National-level Covid-19 vaccination figures can tell a lot about how the battle against the pandemic is going. But they say nothing about the populations most likely to be missed altogether: the many millions who aren’t part of any country’s vaccine roll-out plan: stateless people, refugees, asylum seekers, internally displaced people, vulnerable migrants, and people living amid conflicts or humanitarian emergencies.
The world now has a system in place that can reach them. Last month, 1.6 million vaccine doses landed in Tehran, earmarked for 800,000 Afghan refugees, migrants, and displaced people living within Iran’s borders. But the effort to deliver more doses to vulnerable populations is being hindered by some vaccine manufacturers.
Given the need to protect people — particularly high-risk people — in every part of the globe to stop the spread of Covid-19, any barriers to this project are worrisome. Allowing populations to be missed and go unvaccinated provides space for the virus to replicate unchecked, and for new variants to emerge. People who are overlooked, most of them forcibly displaced by conflict or other crises, constitute a sizeable proportion of the global population and as such, one of the largest Covid-19 blind-spots.
It is estimated that 167 million people, concentrated in low- and middle-income countries, are at risk of outright exclusion from Covid-19 vaccination campaigns. That number is subject to sudden shifts: overnight, a storm, a flood, an intensifying conflict, a toppled government, disputed boundary, or shifted frontline can push hundreds of thousands of people out of health systems’ oversight. More people have been forcibly displaced in the last decade than ever before, because the weather is both more extreme and less predictable and violent conflict is increasingly common.
For everyone, but most starkly for the most vulnerable people, the pandemic has had a compounding effect on insecurity. Not only are these individuals omitted from vaccination campaigns, but many of them are at extra-high risk of contracting the disease because they live in close quarters with limited ability to physically distance or self-isolate and often with poor sanitation.
To be clear: it is the obligation of national governments to vaccinate all people within their borders, regardless of their legal status. But emergencies can knock plans out of sync with reality and, amid supply constraints, national priorities sometimes sideline people who are already marginalized. A recent World Health Organization report found, for instance, that only 17% of national vaccine deployment plans explicitly factored in undocumented migrants. In some places, persecuted minorities exist under the control of hostile governments; in many, undocumented people try to remain deliberately invisible to health authorities for fear of deportation. And somewhere between 60 and 80 million people worldwide simply live beyond the reach of national health care systems, in zones controlled by non-state armed groups.
Ending a global pandemic requires authentically global — and not just international — mechanisms for getting vaccines to unprotected people. One such measure is the COVAX Humanitarian Buffer, administered by Gavi, the Vaccine Alliance, which I lead, and its partners. The buffer recently began its rollout to provide vaccines to displaced people in Iran.
A measure of last resort, the buffer is a flexible, responsive safety net — a reserve of Covid-19 vaccine doses that is untethered from country allocations but is, instead, borderless: ready to be made available to populations of concern, regardless of their location or legal status. That no one must be left behind is both a moral and epidemiological imperative.
Applications to the buffer from humanitarian agencies and country governments on behalf of missed populations are being assessed by an expert group constituted by the Inter-Agency Standing Committee, a forum of United Nations and non-U.N. partners. As I write this, two applications, the first from Iran and a second on behalf of a vulnerable population in Thailand, have been approved so far; a third decision is anticipated imminently. In the coming months, millions of vaccines will make it into some of the world’s Covid-19 blind spots for some of the world’s most excluded people.
But the buffer should already have protected many more vulnerable communities than it has been able to. The reason it hasn’t is that private-sector vaccine manufacturers have not stepped up uniformly to play their part.
To allow Covid-19 vaccine doses to be sent to any country, manufacturers require governments to indemnify them against any liability in the extremely rare cases where people might suffer injury from the vaccine. Needless to say, the humanitarian agencies that are sometimes the only point of contact with the buffer’s populations of concern are in no position to indemnify multibillion-dollar corporations for unlimited amounts of liability.
Unless manufacturers waive these indemnification requirements, vaccine doses cannot be delivered to people in desperate need of them.
After six months of intense effort, just four vaccine manufacturers — Clover, J&J, Sinopharm, and Sinovac — have agreed to waive these requirements for the COVAX Humanitarian Buffer. Since Clover has yet to receive WHO approval for its vaccine, the practical upshot of this legal stalemate is that only three of the eleven vaccines being supplied to countries through COVAX can be deployed to the high-risk, often hard-to-reach communities the buffer serves. In other words, the global community is failing the people who need its help the most.
We need to do better. Protecting highly vulnerable people, and ultimately ending the pandemic, requires the commitment of all stakeholders. In the case of reaching displaced populations with life-saving Covid-19 vaccines, that means all vaccine manufacturers must choose global solidarity over technicalities.
Seth Berkley is a physician, infectious disease epidemiologist, and CEO of Gavi, the Vaccine Alliance.
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