 An Ivory Coast fan registers to receive the coronavirus vaccine at a vaccination center before watching an Africa Cup of Nations soccer match in Abidjan, Ivory Coast, on Jan. 12. (Luc Gnago/Reuters) | As vaccine shipments finally surge into poorer countries, the world is in danger of trading in one form of vaccine inequality for another, with disparities in access replaced by disparities in the ability to distribute them on the ground. After a trying period of vaccine hoarding by wealthy countries, the last 40 days of 2021 saw more doses shipped to countries in need through the U.N.-backed Covax program than in the rest of last year combined, according to the World Health Organization's vaccine director. But distribution campaigns on the ground can take months to ramp up, even in rich nations, and a host of developing countries now receiving shipments are facing a combination of rollout challenges. Some are the same witnessed during the early-stage campaigns in the United States and Europe — including where, when and how many vaccines can be made available on a regular basis, as well as how to convince the vaccine resistant to roll up their sleeves. On top of that, they're confronting additional complications from often harder-to-access populations and limited resources, particularly poorly funded health-care systems. The World Bank, U.N. agencies, the Gavi vaccine alliance and charities have rolled out efforts and funding to bolster distribution programs in the developing world. But critics contend that not enough resources are being allocated to help poorer countries get shots in arms. The result: A whole mess of vaccines sitting around and waiting to be used as the clock on expiration dates ticks down. According to research by the international humanitarian organization CARE, 32 low- and middle-income countries have used less than half of the vaccines they've received from the Covax program, bilateral donations and other sources. Only 27 percent of received vaccines have been used in Burkina Faso, 37 percent in Ghana and 26 percent in Somalia. Burundi has used only 1 percent of received doses, according to CARE. That's in part, critics say, because there's been a huge global focus on vaccine access — but not enough on how to deploy vaccines when they land. By late November, only 14 percent of the $5.8 billion spent by the World Bank on vaccine assistance went toward distribution, according to CARE's research. Developing countries "don't have the ability to distribute because there hasn't been the corresponding investment, and if they were going to do that, they would have to make such serious tradeoffs in their health systems," Emily Janoch, CARE's director of knowledge management, told me. Kate O'Brien, the World Health Organization's vaccine director, told me last week that distribution funding "is absolutely an issue that we're experiencing and hearing about from countries, that the funding that's needed at the peripheral level where the funding is actually spent is not what it needs to be." Much has been made, perhaps unjustly, about vaccine hesitancy in poorer nations. South Africa delayed coronavirus vaccine shipments in November just ahead of the omicron explosion, with resistance cited as one factor. But experts including Stephen Morrison, director of the Global Health Policy Center at the Center for Strategic and International Studies, told me that while particular countries may face a relative excess of vaccine hesitancy regardless of their economic strata, there is no evidence that reluctance is any greater on average in the developing world than in the United States or Europe. They are, however, combating resistance later on in the pandemic due to massive delays in access, and are doing it with fewer resources than richer nations that have funded expensive marketing and mobilization campaigns and publicity stunts. "Studies after studies are showing that 80 percent of our population is ready to take vaccines if they are available," John Nkengasong, director of the Africa Centers for Disease Control and Prevention, told a World Economic Forum virtual conference last week. "No one can dispute it." Vaccine access still remains an issue in many countries. But increasingly, logistical challenges, staffing problems and doses offered too close to their expiration date — a particular problem with donated vaccines from the West — are replacing access as the primary obstacle. UNICEF this month announced that developing nations had rejected 100 million doses of vaccines that were too close to their expiration date, and their ground games for storage and distribution were not strong enough to ensure use before expiry. African nations are confronting particular challenges with underfunded health-care systems, the Wall Street Journal reported. In Congo, doctors largely stayed away from public hospitals last year "amid a bitter pay dispute with the government." In other countries, including Uganda, Kenya, Nigeria and Guinea, the Journal reported, "strikes by healthcare workers over poor working conditions and low pay have routinely paralyzed the already creaking systems since the outbreak of the pandemic." "Vaccine rollouts depend largely on an effective and efficient healthcare system, this is impossible when healthcare workers are demoralized," Genevieve Begkoyian, the head of health policy at UNICEF in Congo, told the Journal. "You don't expect to achieve much when health workers are frequently going on strike." Officials at CARE say the actual cost for vaccine rollouts in developing countries has been vastly under-calculated by international donors. Take, for instance, Nepal — an exceptionally mountainous and linguistically diverse nation with rural areas that often lack the health-care centers typically used for vaccination drives. Rachel Wolff, CARE's Nepal director, told me that vaccine access ceased being a major problem for Nepal as far back as September. But distribution on the ground has been challenging — and expensive. Covax, she said, had estimated delivery costs there at $3.70 per person in the developing world. But a CARE analysis showed the average actual cost — including sending health-care workers into remote areas with portable cold storage — is actually above $8 for one dose. In Nepal, filled with hard-to-reach communities, the cost per person for two doses is above $18, she said. As a result, vaccination rates in the easier-to-access capital, Kathmandu, is now above 60 percent, far higher than the 36 percent national average. In Nepal, charities are working to fill in the gaps, but, she said, the international community needs to step up with more funding. The distribution challenges on the ground "are a reminder that this isn't over yet, and time is not on our side," she said. | 
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