The idea was born over drinks at the Hard Rock Hotel in Davos Switzerland, on January 23, 2020.
There was a new virus ringing alarm bells in China, but it hadn't yet become an international concern. It didn't even have a name. Yet Seth Berkley was already thinking about how to protect the world with vaccines against it.
Berkley was the CEO of Gavi, the Vaccine Alliance, a nonprofit group dedicated to expanding access to vaccines around the globe.
He and some of his colleagues at the World Economic Forum didn't know whether it would be possible to come up with a vaccine for the virus that would soon be called SARS-CoV-2. But they figured if scientists pulled it off, the next challenge would be to ensure that every country, regardless of its wealth, would have plenty of vaccines for its citizens.
At the bar, Berkley and his team outlined what would become COVAX, the international venture to equitably distribute vaccines. The basic idea was to pre-purchase bulk quantities of vaccines from manufacturers who'd announced plans to develop them — before it was clear whether they'd even work — and when they were ready, ship them to countries equitably, based on their population size, not their ability to pay.
Ultimately, COVAX's success was mixed. Between 2021 and 2023, the entity distributed 2 billion doses, but many low- and middle-income countries lagged far behind wealthier ones.
Now, Berkley has written a new book — Fair Doses — that tells the inside story of the effort and outlines a vision for how the globe might do better next time. NPR spoke with the author, an epidemiologist who stepped down as CEO of Gavi in 2023 and is now a global health consultant, about what went right with COVAX, what went wrong and how in some ways the globe is now less prepared to deal with another pandemic than in January 2020.
This interview has been edited for length and clarity.
You write that the initial idea for COVAX was hatched in late January 2020 at the World Economic Forum. Can you bring me back to that moment, and why you started thinking about vaccine equity even then?
We're talking about a moment where the world had heard that there was some new infectious disease in Wuhan, China. But we didn't know whether it spread from person to person or through the air. Others at Davos were saying this was not a problem. But there were some reports that suggested there might be human-to-human transmission. We didn't know if this was the big one or a dress rehearsal for the big one, but we knew we had to treat it as if it was a big one.
We'd known that when the last pandemic occurred, swine flu, they were able to make a vaccine. But the vaccine stayed in high-income countries, and we worried that's what would happen. So Richard Hatchett (then CEO of the Coalition for Epidemic Preparedness Innovations, or CEPI), myself, my wife, who is a physician, we sat and began to discuss what we might do. We had no money, we had no people and we had no mandate. And so this really was about how to rapidly begin to build that, as I said, not knowing yet what the magnitude was going to be.
What was that vision?
The goal was about trying to have as equitable access as possible. Now some people said that was naive, to think that the developing world would get vaccines at the same time as high-income countries. We knew leaders of high-income countries were going to demand them. The question was could we begin to plan such that we could at least cover the high risk groups elsewhere.
You write "We wanted to buy vaccines that didn't exist with money we didn't have. Countries had to hand over that money to us with no guarantee they were going to get all the vaccine doses they were buying." That strikes me as a very difficult dynamic. How do you do that?
In a pandemic it's all about risk, because you don't know yet what's going to happen. If you want to move forward, you have to spend money on things that you don't know if they're going to work. Now, worst case scenario, you end up spending billions of dollars, and none of the vaccines work. And you know, my head would be on a stake, you know, in that circumstance.
But we had already invested heavily in two things: making vaccines against coronaviruses, after SARS and MERS. And this new technology, mRNA, that was a mechanism to make vaccines super fast. Nobody thought that we would get there in 327 days, which is what we did.
So you ended up raising billions of dollars, and ultimately sent out 2 billion doses between 2021 and 2023. Still, many argued that COVAX failed to live up to its promise. What do you think worked, and what didn't?
This was the fastest and most equitable rollout of vaccines in history. After the first jab in the U.K. (on December 8, 2020), we had the first COVAX vaccine in a low-middle income country 39 days later, in India, and 43 days later it was rolled out in Africa, in Ghana and Côte d'Ivoire.
We ended up sending 2 billion doses to 146 countries. We ended up with vaccine coverage of primary doses of 57% in the 92 poorest countries, which is half of the world's population, and that compares to about 67% you know, global coverage, so not quite equitable, but not that far off.
But we also ended up with lots of problems.
We had vaccine nationalism — we didn't know if any of these vaccines would work, so the rational thing [for a wealthy country] to do, if you had the money, was not to buy one vaccine. But to buy 3,4,5,6 vaccines. And of course, when you do that, you suck up the global supply very quickly..
We also had export bans, we had supply chain problems. And at the end, the poorest countries ended up getting the short end of the stick. There were delays that meant that in the lowest income countries, only about 1% of the population was covered in the first year.
One of the biggest problems was when the Delta variant wave hit India during the spring of 2021, and one of COVAX's major suppliers — Serum Institute of India — stopped shipments abroad, because of a de facto export ban to keep vaccines manufactured in India in the country. Was it a mistake to lean so heavily on them?
The advantage of going to the Serum Institute of India, of course, was it is the largest vaccine manufacturer in the world. We were able to give them money ahead of time to buy equipment to scale up. Ultimately, they were able to deliver 300 million doses a month.
The challenge was that Prime Minister Modi ended up doing some vaccine diplomacy, and India gave some of those doses to other countries outside of COVAX. But then delta hit and there were funeral pyres and horrible death rates, and [critics] pointed and said "Here's the Prime Minister giving out your vaccines to other countries." All of a sudden, exports just stopped.
We tried everything to see if we could work around that, every type of diplomacy, engagement, relationships, we even talked about suing the company. But in the end we couldn't get that released, and that put us 600 million doses behind.
We got accused of putting all our eggs in one basket. That wasn't the case at all. We negotiated with every vaccine manufacturer. We ended up having the largest number of vaccines in the portfolio of anybody. But because most of the vaccines were being bought up by high income countries, we weren't able to get deals with some companies.
What have you learned to make sure that vaccines are more equitably distributed if and when there's another pandemic?
That's the $64,000 question.
Having funds available on day zero, to be able to get in the queues and make deals with vaccine manufacturers is the single biggest thing. Gavi maintains it now has half a billion dollars in capital for that purpose.
I believe the best way to work in a pandemic is to have a network. Not to say, "Oh, we're going to be the institution that does it all." But rather, figure out how does UNICEF help? How does WHO help? How does the World Bank help? How does civil society come together? So again, putting some money aside to be able to create conversations that are regularly happening.
We also need to expand manufacturing of vaccines. Expanding that base gives you more capacity to produce doses. And obviously, if they're geographically dispersed, that's better. Africa has a substantial percent of the world's population, but less than 0.1% of the production of vaccines. Building some facilities there may be helpful, but doesn't guarantee access to all 56 countries in Africa.
Do you think we're more prepared than we were pre-COVID to do this?
It's really about having these discussions and then trying to prepare as best as possible. But one of the challenges after COVID was people didn't want to talk about it, they didn't want to discuss it. And now we are less prepared than we were then.
So what needs to be done to be … better prepared?
The challenge right now is the misinformation and disinformation that's being put out there. It's not only Russian bots, Chinese bots and North Korean bots, it's also now the U.S. Defense Department, it's RFK Jr.
How do you counter all of this?
The way to do that in the past was to go to local experts and get them involved: doctors, nurses, church leaders, community leaders. The problem is when you get a message from the president of the United States, [who in recent months has questioned the effectiveness of COVID vaccines and called for changes in the childhood vaccine schedule] it's much harder to try to reverse that with facts. It's challenging.
And how have the Trump administration's cuts in the funding of foreign aid and health institutions had an impact on preparedness?
We've dismantled institutions and global systems that are absolutely critical, [laid off] the National Security Council people focused on pandemics, responsible people in CDC. Even Gavi, which has had bipartisan support, [the administration] just stopped all funding for it. It's estimated that will mean 75 million kids don't get immunized and could cause an additional 1.2 million deaths.
So what's the solution in your opinion to becoming better prepared?
In the end, the only tool we have is science, and we have to follow science. When a new disease appears on day one, you know nothing. So what you have to do as an expert is to give advice based upon what you do know. But you also have to have a lot of humility. You've got to be willing to say it's going to change, and it's going to change as you get more information. I think we didn't talk about that uncertainty, and we need to do a better job.
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