Vaccine Inequality: We are not all safe

The unfolding tragedy of Afghanistan has eclipsed reporting of the COVID pandemic while a fourth wave of infections is sweeping the Earth. Paul Rogers argues that global vaccine inequality risks those in all countries as the Delta variant tests the limits of current vaccines.

With so many governments immersed in the sudden Taliban ascent to power in Afghanistan, there is seemingly an assumption that the COVID-19 pandemic is now less of a problem. This is not the case and there are many indications that the pandemic continues to evolve in hazardous ways and is now entering a particularly dangerous phase. As these briefings have argued before, the very slow pace of vaccinations in many parts of the Global South risks the development of new variants with more lethal properties, and this is being exacerbated by current trends, especially the spread of the Delta variant with its increased infectivity.

This article examines the trends of the past month in relation to the experience of countries with both high and low vaccination rates, finding many examples where that experience reinforces the need for much more effective action.

As of the end of August, the World Health Organisation (WHO) was reporting just under 4.5 million deaths, 215 million confirmed case and 5 billion vaccine doses administered. Most of the vaccine doses have been delivered to people in high-income countries. For full global vaccination, including booster vaccinations, more than 25 billion doses will be required (two doses each plus booster). Furthermore, the pandemic’s impact is being felt far more by marginalised communities across the world.

The pandemic in wealthy states

Experience varies hugely between countries. However, Iceland is one country that has been very successful in pandemic control but in the past two months has seen a considerable surge in cases. This follows an impressive programme of vaccination and stems from a combination of a marked easing of control measures and the rapid spread of the Delta variant.   Fortunately, while the surge has led to some increases in illness, the pressure on the hospital system has been small and there have not been any deaths since May. The rate of spread among a largely vaccinated population does confirm other evidence that the Delta variant is highly infectious.

Israel (but not the Occupied Territories) has had a world-leading programme of vaccination and associated public health measures. After the mid-winter surge it successively reduced the pandemic to what appeared to be little more than an inconvenience. The introduction of the Delta variant and the premature easing of restrictions has allowed the virus to reassert itself to the extent that daily rates of new infections have briefly exceeded even the previous February peak before vaccines began to take effect and the COVID occurrence dwindled to near-zero by May.

Israel has re-introduced and enforced mask-wearing requirements, ’green passes’ are required for entry into restaurants, museums, public pools and some other public places, third ’booster‘ jabs have already been given to one-in-seven of the population and the government has warned that it will bring in much stricter lockdown measures if necessary.

In the United States, some cities such as San Francisco have achieved high vaccination rates while maintaining social precautions such as proof of vaccination for entry into restaurants, bars and gyms. Others are maintaining a masking policy. Other parts of the country eschewing these measures, such as Florida and Arizona, have seen such substantial surges that hospitals are having difficulty coping.

Before the pandemic the United Kingdom was regarded as one of the world’s best-prepared countries but in practice it was repeatedly too slow to take the necessary actions to control COVID-19, including failure to address the vulnerabilities of care home residents and repeated lateness in enacting lockdowns. By the end of August, its daily new case rate of over 30,000 was the world’s third highest.

With the welcome development of vaccines, it was able to reduce the death rate substantially earlier this year and was, for a time, the leading European country for vaccination rates. This has been overtaken by other states, including Ireland, but the Westminster government has still taken the decision to remove almost all regulations on restraint, a decision causing concern among many health professionals. The particular focus is on the full reopening of schools and the effect of that when infection rates are already rising rapidly.

With partially devolved governance, Scottish schools reopened in mid-August and the country is now experiencing a substantial surge in case numbers. English schools reopen over the next week and public health professionals in many countries will be following closely the development of the pandemic in the UK in the closing weeks of September. What happens across the UK may well influence COVID-19 control policies in many high-income countries.

Lessons to learn

The main factors behind the Israeli experience and of some other earlier successful states are relevant across the world as their early lead in pandemic control provides a foretaste of what could be to come for many other countries.

Vaccination rates over 70% may sound good but age is crucial in this. In Israel, vaccination rates for people over 12 are very high at over 78%, but Israel has a young population with 25% aged twelve or younger so the overall vaccination rate is closer to 60%. 

The Delta variant has swept rapidly across the world in the past four months and has an R0 of 6.4 (an infected person would infect over six people in the absence of vaccines and restrictions) whereas some of the earliest variants had an R0 of just 2.5.

The Delta variant may not lead to serious illness in those vaccinated, but it is readily capable of asymptomatic transmission, up to 70% of Delta infections stemming from this. There is some evidence that even very young children (under two years) will spread the virus if mostly unaffected themselves. Finally, now that there is a sizeable population that has been vaccinated for six months it has become clear that the effectiveness of vaccines does decline over time.

The global scene

China had a very tough control policy which initially worked well. Prior to the start of vaccination ten months ago it dealt with outbreaks principally through rigorous local lockdowns and travel control, but it is struggling to control the spread of the Delta variant with outbreaks in the past month in Wuhan, Nanjing, Yangzhoa and other cities.  

In Iran, the health system is being overwhelmed by waves of the Delta variant. The country had had problems since the start of the pandemic but the current surge is reported to be the worst so far, described by the New York Times as cataclysmic.

Cuba is not a wealthy country but its health service is widely acknowledged to be very effective and Cuba’s life expectancy exceeds that of the United States. Yet it, too, is struggling to contain the Delta variant, especially in the less populated provinces away from the major cities. According to the Ministry of Health, more than 9,700 new cases were reported on 18 August, more than six times the number just two months earlier. This is despite Cuba developing its own vaccines. Likewise, Russia, which has touted its own vaccine development and supply programme, currently leads the world in COVID-related deaths of around 800 per day.

It is all part of a pattern being repeated across much of the Global South and as the pandemic develops and the virus evolves, one of the worrying changes is the burgeoning death rate among very young people, especially in poorer countries and marginalised communities elsewhere. Indonesia has seen at least 1,245 children die. In Brazil it has been over 1,500 and the figure in India is over 2,000. Both countries have much higher death totals among all ages than Indonesia, but the concern is that COVID-19 must no longer be seen as a disease of adults; children are not just carriers of the virus, they are increasingly victims too.

Global vaccination 

Previous articles have highlighted the need for rapid global vaccination but progress is extremely slow, especially in low-income countries. A third of the world’s people have had a single dose but only a quarter are fully vaccinated. A few high-income countries, including the UK, are starting booster vaccinations and these will almost certainly be needed world-wide, even if there are no further variants of concern. The contrast is with low-income countries where only 1.4% have received even one dose.

If the current rate of vaccination was maintained and if it was successfully extended worldwide to include the many parts of the world with weak infrastructure, it would take until mid-2023 to complete the task. This would not take into account any new variants and would also require massive international assistance to achieve. The experience so far is ominous. The WHO has organised the COVAX programme to provide vaccines for low-income countries, but it has had difficulty getting the programme fully operational. The main problem is not necessarily airlifting vaccines to countries needing them but “getting doses from airport tarmac into people’s arms”.


An earlier article in this series highlighted the risk of “COVID complacency”. High income countries would be content with their own vaccination success and pay even less attention to the need for global cooperation, especially in relation to vaccination across the Global South. The concern was that a widely circulating virus at a time of varying levels of vaccination across the world created a highly conducive environment for new variants to emerge. That remains the case, and while the worldwide security focus during August has been on the rapid changes in Afghanistan, addressing the far more serious problem of global health is getting far too little attention.

The views and opinions expressed in posts on the Rethinking Security blog are those of the authors and do not necessarily reflect the position of the network and its broader membership.

Image Credit: Per Meistrup via Wikipedia: Queue for COVID-19 vaccination, Koh Samui, Thailand, June 2021.

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