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What A Donated Vaccine Can Do

The United States has a surplus of COVID-19 vaccines — more than enough to vaccinate every adult. Poor countries, however, are still struggling to secure doses. Should those vaccines be sent to countries in need? If not, who will do the sending? And should rich countries profit off the exchange?

We discuss it all on this week’s PODCAST-19, FiveThirtyEight’s coronavirus podcast. Audio and a transcript follow.

Omar Ebeid: We have about 27 patients in the ER, at least 12 of which need to be admitted into our facility. We can’t refer them elsewhere. Like, if you think of it as, I mean, not, not to be too bleak about it, but like a mass casualty where you have kind of, where you triage the patients, you don’t treat the ones that you feel, like, have very little hope of making it. You try to take the critically ill that have a better chance. And it is difficult to see in a place where you are having to turn away patients, because the number of cases are increasing, whereas in other countries, you do have a surplus of vaccines. 

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Anna Rothschild: That was Omar Ebeid, the project coordinator for Doctors Without Borders’s COVID response in Baghdad. Ebeid told me that cases in Iraq are beginning to surge again, but the country of 40 million people will have only around 1.5 million doses within the next few weeks

That’s obviously very different from what’s happening in some of the world’s richest countries. In the U.S. alone, we’ll have 800 million doses by the end of July, enough to vaccinate 1.5 times the entire population. And the gap in vaccine access between the global rich and poor is only getting wider. On April 9, the director of the World Health Organization said that of the more than 700 million doses administered globally, only 0.2 percent have gone to low-income countries.

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We’ve heard time and again that we’re not getting out of this pandemic until the entire world is vaccinated. No one is safe until everyone is safe. If so, how can we ensure that people like Ebeid get vaccines that can help save lives? Is a wealthy country responsible for helping less wealthy ones? Should they try and profit off that relationship? And to ask a callous question, If a poor country hasn’t been hit hard by COVID, should they be a priority for vaccines? I’m Anna Rothschild, and you’re listening to PODCAST-19 from FiveThirtyEight. 

To discuss the challenges in getting vaccines to poor countries, I called up …

Jon Lascher: Jon Lascher. I’m the executive director of Partners in Health, Sierra Leone.

Anna Rothschild: Full disclosure, Jon was my roommate for six years — well, sort of. He was really only home half the time. While we lived together, he supported Partners in Health’s cholera vaccine campaign in Haiti and its response to the Ebola outbreak in Sierra Leone, where he’s based today.

Convincing the world that getting vaccines to low-income countries should be a high priority is not a new challenge. In 2010, after an earthquake devastated Haiti, United Nations peacekeeping troops meant to provide support ended up causing a cholera epidemic in the country. And, although there was a safe and effective oral vaccine, the World Health Organization officially recommended …

Jon Lascher: To not use the cholera vaccine in epidemic settings. 

Anna Rothschild: Why? 

Jon Lascher: They felt like, rather than invest in something like a vaccine, which would require logistics, it would require cold-chain vaccination teams. The complexity of that, I think, pushed the World Health Organization to say there’s a better use of these limited resources. So that was one of the reasons. There were other reasons. There was concern that it was a two-dose vaccine. So, how could you get someone living in a rural place in Haiti to come back after two weeks to come back and take their second dose?

Anna Rothschild: I mean, on its face, I get those concerns. It was hard enough for my mom to get the COVID vaccine in the United States! I can’t imagine the barriers in a poor country that was already struggling after a devastating earthquake. But despite these challenges, Partners in Health tried to vaccinate as many people as possible anyway.

Jon Lascher: And after the successful completion of the first cholera vaccine campaign in Haiti, which vaccinated 100,000 people, where 91.1 percent of people who took the first dose came back and took the second dose, the World Health Organization actually came together and changed their official recommendation to governments around the world, stating that now they do recommend the use of the cholera vaccine as part of an integrated approach to managing a cholera epidemic. 

Anna Rothschild: With COVID, most public-health officials agree that everyone needs to get the vaccine. Yet, to date, the nearly 1.4 billion people on the entire continent of Africa have received around 15 million doses of the COVID vaccine. And as of early April in Sierra Leone …

Jon Lascher: There are 296,000 COVID-19 doses in the country of 8 million people. And just under 40,000 people have received their first dose. It’s great news that the vaccine is here, and it’s starting to be administered around the country. But the reality is, it’s a small drop in the bucket compared to what’s actually required for the country.

Anna Rothschild: That said, Sierra Leone has had about 4,000 confirmed COVID cases in a country of 8 million. As a comparison, New York City has a population of about 8.3 million and has had around 900,000 COVID cases. That’s more than 200 times as many! But while the cases in Sierra Leone have stayed pretty low, the economic impact has been devastating.

Jon Lascher: What happens in a country like Sierra Leone, which is among the poorest countries in the world, when you shut down the economy, when you make it so that students can no longer go into schools, when you force people who have meager resources to decide whether they’re going to send someone into a hospital or clinic or pay for food, the price of food increases, the ability to maintain jobs becomes more difficult. 

Anna Rothschild: Unlike the United States and other wealthier countries, there’s no unemployment insurance to fall back on in many poor countries. And when schools close …

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Jon Lascher: You’re not going to be able to send your child into a remote learning situation, probably aren’t gonna have access to a laptop or electricity to charge it anyway. So, the toll on already impoverished people is much, much higher. 

Anna Rothschild: So, what can wealthy countries do to help poor countries gain access to vaccines? Omar Ebeid thinks …

Omar Ebeid: One way to resolve it is basically by looking at it as a collective problem and not each country trying to make the strongest arguments for itself.

Anna Rothschild: Some countries have been donating doses to those with lower vaccine stocks. About 27.5 million doses have been donated globally, by about 20 countries. But while countries may officially state their vaccine donations are motivated by a desire to improve global public health … 

Thomas Bollyky: The reality doesn’t match the rhetoric.

Anna Rothschild: Thomas Bollyky is the director of the Global Health Program at the Council on Foreign Relations. He notes that, for some countries, economics could motivate their vaccine donations. 

Thomas Bollyky: Russia is by and large focusing on trying to sell its vaccine as opposed to donate it. To the extent they’re donating, they’ve been donating through oligarchs and firms that had been providing free vaccines almost as a free sample. So Latin America’s are good examples of where they’ve provided a small amount of free doses in the midst of negotiating larger purchases.

Anna Rothschild: India and China have pledged to donate around 16 million doses across the Asia Pacific region. But … 

Thomas Bollyky: Since November, the Asia Pacific region is responsible for just 8 percent of the reported coronavirus cases. So there’s not a lot to indicate the way these donations are being distributed is being very motivated by public health. Where those doses go today, the influence of those countries may increase tomorrow.

Anna Rothschild: In other words, this is about diplomacy as much as it’s about public health. There is some nuance here, of course. As we heard earlier, there are reasons besides case load to vaccinate people in poor countries. Further, China and India are also donating to countries in Africa and Central and South America. 

Thomas Bollyky: India is a really interesting case. It is really the only democracy that is donating globally. All the other countries involved in this really are autocracies. And it’s an interesting distinction because most wealthy democracies are using all the doses domestically and donating cash instead. India is the only exception to that. In India’s case, however, that may be coming to an end. The Serum Institute of India, the world’s largest contract vaccine manufacturer, announced for the next several months it will have to prioritize Indian needs over the rest of the world.

Two bills laid over each other so the Benjamin Franklin face on the $100 bill overlaps the face with the George Washington face on the $1 bill. Together they make one face, wearing a medical mask.

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Anna Rothschild: And what about the U.S.? Well, we’ve loaned (not donated) 4 million doses of AstraZeneca to Mexico and Canada. Though the Biden administration refused to let AstraZeneca loan American doses to the European Union, despite shortages there.

Do you have any sense why that would be, especially since AstraZeneca hasn’t even been approved in the U.S. yet?

Thomas Bollyky: So, it’s for a couple of reasons. First and foremost, and we should just acknowledge this, politicians are reluctant to donate doses abroad, when voters and their loved ones are still waiting for doses at home. And it’s not just the United States. There are no wealthy democracies donating doses currently. The second part of the reason is, we still don’t know which of these vaccines will be most effective against the different variants. And, ultimately, the U.S. plans to vaccinate children. And it may be that that’s where those doses ultimately go.

Anna Rothschild: One route that countries are taking to donate vaccines is through a global vaccine initiative called COVAX. COVAX is an effort between several international organizations. Each member organization has particular expertise in the vaccine development and distribution process, from research and development to getting vaccines into someone’s arm. Countries with extra vaccine doses can donate them to COVAX for global distribution. Dr. Nicole Lurie advises the CEO of one COVAX organization, the Coalition for Epidemic Preparedness Innovations.

Nicole Lurie: One thing I think you need to understand is the situation is a lot more complicated than us just saying, “We’ve got these extra doses, let’s donate them, or let’s shift them.” There are a set of legal and contractual issues that one needs to go through with the companies. And my contention is, it’s going to take many weeks to work out all of these nuances. 

Anna Rothschild: During the H1N1 epidemic, it took six months from the decision to donate the vaccine for the doses to reach the first recipient country.

Nicole Lurie: And when we sat down at the end of H1N1 and wrote them all out, there were something like 68 steps. My very favorite was that there was a fumigation certificate for the wood pallet on which vaccines to the Philippines were going to be shipped. And it took over two weeks to get that fumigation certificate from the government of the Philippines. 

Anna Rothschild: So now think about shipping vaccines to 190 countries …

Nicole Lurie: And there are processes like that that need to go on in every country. And all of the paperwork and certification that’s required, much of it is not electronic, it just gets put in a backlog. You can’t ship a vaccine into a country till all of that paperwork is done. Somebody is going to have to figure out who’s going to pay for shipping, who’s going to pay for the syringes and needles and all the stuff that go with it.

Anna Rothschild: Under the Biden administration, the United States recently joined COVAX, and pledged, well, not surplus doses, but $2 billion to support the purchase of COVID vaccines.

Nicole Lurie: You know, I’m hopeful that there will be two more really tangible ways in which the U.S. joins COVAX. One will be through the donation of excess doses. And the other will be by providing intellectual and technical support and engagement to solving many of the other sticky problems that we are all now facing. So, for example, the biggest limitation now in making more vaccines is the supply chain of raw materials.

Anna Rothschild: That means sending things like glass vials, rubber stoppers, and bioreactor bags: things we need to make and deliver vaccines but that are in short supply.

COVAX aims to provide 2.3 billion doses by the end of 2021. But due to slower-than-expected production and shifting priorities in some member countries, it may only deliver around 20 percent of that by June. And to be clear, even if COVAX could hit their 2 billion-dose goal, it still wouldn’t be able to vaccinate everyone in low-income countries. In Iraq, for example, COVAX has promised 16 million doses. That’s only going to cover about 25 percent of the population. And in Baghdad, where cases are rising, Omar Ebeid is worried. 

Omar Ebeid: What we’re seeing right now is that basically the hospitals are getting overwhelmed.You’re going to have more and more hospitals that are going to have to see COVID patients, which means that they’re closing other services down, So people eventually start losing faith in the health system — and then stay at home and then it’s much harder for the health system to get people to come into the hospital in time. Then people get worse. I mean, they deteriorate to a point where it’s much harder to treat, and they come in very late.

Anna Rothschild: Ebeid and his colleagues can’t fight COVID-19 on their own. The faster we vaccinate other countries, the more chance we have of shutting down new mutations. And the fewer new mutations there are, the sooner we’ll all be able to regain some of what we’ve lost. Generosity can bring its own rewards.

That’s it for this episode of PODCAST-19. If you have a question you’d like us to answer on the show, email us a voice memo at That’s “ask podcast one nine at gmail dot com.” And speaking of which, a few of you wrote in to express your frustration with our episode on AstraZeneca, and we’ve taken your comments to heart. When we made that episode, we were very much speaking as science journalists in the United States, a country where AstraZeneca has not been approved — but that doesn’t mean that the safety assessments in other countries aren’t valid. Our critique of the AstraZeneca vaccine was mostly about poor communication and transparency, not safety. And upon reflection, I think that we could have communicated better. So, thank you for your comments. I’m Anna Rothschild. Our producer is Sinduja Srinivasan. Chadwick Matlin is our executive producer. Thanks for listening. See you next time.

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Anna Rothschild was FiveThirtyEight’s senior producer for video.

Sinduja Srinivasan was the producer for PODCAST-19.