The Biden-Harris administration recently promised to distribute 1.5 million vaccine doses a day in the first 100 days, an increase from its original commitment of 1 million doses. In addition, it has committed to buy an additional 200 million doses of vaccine from manufacturers (Pfizer and Moderna are the two vaccines approved for use in the US, with others likely on the way). This coordinated and organized campaign is a welcome improvement. And yet, despite the best intentions, herd immunity within US borders will do little to solve the global crisis and, despite wishful thinking, will not restore our economy.
Vaccine nationalism, or the hoarding of vaccines for use within the borders of individual countries, is a major impediment to the widespread control of SARS-CoV-2, the virus that causes COVID-19. Like many infectious respiratory illnesses that are spread through droplet and airborne routes, true control cannot realistically happen without a widespread campaign targeting an entire population—in this case, the world’s 7 billion people.
Focusing vaccination on single groups overlooks the fact that the virus will continue to reside and propagate in non-immune reservoir populations. This presents a serious logistical challenge. While vulnerable groups such as the elderly or minorities will experience important benefits in terms of prevention of excess deaths, community transmission cannot be controlled until immunity—either through vaccination or recovery from infection—reaches a threshold.
That threshold depends on the infectiousness of the pathogen (measles, for example is very infectious and requires about 95% immunity to prevent community transmission). Herd immunity is not exactly known for SARS-CoV-2, and while initial estimates placed immunity thresholds around 70%, recent research suggests that it may be less than 50%. (This number is in dispute, with researchers arguing different levels for obtaining herd immunity. Ultimately it is probably safest to assume higher thresholds as a means of controlling spread until more information is obtained.)
The misconception is that reaching this threshold within a country will control the pandemic and restart the economy. That thinking explains the focus on national immunizations, while simultaneously underfunding global vaccination efforts.
Yet the SARS-CoV-2 virus is mutating, and new strains are crossing borders at breakneck speed. As a result, simply vaccinating the entire US population will not prevent the spread of novel coronavirus strains.
That reality not only threatens our efforts at home, but may also undermine confidence in medicine and science, especially in a world of misinformation and vaccine skepticism. If populations outside America do not control infection through widespread vaccination campaigns of their own, coupled with critical public health measures such as hand washing, social distancing, and routine masking, global travel will remain a challenge and novel strains will continue to threaten immunized populations at home.
Two primary factors are at play: 1) the mutagenicity of the virus and 2) ongoing cross-border travel that brings populations together, exposing new hosts to the virus.
Viruses naturally mutate and SARS-CoV-2 is no exception. In fact, given its widespread distribution mutation is to be expected, which if beneficial to the virus will dominate in a population. We are seeing these effects in the UK and South Africa, with modeling predicting that the UK strain may be the dominant variety in the US by March.
While there is no evidence as of yet that the UK strain is more lethal than any other, there is a concern that mutations will create variants that are more resistant to current vaccine formulations. This is particularly noteworthy in the South Africa strain, with current vaccines, including new ones such from Johnson & Johnson and Novavax, less effective at reducing infections in South African populations under study compared to populations in the US and the UK. Certain mutations allow the virus to evade the defenses of immunized people, similar to how the seasonal flu propagates. As the coronavirus continues to spread, we can expect mutations to continue and new strains to emerge that may be more resistant to immunization efforts.
Which brings us to the second issue, that of cross-border travel and the exposing of populations to novel viral strains. The economy has been shocked not by the virus but by our reaction to it in the form of fear of illness and restrictions on movement, gatherings, and interactivity. These restrictions were and continue to be a critical component of transmission control, and while they undoubtedly save lives they have profound economic effects. Simply lifting restrictions will not prevent ongoing infections, deaths, and severe economic harm, as further deaths and the concomitant fear of infection will continue to impact both micro and macro economic trends.
Wealthy countries are buying up massive supplies of vaccine doses, in some cases in substantial excess of their actual populations. This has led the World Health Organization to criticize affluent governments for their moral failure to support widespread vaccinations in poorer countries. The response of countries to prioritize vaccinations of their own populations is, of course, entirely understandable. They are answering to the needs of their people, and in many cases wealthy country governments have spent considerable resources supporting the research, development, and production of these vaccines—they can be forgiven for wanting to be at the front of the line.
However, there is an equally important financial reason for sharing vaccine doses with low-income countries, namely the profound financial implications of failing to control the virus globally. A recent paper from the International Chamber of Commerce Research Foundation has highlighted the grave risks to the global economy if nation-first vaccination policies continue. No national economy can return to pre-pandemic levels of productivity or activity until vaccinations are widely available globally. In particular, wealthy countries that fully vaccinate their citizenry will be unable to realize full economic gains as long as the pandemic continues unabated and uncontrolled in low- and middle-income economies.
What can be done?
The Access to COVID-19 Tools (ACT) Accelerator is a collaboration and investment scheme that seek to address this imbalance. It is a global platform based on three pillars that allow for equitable access to testing, treatment, and vaccinations.
Testing has expanded rapidly over the past year and is a critical component for understanding baseline infections, community transmission, and guiding public health policies—in particular the regulation of movement and gatherings to prevent spread. Treatment is an expensive undertaking, particularly for severely ill COVID-19 patients. In the US, costs of treatment alone are likely running into the billions of dollars.
Vaccinations are, of course, the main way out of this crisis, and the ACT Accelerator has launched the COVAX Facility, a global risk-sharing mechanism for pooled procurement and equitable distribution of COVID-19 vaccines. The goal is to improve access to vaccines as quickly, safely, and equitably as possible. The concept is that countries commit to the funding scheme, and the facility evaluates and manages the full portfolio of available vaccines, monitors the vaccine landscape to identify promising vaccine candidates, and works to incentivize their production in advance of regulatory approval. This jump-starts the manufacturing process and shaves months or even years off vaccine distribution timelines. By committing financial resources and support in advance—known as an Advance Market Commitment—industry can develop manufacturing capacities and invest in vaccine research and development knowing that there are financial backstops against loss should a vaccine not prove effective.
This model has worked for vaccines and other high cost, low return investments in health in the past. Most importantly, these kinds of investments defy zero-sum politics and economic thinking. Improvements in health, especially in lower income economies, do not come at the expense of others, but rather close health gaps while also buttressing improvements in both health and economic productivity of wealthier countries.
The urge to focus on domestic immunity is natural. As people we are most committed to those closest to us, starting with our family and then our friends, neighbors, community, city/county, and country, moving outward in concentric circles of obligation. And yet our way out of the pandemic is intimately tied to the global control of SARS-CoV-2. The pandemic has already cost the US an estimated US$ 7.6 trillion and continues to cost the global economy billions of dollars every month. It is unusual for an action of this importance to be both morally upstanding and financially self-interested, yet investments to end the pandemic worldwide are not only morally sound—they are sound economics as well.
