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February 20th, 2021 
Awake Goy 
Above photo: Mpilo Central Hospital in Bulawayo, Zimbabwe, one of 130 countries that don’t have COVID-19 vaccines yet. KB Mpofu/Stringer/Getty Images.
On 6 January, gastroenterologist Leolin Katsidzira received a troubling message from his colleague James Gita Hakim, a heart specialist and noted HIV/AIDS researcher. Hakim, chair of the department of medicine at the University of Zimbabwe, had fallen sick and had tested positive for COVID-19. He was admitted to a hospital in Harare 10 days later and moved to an intensive care unit (ICU) after his condition deteriorated. He died on 26 January.
It is a crushing loss to Zimbabwean medicine, Katsidzira says. “Don’t forget: We have had a huge brain drain. So people like James are people who keep the system going,” he adds. Scientists around the world mourned Hakim as well. He was “a unique research leader, a brilliant clinical scientist and mentor, humble, welcoming and empowering,” wrote Melanie Abas, a collaborator at King’s College London.
But Hakim’s death also highlights a stark reality in the global response to the coronavirus pandemic. Countries in Europe, Asia, and the Americas have administered more than 175 million shots to protect people against COVID-19 since December 2020, with most countries giving priority to medical workers. But not a single country in sub-Saharan Africa has started immunizations—South Africa will be the first, this week—leaving health care workers dying in places where they are scarce to begin with.
The exact toll of COVID-19 among health workers is hard to gauge, but Hakim was one of several prominent doctors to succumb in recent weeks in Africa, which has suffered a second pandemic wave. Just 1 day before him, U.S. physician David Katzenstein, who had moved to Harare after his retirement and directed the Biomedical Research and Training Institute there, died from COVID-19 at the same hospital. Those losses stand for many others, says Robert Schooley, an infectious disease researcher at the University of California, San Diego, who worked with Hakim for many years. “We don’t hear about a lot of the others who are laboring in the health care workforce behind them.”
Neighboring Mozambique lost an anesthesiologist, a gastroenterologist, and a urologist in recent weeks, says parasitologist Emilia Noormahomed of Eduardo Mondlane University, as well as two young general care physicians. Several more are seriously ill. Such losses hit hard in Mozambique, which only has about eight doctors per 100,000 people, compared with almost 300 in the United States. “It will literally take an entire generation to rebuild” from such losses, says Ashish Jha, dean of Brown University’s School of Public Health.
Global inequities have existed since the start of the COVID-19 pandemic. ICUs, ventilators, and oxygen are scarce throughout the African continent, for instance. But in the early months, the basic public health measures required to control spread of the virus put countries more or less on an equal footing, says John Nkengasong, head of the Africa Centres for Disease Control and Prevention. And Africa has weathered the pandemic relatively well, in part because of its young population.
But now, the rollout of vaccines has put rich countries at a definitive advantage. Many have bet on several vaccines and signed contracts for enough doses to immunize their populations several times over, constraining supplies for the rest of the world. According to the World Health Organization (WHO), three-quarters of all vaccinations so far have happened in 10 countries that account for 60% of global gross domestic product; 130 countries have yet to administer a single dose. “I don’t know why there isn’t a massive clamor to do something about that,” says Gavin Yamey of Duke University’s Global Health Institute. “The world is on the brink of a catastrophic moral failure,” Tedros Adhanom Ghebreyesus, the Ethiopian-born director-general of WHO, said in January. In a joint statement last week, he and UNICEF Executive Director Henrietta Fore called on governments that have vaccinated health workers and those at highest risk to share doses with other countries, and on vaccine manufacturers to allocate vaccines equitably.
The equity gap could soon extend to COVID-19 therapeutics, as well. The first drug convincingly shown to cut the death rate from the virus, a steroid named dexamethasone, is cheap and used around the world; Hakim received it before he died. But tocilizumab, shown to further reduce mortality in a U.K. study released on 11 February, is an antibody that’s about 100 times more expensive than dexamethasone and not widely available. “The [pandemic’s] second wave, and potentially the third, is fought with a combination of public health measures and biomedical interventions, and that will increase the inequities,” Nkengasong says.
Beyond the moral argument, there are sound economic and public health reasons to close the gap. Vaccinating those most at risk around the world would drive down hospitalizations and deaths everywhere sooner, allowing societies to reopen and economies to recover. It could also help reduce circulation of the virus globally, lowering the risk of new virus variants emerging.
WHO and other international organizations have worked to reduce the gap through the COVID-19 Vaccines Global Access (COVAX) Facility, a joint mechanism to procure billions of doses of several vaccines and distribute them to participating countries. It is beginning to pay off, albeit slowly: On Monday, WHO gave an emergency use listing to two versions of the AstraZeneca–University of Oxford vaccine, manufactured by the Serum Institute of India and SKBio, a South Korean company. COVAX expects to start supplying countries with these shots this month and to ship more than 300 million doses in the first half of the year, including 1.15 million to Zimbabwe and 2.43 million to Mozambique. It is also planning to distribute 1.2 million doses of the Pfizer-BioNTech vaccine.
Bruce Aylward, a senior adviser to Tedros, concedes the initial supply is only enough to cover a small part of many developing countries’ populations. “But the reality is, we’re going to get a lot more doses to a lot more people in a lot more places a lot faster than ever would have happened without the COVAX Facility,” he says.
To secure more vaccine sooner, African countries have formed a vaccine acquisition task force that, with funding from mobile phone company MTN Group, has already bought 7 million doses of the AstraZeneca-Oxford vaccine. The first 1.5 million doses should be shipped to 19 countries on 22 February, allowing health care workers in those countries to be vaccinated by the end of that week. The overall aim is to vaccinate about 35% of the population in African countries before the end of the year and then another 25% next year, Nkengasong says. (Many Western countries hope to have their entire populations covered by this summer or fall.)
Schooley thinks the United States should take a more active role in protecting health care workers in countries such as Zimbabwe. The U.S. President’s Emergency Plan for AIDS Relief, launched in 2003, has saved countless lives by providing more than $80 billion in the fight against HIV, he notes. “We have worked with our counterparts in sub-Saharan Africa for 20 years to try to help them build a more resilient health care infrastructure,” Schooley says, “and we’re sitting on our hands watching that be torn apart by the coronavirus.”
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