The Omicron variant may have finally done what months of anguished calls from African nations and global health specialists had so far struggled to achieve — opening the world’s eyes to the dangers of pushing more than a billion people to the back of the line, while rich nations hoard hundreds of millions of COVID vaccine doses.
Omicron was first detected in Botswana and South Africa last month, although exactly where it originally emerged is still unclear. We also don’t yet know whether Omicron will cause devastating new waves of COVID across the globe — or fizzle out like some previous coronavirus variants that once topped the worry list. But health experts say that low rates of vaccination across much of Africa, where many countries have fully vaccinated less than 5% of their population, have created the conditions for new variants to emerge.
If many more shots don’t get into arms quickly, Africa and the rest of the world can expect more new variants to pop up. “We’ve always known that would be the case,” Edwin Ikhuoria, Africa executive director for the One Campaign, an international nonprofit group that works to end poverty and preventable disease, told BuzzFeed News. “The longer this does not get to everyone, the more the virus will mutate.”
“We will only prevent variants from emerging if we are able to protect all of the world’s population, not just the wealthy parts,” said Seth Berkley, CEO of Gavi, the Vaccine Alliance, in comments released to the media after Omicron was discovered. “The world needs to work together to ensure equitable access to vaccines, now.”
Meeting this challenge means more than simply dumping unused vaccine doses at airports in African capitals. So far, the effectiveness of donated doses has been hampered by poor coordination and logistical challenges, including a failure of pledged doses to turn up at the times they were expected. Often, they have appeared with a few weeks of shelf life remaining — in some cases forcing African nations to return donated vaccines or even destroy doses that passed their expiration dates.
“[T]he majority of the donations to-date have been ad hoc, provided with little notice and short shelf lives,” the African Vaccine Acquisition Trust, the Africa Centres for Disease Control and Prevention, and COVAX, the global effort set up to ensure equitable vaccine distribution, said in a statement issued on Nov. 29. “This has made it extremely challenging for countries to plan vaccination campaigns.”
As these maps show, Africa lags way behind other continents in COVID vaccine rollout. About 44% of the world’s population has completed vaccination, while around 55% have had at least one vaccine dose. Across the entire continent of Africa, the figures are about 8% and 12% respectively. And these numbers mask huge disparities across African nations. While nearly a quarter of South Africans are fully vaccinated, the figure is less than 1% in the Democratic Republic of Congo, Chad, and Burundi.
It wasn’t supposed to be like this. COVAX, led by Gavi, the WHO, and the Coalition for Epidemic Preparedness Innovations, was set up early in the pandemic. Its purpose was to accept financial donations to help poorer nations, and negotiate contracts with manufacturers to “guarantee fair and equitable access for every country in the world.”
The idea was that rich nations would also order some of their vaccines through COVAX, giving it a powerful position in negotiating purchase agreements with manufacturers. That would maximize the bang from each buck donated and ensure that poorer countries didn’t get left behind in the scramble for COVID vaccines.
But that lofty goal has fallen victim to vaccine nationalism, as rich countries struck their own deals with drug companies and hoarded vaccines — some ordering many more doses than they needed to cover their own populations.
Under then-president Donald Trump, the US refused to take part in COVAX. And while the administration of President Joe Biden pledged $4 billion in February 2021, COVAX has failed to meet its targets. By mid-August, COVAX had delivered about 200 million vaccine doses across some 140 countries, rather than the 600 million it had planned.
The biggest single blow for Africa came in April, when India halted vaccine exports as it struggled to vaccinate its own population in the face of a devastating wave of COVID driven by the Delta variant. That created a big problem, because the vast majority of the doses earmarked for Africa by COVAX were being made by the Serum Institute of India in Pune.
“If Nigeria was producing vaccines and its people were dying, and there was a need to vaccinate our people, the Nigerian government would do exactly the same thing,” Ikhuoria, who is based in Abuja, that nation’s capital, told BuzzFeed News. He doesn’t fault the Indian authorities, and other advocates share that view. Instead, blame has focused on COVAX for relying so heavily on Indian manufacturing capacity. “That was bad planning,” he said.
“India is a global vaccine powerhouse, the largest commercial supplier of routine vaccines to lower-income countries, and prior to this pandemic, the Serum Institute of India was the largest vaccine manufacturer in the world,” a Gavi spokesperson told BuzzFeed News by email, defending the decision. “It is impractical to consider that any solution aimed at maximizing global output as well as ensuring global equitable access would not take advantage of this capacity.”
COVAX was also short of other options, as its negotiations with Pfizer to supply vaccines were faltering. And with financial donations lagging, COVAX relied heavily on funding from the Bill & Melinda Gates Foundation — which had worked closely with the Serum Institute of India on other vaccination campaigns. “I’m not sure that there would have been another way, because there wasn’t any other money,” Gian Gandhi, COVAX coordinator for UNICEF’s supply division, told Time in September.
Meanwhile, some rich nations have chosen to give vaccine doses through agreements with individual countries. According to tracking by the Kaiser Family Foundation, so far 51% of US vaccine donations to other countries had been given directly, rather than through COVAX or other international bodies.
This means that donations have been driven in part by donor nations’ foreign policy priorities rather than recipient countries’ needs. “It was unilateral. It was not within a system,” Ikhuoria said. Donations that sidestepped COVAX have also limited the body’s ability to drive down prices by negotiating directly with suppliers.
Differences in African nations’ own planning and logistics have also played a part in the vast disparity in vaccine rollout across the continent. Rwanda started receiving doses of the AstraZeneca vaccine from COVAX in early March, after formulating a plan to prioritize high-risk groups including healthcare workers and setting up a supply chain to deliver shots to hospitals across the country. Today, more than a quarter of the Rwandan population is fully vaccinated. But in neighboring Burundi, where the government initially denied that COVID was a major threat, stating that the nation had been protected by the “grace of God,” almost nobody has received a shot.
Elsewhere, a combination of local obstacles and late-arriving donations have forced nations to return or destroy vaccine doses. In May, for instance, Malawi burned almost 20,000 doses of the AstraZeneca vaccine, part of a batch of 100,000 doses it had received in late March from the African Union, after it failed to distribute them before their expiration date. Meanwhile, the Democratic Republic of Congo was unable to use most of the 1.7 million doses it received from COVAX, passing them on to other countries to prevent them from going to waste. Its rollout was hampered by poor internal transport links making it hard to get doses to remote areas, plus a monthlong pause beginning in mid-March, when concerns were raised about the safety of the AstraZeneca vaccine following reports of rare but severe blood clots.
These examples highlight a need to provide support to address local obstacles to vaccine rollout. “One of the things we’ve been calling for is support in terms of the logistics as well,” Ikhuoria said.
Some African nations have also faced problems with vaccine hesitancy. In part, this has been driven by the spread of false information. According to a report published by the Africa CDC in March this year, 45% of people surveyed across 15 African countries believed people in Africa were being used as guinea pigs in COVID vaccine trials, while a third believed vaccine trials in Africa had led to the deaths of children. For those who remember the carnage through the 1990s, when drug companies refused to lower prices on lifesaving AIDS drugs, distrust of the pharmaceutical industry runs deep.
Mkhokheli Nyala, a doctor at the Mpilo Hospital in Bulawayo, told BuzzFeed News that one big obstacle in Zimbabwe is misinformation from local religious leaders — with some pastors calling COVID vaccines “satanic.”
“There are a lot of twisted theologies that are going around,” said Agony Siwela, a Lutheran pastor in Bulawayo whose church is trying to combat vaccine conspiracy theories.
Even people turning up to be vaccinated in Bulawayo’s central business district said they had been doubtful about getting the shots. “I'm getting my second jab, but like many I was reluctant because of reports about the side effects of the vaccine,” Mavis Lubimbi, a mother of three, told BuzzFeed News.
Many Africans also still need to be convinced of the urgency of COVID vaccination — in part because the continent has yet to be hit by the high death rates seen in Europe, the Americas, and parts of Asia. (Africa’s cumulative death rate from COVID is around 16 per 100,000 people, compared to almost 240 per 100,000 in the US.) In the Africa CDC survey, 54% of Nigerians said that they thought the threat from the coronavirus was exaggerated.
“We’re not dying like flies,” Ikhuoria of the One Campaign said. “People moved on, they went about their lives normally.” He suggested that economic arguments should be stressed more strongly, given the hit taken by many African countries as the pandemic cratered their tourism industries.
What needs to change
As vaccination in rich nations has slowed, and India has finally resumed exports, vaccine donations have now started to flow. “In the last two months alone, COVAX shipped more doses than in the first eight months of this year combined,” WHO Director-General Tedros Adhanom Ghebreyesus told a USAID ministerial meeting on COVID-19 on Dec. 6. More than 600 million doses had now been distributed by COVAX worldwide, he said.
But problems still remain, including tensions over moves by many rich countries to prioritize vaccine boosters for their own people, while most people in Africa have yet to receive their first dose. Meanwhile, the WHO chief told the Dec. 6 USAID meeting that the ACT Accelerator, the effort to provide diagnostic tests, treatments, protective equipment, and vaccines of which COVAX is a part, was “out of cash” and needed $23.4 billion over the next 12 months to get these essential supplies “where they are needed most.”
Building up vaccine manufacturing capacity in Africa would reduce the continent’s reliance on rich nations. “This would obviate the need for donations and liberalize the vaccine market,” Mark Seidner, an infectious disease specialist at the Massachusetts General Hospital, and a visiting professor at Mbarara University of Science and Technology in Uganda, told BuzzFeed News by email.
In September, the WHO announced the creation of a technology transfer hub in South Africa to teach manufacturers how to make mRNA vaccines like those from Pfizer/BioNTech and Moderna. These vaccines are not only more effective than many of the doses distributed in Africa so far but can also be mass-produced efficiently and if necessary tweaked quickly to respond to emerging virus variants.
But it is unclear when the first African mRNA vaccines will be made. “It depends on several factors, including funding, a willingness to transfer technologies and the ability of local institutions to absorb knowledge,” the WHO said in announcing the hub.
“Failure to transfer vaccine technology is a major factor in the world’s failure to meet global vaccination targets and leaves the world far too vulnerable to vaccine-escape variants,” Tom Frieden, a former director of the CDC and president of Resolve to Save Lives, told BuzzFeed News by email. “The WHO’s hub is an important step, but short of receiving tech transfer right away from mRNA originators, this hub is unlikely to provide vaccine doses for months if not years.”
In the meantime, African nations will need to develop plans to ensure that people at the highest risk are prioritized for vaccination with donated doses, Bruce Gellin, chief of global public health strategy with the Rockefeller Foundation, told BuzzFeed News. That includes people with HIV — about two-thirds of the world’s people living with HIV live in sub-Saharan Africa. In the US, people with compromised immune systems have been prioritized for COVID vaccination. And studies in South Africa have found that people with HIV, who comprise almost 20% of the population aged 15 to 49, are more likely to become seriously ill or die from COVID.
People who are immunocompromised are also more likely to become chronically infected with SARS-CoV-2, the virus that causes COVID, which increases the risk of viral mutation. Indeed, one leading theory for the emergence of Omicron is that it emerged in an immunocompromised patient in Africa — possibly someone with HIV.
If Omicron isn’t to be followed by further threatening variants, the world needs to address the gross inequity that has characterized the international vaccine rollout so far, health experts say. And that means recognizing that we’re all in this together, rich nations and poorer nations alike.
“The virus doesn’t know what country it’s in,” Gellin said.