NEW YORK/TOKYO/MANILA/NEW DELHI -- The first generation of COVID-19 vaccines is a modern scientific miracle. In little over a year since the virus was identified, mass inoculations using safe, effective and thoroughly tested vaccines have begun in dozens of countries.
But now comes the hard part: Who gets them? And where? At stake is not just the zero-sum question of who lives and who dies. There is an even bigger issue: The longer the disease is allowed to thrive, the more likely it is to mutate into variants resistant to the vaccines. Vaccine hoarding by rich nations could leave vulnerable populations in poorer countries still exposed and prolong the pandemic for everyone.
On the back of a herculean effort to organize testing and regulatory approvals in record time, getting shots into arms has now transformed from a largely scientific problem into a logistical problem, a public relations problem, a political problem and a geopolitical problem.
"The more people are infected and the more people are passing this virus around, the bigger the risk is that we're going to accumulate new variants that are more resistant to the vaccine," said Bettie Steinberg, a virologist at Northwell Health's Feinstein Institutes for Medical Research on New York's Long Island. "That's just by random chance. If nobody is getting sick, nobody would be generating variants in their cells."
The multiplication of variants already has spooked virologists. In at least one case, South Africa ruled that the vaccine from British pharmaceutical giant AstraZeneca was much less effective against the new B.1.351 variant that has emerged there.
Meanwhile, questions remain about how well the first generation of vaccines controls the transmission of the virus. Though they prevent illness and death, some scientists worry that the vaccines may actually increase the number of asymptomatic spreaders. According to news reports, the Oxford-AstraZeneca vaccine may reduce transmission of COVID-19, but experts said it would take months to know more about the vaccine's effects on transmission.
"We all expect that these vaccines are going to reduce transmission, [but] the simple answer is that they're not going to be perfect," said John Wherry, director of the Penn Institute for Immunology at the University of Pennsylvania. "It means that we can't wait too long. ... I think that there's some urgency to really get the vaccination numbers up as much as possible and reduce the spread of these variants."
Experts warn that people must continue wearing masks and following social distancing rules after vaccination to prevent the virus from evolving into more resistant variants. In other words, scientists worry that the vaccines will make populations complacent.
"We really need to keep social distancing and mask-wearing in place," Wherry said. "I think it's important for us to keep reiterating that we're not only putting ourselves at risk, we're putting the rest of the people around us at risk."
Another danger is that vaccine doses will be concentrated in a few wealthy countries and that people in many poorer nations will not receive vaccinations in a timely way.
About 19 million people have been fully vaccinated worldwide, according to Oxford University's Our World in Data. Israel leads, with 28% of its population fully vaccinated as of Feb. 13. The U.S. ranks second with 4% -- though 11% of its population has had at least one shot of a two-shot regimen, the country's Centers for Disease Control and Prevention said. The U.K. follows with 0.8%, though 22% have been given one shot, according to the government. The world's fully vaccinated rate stands at 0.2%, with data unavailable in many countries.
Up to 10 billion doses of the first generation of vaccines could be given by the end of 2021, based on company forecasts collected by consultancy Airfinity. But Airfinity CEO Rasmus Bech Hansen cautions that this figure is unlikely to be met.
"Currently, the producers are nowhere near meeting these targets," the CEO said.
Eventually, 70% to 80% of the human race must be fully vaccinated for normal life to return, scientists say. But one of the main obstacles is hoarding by wealthy countries. Experts say that "vaccine nationalism" will prolong the pandemic for everyone, compared with a strategy of inoculating the most vulnerable in all countries first.
The COVID-19 Vaccines Global Access Facility (COVAX), which is supposed to provide doses to poorer countries, is underfunded and in danger of being unable to perform its mission at all, said Mandeep Dhaliwal, director of the HIV, Health and Development Group at the United Nations Development Program.
"Ninety-two poor countries receiving the majority of COVAX-purchased vaccines will only receive enough to vaccinate 3% of their population by the end of the first half of 2021," Dhaliwal said. "The wealthiest nations, which are only 14% of the global population, have purchased more than half of the promising vaccines. We've got a disparity in purchase [and] in delivery."
"The wealthiest nations, which are only 14% of the global population, have purchased more than half of the promising vaccines"Mandeep Dhaliwal, director of the United Nations Development Program's HIV, Health and Development Group
She told Nikkei Asia that the Access to COVID-19 Tools Accelerator, the umbrella mechanism that includes COVAX, has a $27 billion funding gap for coronavirus tests, drugs and vaccines. Projections show that it could take years for the world population to be sufficiently vaccinated, she said.
The U.N. director called for global solidarity to share vaccine technology and boost investment into both health care systems and vaccine procurement to mass-produce doses and distribute them worldwide.
"It's a much bigger effort that's required. Just vaccinating a few people in some rich countries is going to reduce the effectiveness of the vaccine," Dhaliwal said. "If we could [mass vaccinate] throughout the world, we could severely reduce the excess mortality and morbidity, which is burdening health systems. That's why a multilateral approach is really needed, and it needs to be properly funded."
The Philippines: "Our greatest disadvantage is we are not rich"
Those vaccine "have-nots" face an uncertain future over when -- and whether -- they will get enough doses.
One such country is the Philippines, which has recorded over 549,000 infections -- the second-highest tally in Southeast Asia after Indonesia. This tally comes despite the Philippines having enforced one of the world's longest lockdowns, sending the economy into a 9.5% decline for 2020, its worst dent in growth since World War II.
President Rodrigo Duterte opened his televised public address on Feb. 1 with: "This COVID problem is not that easy. For one, our greatest disadvantage is we are not rich. ... this is a fight among the highest bidders."
Duterte has noted the plight faced by developing countries like the Philippines in the global scramble for coronavirus vaccines. "We don't have connections; we don't have the money," he said.
But poorer countries are not entirely powerless. Duterte has used geopolitics as a bargaining chip to secure doses, threatening to cancel the Philippines-U.S. military Visiting Forces Agreement -- which is currently under review -- unless the U.S. coughs up more vaccines.
"If they fail to deliver a minimum of 20 million vaccines, they better get out -- no vaccine, no stay here," Duterte said, referring to U.S. troops, during a televised meeting with cabinet members.
Though the COVID-19 shots developed by AstraZeneca and Oxford University have been the vaccine preferred by many local municipalities and businesses, Duterte has cast a wider net.
As early as July last year, Duterte had asked Chinese President Xi Jinping -- with whom he has forged close ties, despite the South China Sea territorial dispute -- to make the Philippines a priority for vaccine allocation. He also volunteered to be a guinea pig for Sputnik V, the vaccine developed by Russia's Gamaleya Institute.
China's Sinovac Biotech has allocated 25 million doses of its CoronaVac vaccine, Philippine officials said, on top of the 600,000 free doses pledged by Chinese Foreign Minister Wang Yi during his recent visit.
CoronaVac doses donated by China are expected to arrive on Feb. 23, Duterte's spokesperson Harry Roque said last week. But Sinovac has yet to gain an emergency use permit from the Philippine Food and Drug Administration.
But while Duterte has openly favored inoculations developed by Chinese and Russians, his COVID-19 task force and diplomats have turned to the U.S. for vaccines from Pfizer and Moderna. Only vaccines by Pfizer and AstraZeneca have secured emergency use authorization in the Philippines, so far.
"Duterte often hopes to play big powers off against each other," said Peter Mumford, Southeast Asia analyst at Eurasia Group. "But in this case, I am not sure it will really work as U.S. and EU/U.K. governments do not direct where vaccine supplies from their pharmaceutical companies go -- [European Union] export restrictions aside. That is decided by the firms themselves. What Manila has done, though, is diversify supply sources, which is a sensible strategy in the circumstances."
India: Like Beckham?
Not all developing countries are in dire straits. India, blessed with a large pharmaceutical industry that thrives on low production costs and favorable government policy, has rolled out the world's largest inoculation program so far. Vaccinations are taking place at 10,000 sites nationwide, with up to half a million people receiving shots per day.
There are even enough doses left over to send abroad. Indian-made vaccines have been supplied to many countries including Bangladesh, Myanmar, Mauritius, Brazil and Morocco, at a time regional rival China is pursuing its own vaccine diplomacy.
Earlier this month, India approved 100,000 doses for Cambodia -- a key ally of Beijing -- "on an urgent basis," following a request from Cambodian Prime Minister Hun Sen to Indian counterpart Narendra Modi. Modi called his country's vaccine production "shining proof of India's strength, India's scientific proficiency and India's talent."
But it will be a huge challenge for India to cover 300 million residents in the next few months as planned in terms of facilitating their travel to designated sites.
Perversely, good news is breeding other challenges.
The country of over 1.3 billion has reported a steady decline in infections since mid-September. This is possibly due to previously unrecorded infections burning through the population, which may have delivered some natural resistance from antibodies in people who recovered from the disease.
"India has 'bent it like Beckham,'" the Reserve Bank of India said of the nation's COVID-19 curve in a report released Jan. 21. "Barring the visitation of another wave, the worst is behind us."
But this confidence is undermining the effort to convince Indians to take the vaccine. Many are questioning the need to get the shot at all -- especially with the untested Indian vaccine Covaxin -- now that infection rates are falling and the government is declaring victory.
"We need to develop herd immunity not through the virus infection, but through vaccination," urged V. K. Paul, India's top health adviser, who highlighted the need to remain cautious. A recent medical survey showed that over 70% of the Indian population was still susceptible to COVID-19.
India's drug regulator granted emergency use approval last month to Covaxin, developed by domestic company Bharat Biotech, and to the Oxford-AstraZeneca inoculation, which is locally manufactured by the Serum Institute of India under the brand name Covishield. Both are two-dose vaccines that need to be administered 28 days apart.
However, Covaxin has yet to gain public acceptance.
"People continue to be hesitant about [Covaxin], as its efficacy data is not out," said professor Rajinder K. Dhamija of Lady Hardinge Medical College.
But authorities are hopeful that inoculations will accelerate in weeks to come as at least six more vaccines are in the pipeline including Russia's Sputnik V, which also will be made locally, and one from domestic company Zydus Cadila.
India's state-run and private airlines have been delivering vaccines across the country, working with manufacturers, airports and ground transport companies to ensure the cold chain remains unbroken. The two Indian vaccines must be stored at a constant temperature of 2 C to 8 C.
India also intends to bolster its cold chains in order to store more vaccines at any required temperature. "Such a vaccination drive at such a massive scale was never conducted in history," said Modi.
U.S.: 'It's a mess'
Vaccine supply should not be a problem in the U.S. The country accounts for 4.25% of the world's population, but 6.64% of contracted vaccine supply.
But poor planning and an epidemic of misinformation from the previous administration of Donald Trump -- such as promoting hydroxychloroquine and injecting disinfectant -- have left President Joe Biden playing catch-up with the nationwide vaccine distribution. The lack of a uniform tracking system, poor coordination and logistics challenges have made it difficult for many Americans to receive their doses.
Robert Handfield, a professor of supply chain management at North Carolina State University, criticized the lack of a national system to coordinate supply and allocation.
"There's a lack of integration between the allocation of the doses, the scheduling of the patients and the location of the vaccinations," Handfield said. "It's a mess."
Handfield noted that states have been told by the Centers for Disease Control and Prevention that they need to use up their doses in order to receive more, which results in states not reserving enough supply for the second shots.
Vaccine delivery also requires a cold chain, and Pfizer doses especially need to be stored in special ultralow-temperature freezers. This complicates the rollout.
"There is definitely a shortage of freezers at the moment," Handfield said. "It's more difficult to roll out, and especially to rural areas [and] tropical areas."
Dr. Wafaa El-Sadr, director of ICAP and professor of epidemiology at Columbia University in New York, said the highest priority is to develop a system that tracks exactly where each vial is, its destination and its source.
"I think we don't want to be in a situation where one place has more supply than the demand and another place has the demand but not the supply. We need to be nimble and flexible," El-Sadr said. "To be able to act quickly, you need to have data, [and] I think that's quite doable."
Another problem is the willingness of the population to be inoculated. Pew Research Center published a report in December indicating that 29% of Americans said they definitely would get vaccinated, 31% said they probably would, 21% said probably not and 18% said they definitely would not.
"When the vaccine rollout reaches people who are hesitant to receive it, there could be vaccine oversupply that may go to waste"
Stacy Wood, a marketing professor at North Carolina State University, told Nikkei Asia that considering how difficult it is to secure an appointment and go twice for the shots, it takes a strong commitment to get vaccinated. From looking at surveys, a "probably yes" does not indicate a strong commitment.
"If we want to get to 80% [of the population fully vaccinated], it means that we have to have a 100% compliance from the people who say 'definitely yes,' 'probably yes' and 'probably no,'" Wood said. "You can see that it's really a challenge in terms of persuasion. A lot of public health organizations have never been in this situation before."
Wood said that the federal government needs to invest more into public communication to convince enough of the population to receive the vaccines.
Wherry, from the University of Pennsylvania, echoed the concern and called this a long-standing issue.
"I think it tells us about a challenge in our society of trusting facts, believing science and actually messaging how science works in an effective way," he said. "And we need to do a better job about that."
Japan: 'No political will'
In still other countries, including many that initially succeeded in controlling the coronavirus, vaccination efforts are late to begin as complacency takes hold. This is the case in much of Asia, where effective control policies meant many countries could reopen their economies last year after locking down. But early success has caused many to fumble the rollout of vaccines.
Japan's response was one of them. After peaking at 700 in the spring, new daily cases plateaued over the summer, once falling as low as 21 nationwide. But as of Monday, Japan was the only Group of Seven country with zero vaccine doses administered. This absence has become a political scandal for Prime Minister Yoshihide Suga.
The government's unspoken deadline is the Japan leg of the Olympic torch relay -- delayed by a year last summer. If the vaccine rollout has not significantly covered vulnerable populations by the relay's scheduled start on March 25, Japan's postponed Olympics may face cancellation.
Japan began vaccine shopping last June, as the government and pharmaceutical companies deployed negotiators to secure supplies of foreign inoculations.
But Japan has been hamstrung by stringent drug standards -- a legacy of scares involving inoculations for human papillomavirus in 2013 and mumps, measles and rubella in the 1990s. The causality between the HPV vaccine and adverse reactions was unconfirmed, but the MMR vaccine was tied to three deaths. Both vaccines were domestically developed.
Partly due to the lingering effects of these tragedies, Japan has no mechanism similar to the U.S. Food and Drug Administration's emergency approval of the Pfizer vaccine, which happened within a month.
Changes to Japan's pharmaceutical laws in 2014 created a faster drug approval process of nine to twelve months. That kicked up a gear in mid-December when Pfizer applied for fast-track approval, which was cleared after about two months with the first shots scheduled for Wednesday.
Neighboring South Korea, also due to start inoculations this month, cut its approval process for COVID-19 vaccines to 40 days, down from 180.
Nikkei reported in January that Suga, eager for progress on vaccines, asked the Japanese Embassy in Washington to negotiate with Pfizer for clinical trial data. But Japan's Pharmaceuticals and Medical Devices Agency still insisted on conducting local clinical trials before approving the Pfizer vaccine, citing the possibility that the ethnic differences might affect efficacy and safety.
The American CDC said U.S. trials found the Pfizer vaccine was effective across ages, genders and ethnicities. Of the participants, 4.4% were Asian.
Despite its wealth and top research universities, Japan mostly declined to support the development of domestic alternatives, instead readying its purse for programs like Operation Warp Speed in the U.S. to yield viable vaccines.
Takakazu Yamagishi, a professor of political science at Nanzan University, said a domestic COVID-19 vaccine "might have side effects, and people would blame bureaucrats and politicians. The easiest thing to do is import vaccines from abroad."
"Japan has the financial and technical resources to develop vaccines, but no political will," he said.
Additional reporting by Grace Li in Tokyo.
This article has been amended to clarify that a funding gap cited applies to the umbrella entity that includes COVAX.