Relentless pursuit of an equitable world

The Optimist

Vials in lab

Fighting COVID-19 globally—and specifically

As far as historically significant documents go, an “investment case” for the Access to COVID-19 Tools Accelerator (or ACT-A) doesn’t seem like much of one at first. The title is, admittedly, more wonky than grand. But the plan, which is actually a collection of strategy documents released last week by big global health organizations1, is a turning point in the global fight against COVID-19.

The WHO officially declared the virus a global public health emergency on March 11, and since then the case has been made (mostly via teleconference) that leaders should address the crisis not as a group of 195 uncoordinated nations, but as one world. “We must attack the virus the way it is attacking us,” our foundation’s co-chair, Melinda Gates has said, “Globally.”

At a high level, the world has known how such a response would work for some time: Pharmaceutical companies are sprinting to produce drugs and SARS-CoV-2 vaccines, and while each nation could strike deals with those drug and vaccine developers individually, it’s a risky proposition. What if they back the wrong horses? Instead, nations can reduce their risk by pooling their R&D funding. They can back all the horses—or at least all the ones that appear to have a chance at finishing fast.

But while the broad strokes of the global response have been clear, the finer details haven’t been. For instance, a very common—and understandably concerning—question is: Once new tools are ready, who gets priority?

Among other things, an effective global response means that tests, treatments, and vaccines can’t just go to the highest bidders. They must be distributed fairly and effectively, in a way that will end the pandemic fastest and with the least possible impact to life and the economy. But what does a fair and effective response look like? And how much will it cost?

The way to limit the length and deadliness of this pandemic is to focus on the individuals who are most at risk for catching, transmitting, and dying of COVID-19.

Mark Suzman


Bill & Melinda Gates Foundation

With the ACT-A investment case, we’re starting to see more specific answers to these questions, and where specifics are still elusive, we’re starting to see why: Leaders (both of governments and international organizations like the WHO) are getting deep into the difficult questions that don’t have hard answers yet—and maybe never will—but still need to be considered thoughtfully if we want to end this health crisis fast.


What does a “fair and effective” response look like?

Let’s take vaccines as an example.

By the end of 2021, the ACT-A aims to deliver two billion doses of the COVID-19 vaccine around the world, including low-income nations. That’s what the plan calls for at least, and the logistics, while not easy, are certainly possible. The Coalition for Epidemic Preparedness Innovations, which is co-leading the ACT-A’s immunization effort, has several promising vaccine candidates in development, and Gavi, the Vaccine Alliance, the other co-leader, has helped immunize three-quarters of a billion children over the past 20 years, sometimes in remote villages and war zones. They know procurement and distribution.

The problem is less complex logistics than basic math: Two billion doses is not enough for all seven billion of the world’s people, even if only one dose of vaccine is required (it will likely be more). It may take years to manufacture and distribute all the billions of doses necessary.

This is a problem that begets an obvious question—Who gets first priority?—and in a narrow sense, the plan provides some guidance: Start with frontline health workers. But the plan also stops short of writing a full list in stone because there are complicating factors that must be taken into account: What if Western Europe is experiencing a second spike in cases at the time a vaccine is ready while Southeast Asia is seeing relatively few? Should a nurse living in the latter still get priority over a construction worker living in the former?

Or what happens, for instance, if a specific population in one country is dying at disproportionate rates, as Black Americans are?

This, as I mentioned, is where things get difficult. The way to limit the length and deadliness of this pandemic is to focus on the individuals who are most at risk for catching, transmitting, and dying of COVID-19. But that risk is a calculation involving innumerable variables—not just job, age, or health status. There is, to use a very wonky phrase, far more than one “axis of equity” needing consideration here.

To be clear: Our foundation won’t decide the answers to these difficult questions. The World Health Organization will provide guidance, but it’s up to individual nations to decide how to distribute vaccines among their populations. Hopefully, they will do it as thoughtfully as possible.


Some people have compared the task of distributing a COVID-19 vaccine to boarding an airplane. It’s a useful metaphor in that prioritizing who pays the most isn’t efficient in either case. (Here’s an interesting article about the speediest way to queue up for a plane. Hint: First-class doesn’t go first). Beyond that, however, the analogy starts to break down.

The world doesn’t really change much between the beginning and end of a plane’s boarding process. But with COVID-19, the situation is evolving day-to-day. Hotspots emerge, then cool. The curve peaks, then flattens, and in some cases rises again. Research yields new insights about how the virus infiltrates bodies and attacks lungs, sharpening our understanding of who is at risk. To torture the metaphor, it’s as if we’re trying board the plane as it transforms from a Boeing 747 to an Airbus A380 to a refrigerator with wings.

In the end, a queue may not be a perfect analogy for understanding what a “fair and effective” looks like. There may never be hard-and-fast rules for who should be first-in-line for a vaccine, who should be last, and who should be in between. The order will vary by location and evolve as the pandemic—and our understanding of it—does. Indeed, the crux of an equitable response lies in studying and considering all the many ways the virus is affecting different people differently and using that to inform the distribution of goods and services.

This is, I admit, a complex and unsatisfying answer, but it is far preferable to a simpler and more satisfying one. After all, the simplest answer is just vaccine nationalism: For each country to compete against all the others for its own supplies, and not worry about the wider world.


Don’t forget about drugs and tests

A vaccine is unlikely to reach everyone before the end of 2022. Probably longer. So, what’s the plan until then? To stop the spread, there are what epidemiologists call non-pharmaceutical interventions—masks, hand washing, physical distancing—but the ACT-A is also working on the pharmaceutical kind, too. In other words, drugs.

At the start of the pandemic, each week seemed to bring about a potential new miracle cure that quickly was revealed to be neither a miracle nor a cure. Clinical trials and news cycles, after all, don’t move at the same speed. The fortunate news, however, is that trials for COVID-19 therapeutics have moved fast enough for there to be several potential approaches in the pipeline, including a few like dexamethasone and remdesivir, which appear to be partially effective in serious cases of the virus. Within 12 months, the ACT-A plans to produce and distribute 254 million treatments like these in the poorest parts of the world.

It also aims to test for COVID-19—and test broadly.

There are many big fears in the time of COVID-19, and one is that we are fighting this disease blind in some parts of the world. In places that lack testing, the disease may be spreading silently, which is why ACT-A plans to bring at least two new COVID-19 diagnostics to market, and train 10,000 healthcare professionals to do the diagnostics across 50 countries. Providing governments better epidemiological intel can help them take measures to slow transmission. ACT-A estimates that it can avert 1.6 billion cases of the virus globally this way.


Big $ in one context, pennies in another

What will it cost to develop and deliver all these vaccines, drugs, and diagnostics? This is one question where the plan has a very specific answer: $31.3 billion over the next 12-18 months, of which $27.9 billion is still needed.

Most of it (hopefully) will come from the world’s wealthiest nations, and it’s undeniably a big ask. Twenty-eight billion dollars is more than twice what the United States—the world’s largest donor of health aid—spends a year.

The usual foreign aid budgets, however, are probably a poor benchmark to measure this effort against. The challenge we’re facing, after all, is anything but usual. In fact, the $27.9 billion price tag is less than 0.3% of what governments have committed to economic stimulus packages in 2020, and the ROI of delivering vaccines, diagnostics, and drugs equitably would be enormous: Shortening the length of the pandemic by even one month could save the global economy $375 billion.


First poetry, now prose

“You campaign in poetry,” the dictum goes, “but govern in prose.”

The many speeches and statements given over the past few months in favor of global cooperation certainly have been important poetry. It was far from certain that the majority of nations would agree to cooperate in their COVID-19 response. (Witness: The United States stepping back from the international institutions it helped create.) But with the virus continuing to spread around the world—and the race to develop drugs and vaccines continuing apace—it’s good the world is adding some prose to the poetry, and to the campaign for global cooperation, some governance.

1 ACT-A is led by CEPI, Gavi, the Vaccine Alliance, the Global Fund to Fight AIDS, Tuberculosis and Malaria, Unitaid, FIND and the Wellcome Trust.

About the Author

Mark Suzman
Mark Suzman, the CEO of the Bill & Melinda Gates Foundation, leads the foundation's efforts to promote equity for all people around the world.

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