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The Whole World Needs Vaccines Before a Worse Variant Than Delta Arrives

The United States has to put global health first unless it wants a new disaster.

Women line up for a COVID-19 vaccine at a free vaccination camp in Siliguri, India, on Aug. 24.
Women line up for a COVID-19 vaccine at a free vaccination camp in Siliguri, India, on Aug. 24. Diptendu Dutta/AFP via Getty Images

Not long ago in the United States, COVID-19 cases were plummeting, vaccine rates were soaring, and the U.S. Centers for Disease Control and Prevention (CDC) issued “mask-off” guidance for the vaccinated. July 4 was supposed to be “Freedom Day.” Not so fast. The seven-day daily average of COVID-19 cases has spiked to 150,000 and is rising fast, and the CDC has said vaccinated individuals with breakthrough infections have high viral loads capable of efficient transmission.

Science gave us the tools to end the COVID-19 pandemic, but we have been poor stewards, from vaccine hesitancy to states banning mask and vaccination mandates. Americans expected a one-way path to herd immunity and a return to normal. Instead, they face an exponentially worsening delta variant-driven spike, with many months of restrictions on the way. Yet without forceful action, an even worse prospect looms: variants that partially or fully evade our best vaccines.

The delta variant has prompted the White House to announce that if the U.S. Food and Drug Administration (FDA) authorizes the move, starting on Sept. 20 a booster shot will become available for Americans eight months after their second shot of the Pfizer-BioNTech or Moderna vaccine (a decision on the one-shot Johnson & Johnson vaccine will come after the results of a clinical trial)—nursing home residents and health care and emergency workers first, followed by older Americans and then everyone else. To be sure, boosters will help protect against delta and other variants. But giving additional shots to already vaccinated Americans en masse, instead of getting them to the rest of the world, where most people have not had a first shot, is a misallocation of a still globally limited supply of vaccines. If the Biden administration wants Americans to live free of fear of further variants, it needs to vaccinate the world, not only the United States.

Not long ago in the United States, COVID-19 cases were plummeting, vaccine rates were soaring, and the U.S. Centers for Disease Control and Prevention (CDC) issued “mask-off” guidance for the vaccinated. July 4 was supposed to be “Freedom Day.” Not so fast. The seven-day daily average of COVID-19 cases has spiked to 150,000 and is rising fast, and the CDC has said vaccinated individuals with breakthrough infections have high viral loads capable of efficient transmission.

Science gave us the tools to end the COVID-19 pandemic, but we have been poor stewards, from vaccine hesitancy to states banning mask and vaccination mandates. Americans expected a one-way path to herd immunity and a return to normal. Instead, they face an exponentially worsening delta variant-driven spike, with many months of restrictions on the way. Yet without forceful action, an even worse prospect looms: variants that partially or fully evade our best vaccines.

The delta variant has prompted the White House to announce that if the U.S. Food and Drug Administration (FDA) authorizes the move, starting on Sept. 20 a booster shot will become available for Americans eight months after their second shot of the Pfizer-BioNTech or Moderna vaccine (a decision on the one-shot Johnson & Johnson vaccine will come after the results of a clinical trial)—nursing home residents and health care and emergency workers first, followed by older Americans and then everyone else. To be sure, boosters will help protect against delta and other variants. But giving additional shots to already vaccinated Americans en masse, instead of getting them to the rest of the world, where most people have not had a first shot, is a misallocation of a still globally limited supply of vaccines. If the Biden administration wants Americans to live free of fear of further variants, it needs to vaccinate the world, not only the United States.

Variants arise all the time when viruses replicate and then mutate to become “fitter” pathogens. Most mutations are harmless, but some give the virus an advantage in surviving—as with delta. If SARS-CoV-2 mutates to enable it to evade vaccines, it will be more likely to survive, replicate—and dominate.

If enough people are vaccinated, there will be very few infections and chances for vaccine-evading or other dangerous new variants to arise. The bigger the pool of infected individuals, the quicker variants emerge. And it doesn’t matter where they emerge—they’ll reach the United States. The only way to avoid the very real risk of the nightmare scenario of COVID-19 variants that defeat today’s vaccines, then, is to get the world vaccinated now. The all-too-possible alternative: a reset of the COVID-19 clock, perhaps millions more deaths as scientists race to produce new vaccines, and our reliving the immense economic and social harm that we thought was behind us.

The danger is real. This year, a People’s Vaccine Alliance survey of epidemiologists and infectious disease experts in 28 countries found that two-thirds of respondents expected that mutations would render current vaccines ineffective within a year. Here’s what we need to do now to give ourselves the best chance of keeping this nightmare confined to the stuff of our darkest dreams, not real life.

In the United States, the path forward begins with mandates. As some have done, all states and municipalities should mandate vaccines for government employees, health workers, teachers and other school employees, and older students—and all students once the FDA approves COVID-19 vaccination in younger children. Private employers should issue comparable mandates for their employees. The FDA’s full approval of the Pfizer-BioNTech vaccine for people 16 and older has enabled a number of mandates to take force—but far more are needed.

The Biden administration should expand on its recent move to withhold Medicare and Medicaid funds from nursing homes that do not require their employees to be vaccinated and similarly withhold certain funds—also in a tailored approach to pass constitutional muster—from universities and other private entities without such mandates, as well as incentivize state mandates. Vaccine mandates should be coupled with vaccine passports, requiring vaccines to engage in certain activities. States and localities should continue to expand incentives, and the CDC could share real-time data on promising approaches.

While U.S. supplies are ample, access remains a barrier for some. The larger problem is vaccine hesitancy and reluctance. Localities, with federal support, should develop armies of vaccine facilitators to address each unvaccinated individual’s reasons for not getting vaccinated. They would go door-to-door, answer the concerns of the unvaccinated, and connect them to trusted local sources of information and resources to overcome access barriers.

Vaccinating Americans won’t be enough. The variants that have caused the most trouble began abroad, where the vast majority of infections are now occurring and most people remain unvaccinated. Only three doses have been delivered in low-income countries for every 200 in high-income countries.

The Biden administration provided $2 billion to the COVAX Facility, the main global vaccine distribution mechanism, with another $2 billion coming by the end of next year. That is too slow. The administration should provide the funds now and, along with other wealthy countries, contribute all additional funds as needed.

Four more steps are foundational. First, accelerate and increase the United States’ vaccine donations. President Joe Biden’s pledge of 500 million Pfizer doses to COVAX is insufficient.

Second, the United States needs to ensure sufficient production to meet global vaccination needs. Production targets will need to accommodate the reality of the growing use of third shots for immunocompromised people and booster shots for other already vaccinated populations in wealthier countries—including, most likely, the United States beginning next month—and growing evidence of the need for booster shots for at least some populations. An appropriate target would be production sufficient for global vaccination of at least 80 percent of populations (including children), including boosters as the evidence dictates.

Even with global production ramping up, we need licensing (voluntary or through emergency powers), technology sharing, and open technology and intellectual property to increase production capacity to ensure a steady future supply, including much faster scale-up for new vaccines if required.

Third, many lower-income countries lack the infrastructure to deliver the vaccines, already leading to expired doses. Inexplicably, the Biden administration cut funding for vaccine infrastructure to pay for Pfizer donations. The United States should instead lead the way with vaccine infrastructure funding.

Finally, the World Health Organization should immediately develop, with full U.S. backing and assurances of funding, implementation, and leadership, a road map that determines that fastest route to global vaccination, combining the current pipeline with how to most efficiently increase production to cover any shortfall and the funding and logistical support each country requires. Biden should then host a global pledging conference to fill the funding need.

We have witnessed the marvel of human ingenuity and the ingenuity of the virus, a microscopic organism that is but on “the edge of life.” Human wisdom or human foolishness will tip the scale between the two to determine what our future holds.

Eric A. Friedman is the O'Neill Institute’s Global Health Justice Scholar and the Project Leader for the Platform for a Framework Convention on Global Health (FCGH).

Lawrence O. Gostin is University Professor at Georgetown University and director of the O'Neill Institute for National and Global Health Law and is the Founding O'Neill Chair in Global Health Law.

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