“It’s all about the money, it’s always about the money,” says my nephew as we are talking about any number of different topics comparing the US to where he lives abroad.  It seems like a pretty simple statement, some would say cynical, some would say all too realistic.  Now that we are in a race to vaccinate the world against COVID-19 before some new vaccine resistant variant can be born, it seems all too relevant.  The vast inequity in COVID vaccine distribution between wealthy and poor countries is stark and short sighted.  Using publicly available figures from Our World in Data, The Washington Post found that 45 percent of all vaccine doses administered so far have gone to just 16 percent of the world’s population in high-income countries as defined by the World Bank.1 A team at Duke University’s Global Health Innovation Center estimate that the world’s poorest 92 countries will not be able to reach a vaccination rate of 60 percent of their populations until 2023 or later.1

The rapid development of Covid-19 vaccines,2  achieved at record speed and financed by massive public funding in the United States, the European Union and Britain, represents a great triumph of the pandemic. Governments partnered with pharmaceutical companies, contributing billions of dollars to procure raw materials, finance clinical trials and retrofit factories for production. They committed billions more dollars to buy the finished product, thereby all but eliminating the usual level of risk that pharmaceutical companies must take in the development of a new and untested product.  In this case, these companies were guaranteed to profit regardless of the outcome.  By partnering with the drugmakers and providing financial support, the process was able to move more quickly as was needed for a global pandemic of this proportion.  However, this also allowed Western leaders to buy their way to the front of the line.

Israel, one of the countries to vaccinate majority of its population most efficiently did so by making a deal of its own with Pfizer.  While they came relatively late to the table in negotiating for vaccines, they made a deal that got them lots of vaccines and quickly. Not only did they pay top dollar for vaccines but to keep up the fast pace of dose delivery, they agreed to give Pfizer partial access to the vast database of information maintained by the country’s national health-care system.3

Distribution of vaccines to poor and developing countries was supposed to happen thru the COVAX program.  The Covax program4 was conceived in early 2020 as a kind of Operation Warp Speed for the globe.  It was supposed to be a model for how to vaccinate humanity, starting with those who needed it the most. Under the original plan, the wealthiest countries would buy enough vaccines for at least 10% of their populations from Covax.  Along with donations, that would help subsidize vaccines for another 92 poor nations that would receive their doses for free.

However, most of the world’s poorest nations were left highly dependent on a single vaccine, produced by a single manufacturer (the Serum Institute of India) in a single country. Then that country, India, ended up being overwhelmed by a huge Covid-19 outbreak needing those vaccines for itself.  There are many other reasons why Covax ability to supply vaccines to poor countries has not been realized.  This Wall Street Journal article lays those out in detail.5

While the wealthy Western countries were making their deals with the pharmaceutical companies, they ignored explicit calls from the World Health Organization to include contract language that would have guaranteed doses for poor countries or encouraged companies to share their knowledge and the patents they control.1

Now the control over the intellectual property rights is the source of tremendous controversy.  Representatives from the pharmaceutic industry claim that granting the TRIPS waiver would set a dangerous precedent to deny big Pharma these patents, squelching the financial incentive for future vaccine production and future therapeutic innovation. Disclosure forms from the first quarter of 2021 reveal that over 100 lobbyists had been enlisted to oppose the TRIPS waiver.6 Many others insist those arguments do not hold water. Proponents of a TRIPS waiver argue that it is not right for a multinational vaccine manufacturer to hold exclusive rights that can stop other firms from being able to produce vaccines particularly in markets not being served by current vaccine producers. In addition, they argue that given the enormous public investment of funds that were provided upfront for research and development and through purchase agreements, the public has already paid for this innovation. The original science behind the mRNA vaccines from Pfizer-Biontec and Moderna were financed by the governments of Germany and the US.7

The other alternative to the temporary waiver of patent rights for COVID vaccines is to allow the pharmaceutical companies to maintain their patents but not allow them to control pricing of the vaccines so that rich and poor countries alike can afford to vaccinate their populations.  All these negotiations, however, is wasting precious time as the numbers of those infected (176 million) and killed (3.8 million) by the virus continues to grow and new variants are being discovered.

The Biden administration has now come out strongly in support of the TRIPs waivers and along with the leaders of the world’s seven richest countries, has agreed to donate 1 billion coronavirus vaccine8 doses to poorer countries over the next year, adding that the U.S. would be responsible for around half of the 1 billion doses and may eventually be able to contribute 1 billion more doses.  The commitment falls far short of the 11 billion doses the WHO has said are needed to vaccinate at least 70 percent of the world’s population.8

In addition to wealthy countries donating doses of vaccines and establishing a realistic financial future for how vaccines will be produced and distributed equitably, there are many complex issues involved in scaling up vaccine production and it is even more complicated to ensure that these vaccines make their way to those in need across the globe.   If infectious variants will remain in circulation (like the cold virus) so that vaccinations will be necessary Indefinitely then it stands to reason that the public good is best served by ensuring continued, affordable access.

In a comprehensive discussion of this issue on the Johns Hopkins School of Public Health site, Dr. Anthony D. So lists these as necessary to future success of equitable vaccine distribution:

  • Public investment in technology transfer
  • Contracting of existing and new manufacturing facilities
  • Sourcing other inputs like glass vials
  • Pooled procurement facilities, from UNICEF to the Pan American Health Organization’s Revolving Fund for Vaccine Access, to buy and deliver the vaccines effectively.
  • Prioritize scaling up second-generation vaccines that have been adapted to address emerging variants or that are better suited for delivery where ultra-cold chains do not exist.

So yes, it is all about the money.  But hopefully with so many lives at stake across the world, companies and nations will do the right thing. Humanity is depending on it.

–Felise Milan, MD, Community of Practice Member

Dr. Milan is a Professor of Medicine at the Albert Einstein College of Medicine in Bronx, NY. She is the Director of the Ruth L. Gottesman Clinical Skills Center and Director of the Introduction to Clinical Medicine Programs.


  1. Mirza A, Rauhala E. (2021, May 6). Here’s just how unequal the global coronavirus vaccine rollout has been. Retrieved from The Washington Post: https://www.washingtonpost.com/world/interactive/2021/coronavirus-vaccine-inequality-global/
  2. Perez-Pena R. (2021, May 4). How Hard Could it be to Vaccinate the Whole World? This Hard. Retrieved from NY Times: https://www.nytimes.com/2021/05/03/world/global-coronavirus-vaccine-shortage.html?searchResultPosition=1
  3. Rubin S, Hendrix S. (2021, January 28). Israel moves to head of vaccine queue, offering Pfizer access to country’s health-care databas Retrieved from The Washington Post: https://www.washingtonpost.com/world/middle_east/israel-pfizer-coronavirus-vaccine-privacy/2021/01/27/b9773c80-5f4d-11eb-a177-7765f29a9524_story.html
  4. Steinhauser G. (2021, May 20). What Is Covax and How Will It Deliver Covid-19 Vaccines to Poorer Countries? Retrieved from The Wall Street Journal: https://www.wsj.com/articles/covax-covid-19-vaccine-11613577473?mod=article_inline
  5. Steinhauser G, Hinshaw D, McKay B. (2021, May 26). Why a Grand Plan to Vaccinate the World Against Covid Unraveled. Retrieved from The Wall Street Journal: https://www.wsj.com/articles/why-a-grand-plan-to-vaccinate-the-world-against-covid-unraveled-covax-11622045728
  6. So, A. (2021, May 10). WTO TRIPS Waiver for COVID-19 Vaccines. https://www.jhsph.edu/covid-19/articles/wto-trips-waiver-for-covid-19-vaccines.html
  7. Supported by the Intramural Research Program of the Vaccine Research Center (VRC), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH); and the Office of the Assistant Secretary for Preparedness and Response, Biomedical Advanced Research and Development Authority, Department of Health and Human Services (contract 75A50120C00034). Evaluation of the mRNA-1273 Vaccine against SARS-CoV-2 in Nonhuman Primates. https://www.nejm.org/doi/full/10.1056/nejmoa2024671
  8. Suliman A. (2021, June 13). G-7 leaders pledge over 1 billion coronavirus vaccine doses for poorer nations. Retrieved from NBC News: https://www.nbcnews.com/news/world/biden-g-7-leaders-wrap-summit-promises-expected-covid-climate-n1270603

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