the start of the pandemic. One of the chief grievances was that some hadn’t been paid in months. Patients, some with Covid-19 symptoms, have been turned away at short-staffed hospitals. The WHO reports that although they may have taken on new staff, 66 per cent of countries globally continue to report health workforce-related reasons as the most common causes of service disruptions.4 https://www.who.int/news/item/23-04-2021-covid-19-continues-to-disrupt-essential-health-services-in-90-of-countries Supply chains are also still disrupted in nearly one-third of countries, affecting the availability of essential medicines, diagnostics, and the PPE needed to safely and effectively provide care.

    Covid-19 mitigation efforts have also had negative effects on essential health programmes. According to the WHO, malaria services have experienced moderate disruption, but this could still lead to thousands of deaths. Prevention, testing and support for people living with HIV have been the most impacted. Nearly two-thirds of low-income countries in Africa and Asia are experiencing disruptions in HIV-service delivery, with 10 per cent experiencing high-level disruption.5 https://www.theglobalfight.org/covid-aids-tb-malaria/ Earlier this year, a Partnership for Evidence-Based Response to Covid-19 (PERC) study on 19 African countries showed that people were missing out on preventative care visits and services for life-threatening conditions and diseases.6 https://preventepidemics.org/wp-content/uploads/2021/06/PERC-access-to-health-services-6-2021.pptx While missed visits for routine checks-up were the most common, people have also been missing out on visits for symptoms aligning with Covid-19 as well as other serious communicable diseases, such as malaria and tuberculosis. According to the study, low-income groups were at the greatest risk of experiencing lost care, with a significant proportion having difficulty accessing medicine.

    The longer African countries remain without access to vaccines, the worse these direct and indirect impacts to health will become, making it more challenging to strengthen health systems to deal with the multitude of health-sector challenges beyond Covid-19.

    Economic Impact

    Fighting the virus has called for unprecedented policy measures. Many African governments imposed lockdowns early on in the crisis, which served to limit the spread of infection and protect populations and health systems. Lockdowns – typically involving the closing of schools and restaurants, curfews and the prohibition of large public gatherings – have become a key tool for managing the crisis, with governments loosening restrictions when cases fall and reintroducing these measures when new waves become apparent. Though useful in controlling transmission, they have had a damaging toll on local economies, which often don’t have the resilience and fiscal support to bounce back quickly.

    For example, to protect lives, South Africa imposed some of the strictest lockdown measures worldwide in April 2020. Despite passing a fiscal relief package to offset those measures, economic output declined by 7 per cent in 2020. By the end of the year, 1.5 million people had lost their jobs and wages fell by between 10 and 15 per cent. Between these losses, the average South African was 18 per cent worse off at the start of 2021 compared to the year before.7 https://documents1.worldbank.org/curated/en/161431626102808095/pdf/Building-Back-Better-from-COVID-19-with-a-Special-Focus-on-Jobs.pdf While the crisis has exposed long-standing structural problems in South Africa’s economy, lockdowns have exacerbated these weaknesses.

    South Africa has since been cycling through various levels of lockdown in response to new outbreaks. Despite positive growth in the first half of 2021, output is still below pre-pandemic levels and any gains were quickly overshadowed by the reintroduction of strict new policies to curb the country’s third wave in June.8 https://www.aljazeera.com/economy/2021/9/7/bbsouth-africa-economic-recovery-quickens-in-q2-but-risks-remain With cases coming back down, restrictions have been loosened, but a predicted fourth wave of infections this December may once again require new lockdowns, especially without widespread vaccination coverage, threatening to further dampen the country’s economic outlook.

    In addition to the impact of domestic lockdowns, international travel restrictions have decimated the tourism industry in Africa, which had been a rapid-growth sector across the continent. For example, the East African Community (EAC) is struggling to rally the sector, which, with 92 per cent of revenue lost, has been the hardest hit by the pandemic.9 https://africa.cgtn.com/2021/10/11/eac-states-lose-92-tourism-earnings-due-to-covid-19-pandemic/ Tourist arrivals to six member states of EAC have fallen from 6.98 million pre-pandemic to 2.25 million today. Before the virus struck, tourism had contributed $1.6 billion to EAC member Kenya’s economy, supporting more than 8 per cent of employment domestically.10 https://www.one.org/africa/blog/kenya-tourism-sector-covid/ Travel restrictions, along with the closure of the hospitality industry in combination with curfews, have left thousands of the sector’s workers without livelihoods and cost the country $1 billion in lost revenue.

    Foreign direct investment (FDI) has also been adversely affected by the pandemic. Investment flows to the continent fell by 16 per cent in 2020 as a result of the health and economic challenges, together with low energy prices.11 https://unctad.org/webflyer/world-investment-report-2021 The United Nations Conference on Trade and Development (UNCTAD) projects that FDI will grow by only 5 per cent in 2021 amid a muted economic recovery and slow vaccine rollouts. This projection is lower than both the FDI growth predictions globally and for developing countries, and will only make it more difficult for governments to pay down debt.

    With pre-existing weaknesses in health systems and limited fiscal bandwidth, the continent has already paid a high toll for the pandemic. In addition to saving lives, access to vaccines would diminish disruptions to health services and stimulate an economic rebound.

    Obstacles to Accessing Vaccines: Setting Course for a Great Divide

    Obstacles to Accessing Vaccines

    In late September, the WHO announced that just 15 countries in Africa – fewer than one-third – had met the multilateral organisation’s goal of fully vaccinating at least 10 per cent of their populations by the end of that month. Among the countries that met this goal, eight were nations of fewer than 3 million people – including the Seychelles, Mauritius and Eswatini – or they had the financial flexibility to procure vaccines outside the COVAX Advance Market Commitment (AMC) facility – such as South Africa, Morocco and Tunisia.

    Although it had been anticipated, the official announcement proved a worrying indication of how far behind the continent is in protecting its population against Covid-19 as a result of escalating global vaccine inequity. This limited progress complicates the likelihood that Africa will achieve the WHO’s global targets of 40 per cent coverage per country by the end of 2021 or 70 per cent by mid-2022.

    Widening Supply Gaps

    At the close of September 2021, the continent had received just 200 million vaccines for a population of 1.3 billion. Approximately 40 per cent, or 75 million, were sourced from COVAX, half of which came from recent dose-sharing by the UK, Europe and the US. Despite this, COVAX supplies have fallen dangerously short of their targets.

    COVAX had committed to supplying participating countries in Africa with 75 million doses by late May – four months prior. It fell behind on its distribution schedule primarily as a result of export restrictions imposed by India (COVAX was set to receive as much as 45 per cent of its supply from the Serum Institute of India), but also because of production issues at manufacturing facilities, the invoking of the Defense Production Act by the United States, delays in regulatory approvals and stockpiling by wealthier nations. (Many high-income countries were able to make advance purchases of vaccines still in development in 2020 thanks to access to financing and “home-court” production advantages.) Because of these ongoing challenges, COVAX recently revised its end-of-year supply forecast down by around 25 per cent.

    To meet its newly revised year-end target for Africa, COVAX must provide the continent with an additional 400 million doses, delivering in just three months more than five times the supply it has provided in the past seven.12 https://news.un.org/en/story/2021/09/1100102

    Yet even if COVAX meets this ambitious goal, that supply will only be enough to vaccinate 17.5 per cent of the total African population.13 This paper calculates supply based on a two-dose vaccination regimen. A further 470 million doses are needed to achieve the WHO’s 40 per cent coverage target by the end of 2021. These vaccines are expected to come from the African Union (AU)’s African Vaccine Acquisition Task Team (AVATT), bilateral purchases and donations from countries with surplus doses.

    Challenging Production Forecasts

    Vaccine-data specialist Airfinity estimates that more than 12 billion doses could be produced globally by the end of 2021.14 https://www.airfinity.com/reports/media-briefing-07-September-2021-download The world needs approximately 11 billion doses to achieve 70 per cent population coverage, the amount generally accepted as a minimum threshold to curb transmission and protect those who cannot be vaccinated.

    Based on these figures, meeting the 70 per cent target globally this year would seem within reach.

    However, this projection is dependent on several factors. It assumes that there will not be any problems at manufacturing facilities leading to delays in production; that vaccines still under regulatory review, including Novavax, Covaxin and CanSino, will receive emergency-use authorisation soon; that 70 per cent of the population in each country is currently eligible to be vaccinated given age demographics; and that export restrictions in key markets such as India will be lifted imminently.

    Moreover, it assumes that even if all 12 billion doses are produced that they would be spread equitably around the world, achieving the target of 70 per cent coverage per country. Yet a significant number of doses slated for production are already claimed. For example, 61 per cent of Pfizer’s total projected supply of 7 billion doses for 2021 and 2022 have been purchased.15 https://launchandscalefaster.org/covid-19/vaccinemanufacturing High- and upper-middle-income countries account for 85 per cent of these allocations, while low- and lower-middle-income countries’ bilateral purchases and COVAX make up the remainder. In another example, one-third of Moderna’s 3.8 billion total doses projected for 2021 and 2022 have already been bought by high- and upper-middle-income countries.

    The Airfinity model anticipates that even if all G7 countries and the EU administer booster shots to everyone who has already received their first two shots, they will still have 1.2 billion surplus doses to donate before the end of the year. However, this projection underestimates the high likelihood of high-income countries stockpiling supply above their population or uptake levels. Ongoing concerns regarding long-term vaccine efficacy against variants such as Delta, and the anticipated approval of vaccines for children aged between 5 and 11, may serve as justifications for nations to continue safeguarding rather than donating their excess supply.

    Finally, of the 12 billion doses projected to be produced this year, around half are the Chinese-made Sinovac, Sinopharm and CanSino. Although Sinovac and Sinopharm have been approved for emergency use by the WHO, these vaccines have lower efficacy against the Delta variant compared to others in the COVAX arsenal.16 https://assets.researchsquare.com/files/rs-828021/v1_covered.pdf?c=1629920029 As a result, several countries who used the vaccines in their initial immunisation programmes, including Brazil, Turkey and the UAE, have already been administering booster jabs, while Malaysia has phased out the use of Sinovac entirely and Singapore is omitting those who have received Sinovac from its official vaccination tally. Under the UK’s new travel rules, only those who have received full courses of AstraZeneca, Pfizer, Moderna or Johnson & Johnson’s Janssen are accepted as vaccinated.17 https://www.gov.uk/guidance/countries-with-approved-covid-19-vaccination-programmes-and-proof-of-vaccination

    These policy decisions reflect the emergence of a vaccine hierarchy, which could end up influencing other nations, with countries choosing to accept or reject vaccines based on preference despite global supply shortages.

    “Vaccine Apartheid”

    The magnitude of the supply challenge is compounded by the ongoing unequal distribution of vaccines globally. The African continent has the lowest Covid-19 vaccination coverage rates in the world. With 185.3 million vaccines administered as of October 2021 (averaging a 70 per cent absorption rate), less than 9 per cent of the population has received at least one dose while just over 5.5 per cent are fully vaccinated.18 https://africacdc.org/covid-19-vaccination/ In contrast, 55 per cent of Europe is fully vaccinated and the region with the second lowest coverage has eight times as many fully vaccinated people as Africa.19 https://ourworldindata.org/covid-vaccinations

    Figure 1 – Vaccination coverage rates by region

    Bar chart showing the share of populations fully and partially vaccinated by region

    Source: Our World in Data

    High and upper-middle-income countries have together administered nearly 75 per cent of the more than 7 billion doses administered worldwide, whereas low-income countries make up just 0.5 per cent of this total – a percentage that has remained stagnant for months.20 https://ourworldindata.org/covid-vaccinations Despite accounting for nearly one-fifth of the global population, Africa has administered just 2.7 per cent of total doses.

    Of the approximately 1 billion doses pledged by the G7 in June to low- and middle-income countries over the next year, only around 150 million had been fulfilled by early October.21 https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---8-september-2021 Africa had received about 40 million of those donations. The Airfinity model suggests that G7 countries could in fact have redistributed 500 million doses to date.

    The existing volume and urgency of donations and dose-sharing pledges are not nearly enough to meet global demand. Apart from publicly committing to vaccine-sharing schemes, there is no clear strategic plan among G7 and other high-income countries to ensure sufficient doses are reaching nations in need. This disparity in worldwide vaccine distribution has generated accusations of “vaccine apartheid” among some African leaders and calls for wealthier nations to donate their excess doses while allowing lower-income nations to jump ahead in the supply queue.22 https://apnews.com/article/climate-change-united-nations-general-assembly-united-nations-africa-science--11425d2449903ba448a96b2b0f106a70?utm_medium=AP&utm_source=Twitter&utm_campaign=SocialFlow

    Manufacturing Timeline

    In light of lacklustre efforts to share vaccines, growing inequity and disillusionment with global aid schemes, African leaders are increasingly looking to local or regional manufacturing as the answer to Covid-19 vaccine access.

    Some leaders are mounting pressure on governments and pharmaceutical companies to support the immediate and temporary waiver of intellectual-property rights on Covid-19 vaccines and technology transfer to additional production sites around the world. Such action would boost supply and facilitate more equitable distribution through regional hubs. Scaling up manufacturing is also key to producing the next generation of vaccines that will be needed to combat new, more dangerous variants of the virus.

    Given that fewer than 1 per cent of the world’s vaccines are currently manufactured in Africa, expanding production capabilities is a requisite for the continent’s health security. But this is no small undertaking. The temporary waiver of vaccine patents, immediate technology transfer and retrofitting of existing facilities are just the first steps in ensuring sustained vaccine supply and in strengthening Africa’s long-term health-system resilience. There will need to be substantial technical and financial efforts too.

    Over the past months, there has been significant continental and global mobilisation to close this gap and support vaccine manufacturing in Africa, not only for Covid-19 but other diseases such as tuberculosis and malaria. These efforts have been driven by the AU and Africa Centres for Disease Control and Prevention (Africa CDC), notably through the establishment of the Africa CDC-led Partnerships for African Vaccine Manufacturing (PAVM).

    PAVM was launched following a vaccine-manufacturing summit in April 2021, which had the goal of building an enabling environment for a sustainable vaccine-manufacturing industry across Africa. The PAVM mandate includes fostering the emergence of a local vaccine-manufacturing industry that aims to locally and sustainably produce 60 per cent of routine and outbreak immunisation vaccines by 2040, as well as to steward a continent-wide strategy that efficiently maintains both the scale and cost-competitiveness of local vaccine manufacturing while promoting equity and security for all countries.

    To date, donor commitments or announcements to support local vaccine-manufacturing initiatives in Africa are valued at approximately $1.6 billion. The commitments are concentrated in South Africa and Senegal, but extend to Algeria, Egypt, Ghana, Morocco, Nigeria and Rwanda.

    The South African manufacturing initiatives aimed specifically at expanding Covid-19 vaccine production include the upgrading of existing facilities and building of new ones, procuring new production equipment, and employing additional skilled professionals. South Africa’s Aspen Pharmacare currently conducts the final fill-and-finish stage of Johnson & Johnson’s vaccine, but it is close to finalising a deal with the pharmaceutical developer to manufacture the vaccine under license as it looks to produce 1.3 billion doses per year by 2024.

    In Senegal, funding from Europe will go towards the construction of a new Institut Pasteur de Dakar vaccine plant that is expected to produce 200 million Covid-19 vaccines per month by the end of 2022. Moderna also recently announced plans to invest up to $500 million to build a manufacturing plant in Africa, where it could produce up to 500 million doses of its Covid-19 mRNA vaccine per year. But the company has yet to decide the location of the plant or share further details.

    These are some of the vaccine-manufacturing efforts already underway to strengthen Africa’s long-term health security. Scaling up regional manufacturing to the level required to close the existing Covid-19 supply gap will take time, however. Moreover, some countries and pharmaceutical companies continue to push back against the temporary intellectual-property waiver, delaying critical vaccine-expansion efforts.

    Although investing in local manufacturing is essential for the continent’s access to vaccines in the long term, it will not resolve the more urgent Covid-19 supply gap, since it is expected to take between 9 and 12 months for vaccines to be produced in Africa.

    The pandemic has dealt a strong blow to Africa’s development outlook. Lack of access to sufficient vaccine supply will only prolong these outcomes. Though global vaccine production is anticipated to ramp up in the coming months, there are still significant barriers to achieving the WHO’s target of vaccinating 70 per cent of the population in every country by mid-2022, which will be crucial to preventing new variants and ending the pandemic for all. Obstacles to meeting supply expectations include regulatory approvals and challenges relating to production facilities. Moreover, general stockpiling of vaccines by high-income nations is likely to continue, especially as eligibility policies for their populations extend to booster shots and children aged between 5 and 11.

    Significant gaps in vaccination coverage rates look set to persist throughout 2022 and beyond.

    A Great Divide: Africa Without Vaccines

    A Great Divide: Africa Without Vaccines

    The current trajectory points toward a Great Divide between those with access to vaccines and those without. This divide will manifest in divergent recoveries from the dual health and economic crises. High-income countries with surplus supplies of vaccines and buttressed by unprecedented fiscal expansionary policies are projected to recover relatively quickly. Meanwhile, unvaccinated Africa is facing a protracted pandemic and economic slowdown.

    Without adequate access to vaccines, millions more cases of Covid-19 are likely to continue to strain health systems on the continent. Tens of thousands of preventable deaths will be caused directly and indirectly by the ongoing presence of the virus. Economic activity is expected to flounder, restrained by slowing productivity, disconnection from international travel hubs and drained government resources. Years of progress in economic and human-capital development are likely to be lost.

    The Great Divide is not inevitable, and the way it could manifest is not precisely known. There is great nuance in how Covid-19 and vaccine inequity is affecting the economic and health sectors of different African countries, the way in which each is managing the pandemic and their varying capacities to recover from its impact in the coming years. Thus, the path to a Great Divide includes a number of potential scenarios: in one, it could mean several years of lost progress due to a vicious cycle of increasing poverty and food insecurity, rising communicable diseases and intensifying instability. Though the exact nature of a Great Divide is hard to pin down, what is certain is that the current outlook for vaccine access in combination with a muted economic rebound both point to a long, difficult road ahead for the continent.

    Undoing Health Progress

    The impact of Covid-19 on health-care systems manifests directly and indirectly so the true magnitude may not be obvious in the immediate future. In 2022 and beyond, however, we are likely to see a resurgence of diseases the world has worked hard to eradicate. Just 12 months of Covid-19 response has already eliminated 12 years of progress in the global fight against tuberculosis, according to a study by the StopTB Partnership, with critical outreach and services set aside, resulting in a 20 per cent drop in diagnosis and treatment worldwide.23 http://www.stoptb.org/

    But the biggest long-running risk posed by Covid-19 is to routine immunisation drives. According to the WHO, more than one-third of countries are still reporting disruptions to immunisation services.24 https://www.who.int/news/item/23-04-2021-covid-19-continues-to-disrupt-essential-health-services-in-90-of-countries#:~:text=More%20than%20one%20third%20of,30%25%20respectively%20compared%20to%202020. For children, these disruptions have serious consequences. In 2020, 23 million children missed out on basic childhood inoculations as part of routine health-care programmes; this has been the highest number in more than a decade.25 https://www.unicef.org/press-releases/covid-19-pandemic-leads-major-backsliding-childhood-vaccinations-new-who-unicef-data The compound effects of this missed preventative care could lead to severe health outcomes, with specific concerns about both measles, one of the most contagious viruses known and a major cause of child mortality in low-income countries, and polio, the only virus currently on course for eradication but which clings on in some parts of the world.26 https://www.nature.com/articles/d41586-021-01022-x

    In March 2020, the Global Polio Eradication Initiative (GPEI) in Geneva called for a pause in mass-vaccination campaigns, repurposing some of its surveillance and laboratory infrastructure to the Covid-19 fight. By the time services had resumed, the poliovirus had taken off. A vaccine-derived poliovirus strain in Africa has been rising exponentially since the start of the pandemic, with cases climbing from 328 in 2019 to more than 500 in 2020, affecting six new countries to bring the total to 18 on the continent.

    In addition, widespread belief that health-care workers can give you Covid-19 has led to them being stigmatised in their communities and further prevented people from seeking care.27 https://africacdc.org/download/using-data-to-find-a-balance-disruption-to-essential-health-services-in-africa-during-covid-19/ The potential adverse effects of these perceptions and of seeking preventive health care are likely to cause significant health crises beyond 2022 – and long after Covid-19.

    In the case of many diseases, it is too soon to assess the impact on illness and deaths. All researchers can do for now is note the missed preventative care and immunisations to try and predict the consequences. Existing data show that the fallout from Covid-19 risks undoing decades of progress in dealing with preventable diseases.

    Escalating Poverty and Food Insecurity

    According to the Goalkeepers Report published by the Bill & Melinda Gates Foundation this year, almost 27 million additional African citizens have fallen into extreme poverty, representing the undoing of four years of progress in poverty eradication.28 https://www.gatesfoundation.org/goalkeepers/report/2021-report/?utm_campaign=covid19&utm_medium=email&utm_source=email

    In Nigeria, a Bureau of Statistics survey revealed that one-fifth of the country’s workforce lost their jobs in the last quarter of 2020 as a result of ongoing supply and demand shocks, higher costs and a fall in consumer confidence.29 https://www.bloomberg.com/news/articles/2021-09-21/a-fifth-of-nigeria-s-workforce-lost-their-jobs-because-of-covid The World Bank estimates that the pandemic-related economic crisis may push as many as 11 million Nigerians into poverty by 2022, signalling a poverty rate of more than 50 per cent for the country of 200 million people.30 https://blogs.worldbank.org/opendata/using-data-combat-ongoing-crisis-and-next-nigeria

    Women will continue to be disproportionately affected by the economic downturn. In sub-Saharan Africa, an average of 60 per cent of non-agricultural work is informal.31 https://blogs.worldbank.org/africacan/social-insurance-informal-sector-can-be-lifeline-millions-africa Women account for 75 per cent of this informal employment for which wages are below average and social protections near non-existent.32 https://blogs.worldbank.org/africacan/inclusive-response-covid-19-africas-informal-workers In the first month of the pandemic, it is reported that informal-worker earnings fell by 81 per cent.33 https://www.un.org/development/desa/dpad/publication/un-desa-policy-brief-93-social-policy-and-social-protection-measures-to-build-africa-better-post-covid-19/ A long-lasting and slow economic recovery will expose many more women to extreme poverty and food insecurity, and exacerbate social exclusion in 2022 and beyond.

    Food insecurity is a growing concern across the continent as prices rise as a result of global shortages, an increase in oil prices thanks to growing demand from the reopening of advanced economies and currency depreciations that are raising the costs of imports. Compared to last year, global food prices in August were up 33 per cent, with emerging markets the worst affected.34 https://www.one.org/africa/blog/covids-aftershocks-high-food-prices/?akid=128470.10442894.wrDRRs&rd=1&t=42&utm_campaign=covid19&utm_medium=email&utm_source=email African governments and the global community should prepare for a surge in humanitarian crises across the continent as a result of a depressed economic recovery.

    Weak Growth

    The IMF’s latest World Economic Outlook (WEO) projection, published in October, expects the global economy to rebound to 5.9 per cent growth in 2021, moderating to 4.9 per cent in 2022.35 https://blogs.imf.org/2021/10/12/a-hobbled-recovery-along-entrenched-fault-lines/ Compared to April’s edition of the WEO, the latest 2022 projection is 0.5 per cent higher. The change is driven by the IMF’s estimation of a relatively improved position for advanced economies (despite near-term supply chain disruptions) in large part due to the accelerated opening of economic activity, achieved as a result of widespread vaccination rates, in combination with significant ongoing fiscal stimuli. However, the institution has simultaneously revised down the economic prospects for low-income economies. Limited access to vaccines and lack of fiscal support for expansionary policies is plaguing their recovery.

    Africa will bear a disproportionate burden of the fallout.

    In our paper “Preventing a Lost Decade in Africa”, we explored potential post-pandemic scenarios based on the drivers of economic growth. In the worst-case scenario, the forecast warned of the potential for African economies to fall into a cycle of declining productivity, leading to GDP growth averages of just 1 per cent or below for the next ten years, as experienced in the “lost decade” of the 1980s. Even the middle-of-the-road scenario forecasts long-term GDP growth at around 2.5 per cent, the same level as in the five years leading up to 2019, with the real risk of growth falling behind population growth of 2.7 per cent, leading to a rise in extreme poverty.

    Modelling by the Economist Intelligence Unit predicts that developing economies will bear the brunt of output shortfalls because of global vaccine inequity. Countries that are unable to achieve at least 60 per cent vaccination coverage by mid-2022 will suffer $2.3 trillion in GDP losses by 2025. With around $230 billion in cumulative projected shortfalls, sub-Saharan Africa will experience the highest losses in terms of GDP share, totalling 3 per cent of the region’s 2022 to 2025 output forecast.36 https://pages.eiu.com/rs/753-RIQ-438/images/q3-global-forecast-2021.pdf?mkt_tok=NzUzLVJJUS00MzgAAAF_HWYL7-YEx7oXFtnZCbZ5S1R73ZCOpe1VZPm9j4o2rX2noBvZ9mYj-8g6T-br29y1Hd3npvUOWvtSz41nj6aiyplCaqYwH2p0rwAIw888UReKHQ&utm_campaign=covid19&utm_medium=email&utm_source=email

    Figure 2 – Counting the cost of vaccine inequity: breakdown of expected GDP losses from 2022 to 2025

    2

    Source: The Economist Intelligence Unit

    Figure 3 – Projected GDP losses by region worldwide as a result of delayed vaccination

    (% of region’s forecast GDP)

     

    2022

    2023

    2024

    2025

    Total 2022-25

    North America

    0%

    0%

    0%

    0%

    0%

    Western Europe

    0%

    0%

    0%

    0%

    0%

    Eastern Europe

    0.1%

    0.1%

    0.2%

    0.2%

    0.1%

    Asia-Pacific

    0.8%

    1.2%

    1.5%

    1.5%

    1.3%

    Latin America

    0.1%

    0.3%

    0.3%

    0.4%

    0.3%

    Middle East & North Africa

    0.9%

    1.4%

    1.7%

    1.7%

    1.4%

    Sub-Saharan Africa

    1.7%

    2.8%

    3.5%

    2.5%

    2.9%

         

    Source: The Economist Intelligence Unit (Note: Cumulative data based on each region’s total forecast GDP between 2022 and 2025)

    These forecasts arrive at the same conclusion: countries without access to vaccines today will take longer to recover from the impact of the pandemic, suffering massive economic losses in the coming years and weighing down overall global output.

    Increasing Debt, Declining Investment

    Weak growth rates will compound negative shocks to fiscal balances and debt positions. Before the pandemic, debt taken on by many African countries was already reaching unsustainable levels. The policy measures required to respond to the pandemic have pushed even more nations into circumstances of debt distress, whereby governments are having difficulties servicing their debt. These countries include Ghana, Tunisia and Zambia; the latter became the first country to default in the pandemic era last November.37 https://www.theguardian.com/global-development/2021/sep/23/more-than-100-countries-face-spending-cuts-as-covid-worsens-debt-crisis-report-warns?utm_campaign=covid19&utm_medium=email&utm_source=email As a result, it is now having to set aside 44 per cent of its annual revenue to pay creditors. Nearly 40 per cent of Ghana’s national budget goes towards interest payments.

    Slower growth and the rising cost of servicing debt in Africa will further stress fiscal policy, limiting governments’ abilities to invest in critical infrastructure and job-creating sectors. A recent study estimates that more than 100 countries around the world are facing cuts to public spending on health, education and social protection to make up for pandemic-related spending, amid growing levels of debt.38 https://530cfd94-d934-468b-a1c7-c67a84734064.filesusr.com/ugd/6c192f_fd4197446ae84b7f9a18582bfda1c172.pdf Governments already facing austerity spent on average 3.3 per cent of GDP on fiscal stimulus for Covid-19, whereas high-income countries committed on average 6.5 per cent.

    African leaders should be closely watching inflation trends in high-income countries. If advanced economies, such as the US, pre-emptively tighten monetary policy in 2022 in order to offset inflation forecasts, this will further stifle the economic recovery for emerging markets and low-income countries. This scenario would worsen Africa’s already-dire financial outlook, since borrowing costs would increase while the region continued to divert resources to battle the pandemic, exacerbating the fragile debt situation on the continent. There is also a real possibility that governments of advanced economies will begin reining in spending in 2022 in response to improving domestic markets, further jeopardising the global recovery.

    Many countries in Africa will be forced to cut back on expenditure that is otherwise critical to their development in order to continue responding to the pandemic while avoiding a default on loans. This will make African countries even more reliant on foreign assistance, perpetuating the broken aid-dependency model.

    Restricted Travel and Tourism

    The fiscal outlook will also be depressed by the continuing reduction in tourism revenues. The services sector, which had been growing rapidly and accounted for approximately 55 per cent of Africa’s GDP in 2016, will see a slower recovery than other sectors, largely because of continuing restrictions and hesitancy around cross-border travel.39 https://unctad.org/news/mission-unlock-africas-services-sector

    Many African countries are currently included on no-travel lists by high-income countries due to rates of transmission but even as case numbers decline, new restrictions are being imposed based on the vaccination status of travellers. From November, the US will replace its current system of travel restrictions with a policy that requires all inbound international travellers to be fully vaccinated and tested prior to entry. While this opens the door to countries that had been excluded from entry, it will still be putting in place a barrier for those without access to vaccines – currently, the majority of Africans. For countries that do allow unvaccinated travellers, the quarantine requirements are so stringent that many cannot afford the time or costs involved. As these requirements persist, many Africans will continue to be excluded from global travel.

    These restrictions will have an impact on domestic tourism as well. In Madagascar, a humanitarian crisis caused by a drought that preceded Covid-19 has been exacerbated by the economic slump generated by the pandemic. Tourists have not entered the country in 18 months.40 https://www.aljazeera.com/news/2021/9/3/madagascar-is-on-brink-of-first-climate-induced-famine-un-warns Loss of revenues from this industry alone contributed to a 4.2 per cent drop in GDP in 2020. The country will continue to struggle to address its humanitarian needs in the face of such ongoing sector slowdowns.

    The tourism trade is not expected to recover until global transmission of the virus has been reduced significantly through vaccination.41 https://www.imf.org/en/Publications/WEO/Issues/2021/07/27/world-economic-outlook-update-july-2021

    Learning Deficit

    Current modelling estimates for growth do not account for the loss of productivity and learning within economies as a result of factors such as illness or school closures.

    In 2020, schools around the world were closed for, on average, 79 teaching days, ranging from 53 days in high-income countries to 115 days in lower-middle-income countries.42 https://www.worldbank.org/en/news/press-release/2021/07/13/1-in-3-countries-are-not-taking-action-to-help-students-catch-up-on-their-learning-post-covid-19-school-closures According to a global survey jointly published by UNESCO, UNICEF, the World Bank and OECD in July, only around 33 per cent of low- and middle-income countries reported that all their students had returned to in-person schooling, while just one in three countries – mostly high-income – are monitoring and measuring learning losses at primary and lower-secondary levels, a critical step in mitigating the consequences of closures.

    In Uganda, public schools have been closed for more than 18 months due to lockdowns and the president’s desire for achieving the goal of “sufficient vaccination of the eligible population” before they can be reopened.43 https://www.theeastafrican.co.ke/tea/news/east-africa/a-ugandan-crisis-in-18-months-no-schools-unpaid-loans-3529880 While some private schools have been able to transition to online learning, the public schools have largely failed to make up for lost classroom time. As a result, a recent report states that more than 15 million children will be behind their regional peers for years to come, with some calling it a lost-generation crisis.44 https://www.theeastafrican.co.ke/tea/news/east-africa/a-ugandan-crisis-in-18-months-no-schools-unpaid-loans-3529880 These learning deficits are greatest among the poorest and other marginalised groups who cannot afford private alternatives.

    In 2022, as the continent continues to move to control new waves of transmission through lockdowns instead of mass vaccinations, domestic and global educational disparities will widen between the wealthy and poor. The education of millions of young Africans is at stake, as well as the future of the region.

    Beyond Africa: Global Consequences of a Great Divide

    Beyond Africa: Global Consequences

    Growing social and economic challenges in Africa caused by lack of vaccine equity will not only be experienced on the continent, but will also have global repercussions.

    As large numbers of the global population remain unvaccinated, the door will remain open for the emergence of new variants of concern. Delta surfaced in India amid high levels of community transmission within an unvaccinated population and it is now the most dominant Covid-19 variant in the world, responsible for a devastating wave of global infections. As vaccination campaigns in high-income countries got well underway by April 2021, many countries started to ease their public-health and social measures, including, for example, the ending of indoor mask-wearing guidance for vaccinated individuals in the US. But within a few months, policymakers were reversing course once more as evidence came to light of Delta’s high level of transmissibility, even among vaccinated individuals. Variants are a risk to vaccination efforts everywhere, threatening to undo the scientific and public-health progress of the past 18 months. It is in the interest of high-income countries to ensure the world is vaccinated as soon as possible to prevent the development of dangerous mutations.

    In Africa, the demand on governments to continue mitigating the health crisis, compensate for development setbacks and address regular policy issues will be overwhelming. Fiscal constraints will limit policymakers’ abilities to deliver on fundamental needs at home. Countries that are already operating in fragile environments, such as those confronting humanitarian crises or internal conflicts, will be especially vulnerable to exacerbated political unrest. But the impact of the enduring dual health and economic crises will be ubiquitous, affecting nearly every African country’s social equilibrium. A protracted recovery will diminish long-term economic opportunities and drive down prospects.

    As poverty, food insecurity and unemployment increase, so does the likelihood of migration. While there is still insufficient evidence for a causal relationship between Covid-19 and migration, sustained falls in living standards have been a key driver of internal and transnational population movements. Migration, including from Africa, has been a divisive topic in UK and European politics, contributing to the rise in popularity of right-wing political narratives and parties, and increased nationalism.

    In countries where scarce resources are already a cause for conflict, the worsening economic conditions exacerbated by Covid-19 could lead to increasing tensions among citizens as governments find it increasingly difficult to fulfil their promises. As UN Secretary-General Antonio Guterres points out, in countries where there is already a complex peace and security environment, the risk of instability is significantly increased by additional inequalities, poverty and food insecurity. The global community should prepare to deal with new or worsened humanitarian crises and the complexities surrounding intervention.

    A study by the UN Counter-Terrorism Committee’s Executive Directorate (CTED) shows that while the long-term effects of Covid-19 on counterterrorism and countering violent extremism are difficult to determine, the pandemic is likely to have a significant impact on global responses, particularly in terms of resourcing.45https://www.un.org/securitycouncil/ctc/sites/www.un.org.securitycouncil.ctc/files/files/documents/2021/Jun/cted_covid_paper_15june2021_1.pdf CTED finds that socioeconomic hardships caused by the pandemic, such as rising unemployment, poverty and inequality, are possible drivers of an increased terrorist risk, with the study stating: "As some states lag behind in addressing economic challenges and social frustrations arise from the pandemic, governance-related challenges from terrorist groups may increase. Several terrorist groups are already exploiting the pandemic to cultivate authority and legitimacy, expanding their recruitment and radicalisation tactics through charity, the provision of food and monetary resources, and other related support." The Sahel, the Horn of Africa and countries such as Mozambique are growing terrorism hotspots, with reaches expanding beyond the region.

    All these factors – from variants to growing extremism – could drive up instability on the continent. This would have negative consequences for the global economy, as uncertainty diminishes consumer confidence and holds back investment. Though the economic ramifications of the Great Divide will be most acutely felt in Africa, the continent’s sluggish recovery and growing instability will dampen the global economic outlook in the long term.

    Global instability and uncertainty will also have geopolitical ramifications. Sentiments such as “vaccine apartheid” expressed by African leaders when it comes to the West are unlikely to fade unless the remedying of vaccine inequity is urgently undertaken. It is entirely possible that the Great Divide debilitates the world’s capacity to solve other existential issues, such as the climate crisis and the next pandemic.

    In the short term, the Great Divide is Africa’s problem. But in the long run, the Great Divide is every country’s problem.

    Preventing a Great Divide: How to Change Course

    Preventing a Great Divide

    Widespread vaccine inequity has revealed flaws in the systems of global health and economics, where access depends more on a country’s wealth than its need. Preventing an ever-worsening division between countries that are recovering and those that are not requires a global, strategic and forward-looking approach.

    By choosing a different path to the one we are on at this crucial time in the course of the pandemic, it would still be possible to avoid the Great Divide or similar by instead working towards equitable access to vaccines globally. This would ensure the majority of the global population are immunised, decreasing the likelihood of new variants emerging, and thereby minimising the impact of Covid-19 on health, the prevention of communicable diseases, economic development, poverty, food insecurity and other sources of geopolitical tension.

    The target missed in September of vaccinating at least 10 per cent of the population in Africa should serve as a wake-up call for leaders to act now and to avoid the consequences as laid out in the Great Divide. This can be achieved if global leaders focus on two issues: increasing access to supplies and going beyond supplies to support the process of building back better.

    Creating Equitable Vaccine Access

    • The G7, industrialised nations and other countries that have committed to dose sharing need to fulfil their pledges, and be transparent about their pipeline and product shelf lives, while enhancing their support of ancillary equipment provision. In addition industrialised nations should also commit to vaccinate at least 70 per cent of the population in all income categories by September 2022. Vaccine manufacturers need to prioritise and fulfil their contracts to COVAX and AVATT. They should also share details on month-by-month delivery schedules for all vaccine shipments, especially for COVAX and AVATT, so that doses can be openly directed to countries that need them the most, particularly low- and lower-middle-income countries. This will also enable countries to better prepare for shipments.
    • Countries with export restrictions, and other trade barriers on Covid-19 vaccines and inputs involved in their production, must immediately remove them. The world has already seen a significant failure in the COVAX scheme’s ability to deliver on its commitments due to export restrictions in India. In addition, the EU and US have also enforced export restrictions on raw materials needed to produce vaccines. Countries should refrain from enforcing these types of restriction, which are short-sighted and not in their long-term interests.
    • High-income countries need to distribute the surpluses they have stockpiled in sufficient time before they are due to expire. This could potentially amount to a surplus of more than 1 billion doses, which are not yet designated as donations to low-income countries, by the end of the year. Leaders will always want to do what they can to protect their own people in the short term, but they must have regard for the longer-term costs of global vaccine inequity, including for their own populations. Unless surpluses are redistributed, the world will continue to witness the fallout of Covid-19 for years to come.
    • Countries with high vaccination rates should step aside in production lines, accepting later delivery dates so that COVAX can be prioritised, accelerating the shipment of vaccines to low-income countries.

    Beyond Supply: Building Back Better

    • Beyond ensuring adequate supplies, there remains the logistical task of getting shots into arms. African countries face various challenges with vaccine rollouts, ranging from weak cold-chain storage and management to resource shortages and vaccine hesitancy. Increased vaccine supply therefore needs to go hand-in-hand with scaling up support for logistics and cold-chain management, providing medical supplies and ancillary equipment, supporting community-engagement campaigns and resourcing any other aspects of vaccine rollouts for a holistic approach.
    • The IMF and the World Bank should push the G7 and the G20 to endorse a comprehensive financial-assistance package for Africa and then allow governments on the continent to decide how this money be best deployed. This should include continuing the Debt Service Suspension Initiative into 2022, at least, and pressing lenders like China to be more transparent about their debt negotiations. The international community should also approve the IMF’s $650 billion Special Drawing Rights (SDR) allocation, and then redirect $100 billion of those funds from advanced economies to low-income countries. By the end of 2021, advanced economies should commit to a rapid channelling of an initial 25 per cent of their SDRs to reach $100 billion.
    • There is consensus among African heads of state and the Africa Centres for Disease Control and Prevention that the continent cannot rely on charity and foreign support in times of global crisis. African leaders are determined to move forward with plans to build continental facilities for vaccine production, both for Covid-19 and other diseases. Governments of high-income countries need to scale up support for vaccine manufacturing in Africa and strengthen vertical and horizontal linkages. In addition to setting up new plants, policymakers need to explore how to support existing African facilities to participate in the production of Covid-19 vaccines by creating incentives for the sector and by seeking to integrate the capabilities of different countries into the global production chain. This can help ensure self-sufficiency for Africa and decrease the dependency on foreign support during future crises.
    • Travel restrictions not founded on scientific evidence need to be lifted and vaccine discrimination based on where the doses were administered needs to be avoided, so that low-income countries are not unduly affected and inequalities inadvertently widened.
    • Countries need support to build not only the infrastructure capabilities and distribution systems to ensure effective vaccine absorption, but also institutional strength. For this, a focus on institutions is crucial. Managing a crisis such as Covid-19 calls for agile government systems, structures and skills. Governments and world leaders committed to the global fight against Covid-19 need to go beyond policies and look at the strengthening of relevant institutions. This means ensuring that institutional structures allow for clear coordination among different parts of government, for the implementation of systems that enable oversight across sectors to track both success and the challenges of meeting targets, and equipping staff with sufficient capacity to take on the challenges that a pandemic presents. The Nigeria CDC is a good example of why it is necessary and how to strengthen health institutions.

    Changing course requires a strategic response coordinated at the global level. Countries that go it alone will only contribute to prolonging the pandemic and its adverse health, economic and social impacts. Countries must approach the crisis as a transnational issue in need of globally orchestrated, evidence-based solutions.

    Conclusion

    Conclusion

    As part of the current pandemic response, the world is at risk of widening global inequality. While some countries are vaccinating the majority of their populations, reopening economies and building back, others are yet to vaccinate even 10 per cent of their populations, as they experience continued disruption of health services, the undoing of years of progress in fighting poverty and communicable diseases, and ongoing economic lags. Out of necessity, African countries are opening up economies and social activity in an effort to recover to pre-pandemic levels. Without widespread vaccination, however, the virus will continue to circulate and mutate, increasing the risk of more potent variants emerging.

    World leaders, policymakers, vaccine manufacturers and the overall global community have an opportunity at this time in the pandemic to secure the vaccine equity needed to minimise future impacts of the pandemic while avoiding decisions that threaten the future of Africa and the world.

    The rise of Covid-19 variants and other infectious diseases, economic and political instability, and loss of life and productivity are all potential outcomes of vaccine inequity. While the vaccine hoarding and supply inequity that many are turning a blind eye to may appear, at first, a problem for low-income countries and emerging economies, there is no nation that will truly be safe from Covid-19 until every nation is safe.

    For the world to recover from Covid-19 as soon as possible, countries need to start delivering on their vaccine-sharing pledges, redistribute the surplus vaccines they already have in stock, lift export restrictions on vaccines and inputs for their production, and provide rollout support to increase the pace of vaccinations in low-income countries.

    Lead Image: Getty Images

    Charts created with Highcharts unless otherwise credited.

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