The man who is trying to save the world is standing in a nursery in a Connecticut home. He's got his laptop in front of him and the sun is shining through the window onto a crib. A mobile is turning in the wind.
Benjamin Schreiber is barefoot, his hair tousled. The 46-year-old looks like he’s just gotten up, but as is the case almost every day, he’s been up since sunrise. Schreiber’s job is among the most important and difficult in the world. As the deputy head of immunization for the United Nations Children’s Fund (UNICEF), he is in charge of ensuring that 2 billion doses of vaccine against COVID-19 reach people in the poorest and most remote countries in the world.
The German leans on a standing desk. A woman and two men appear on the laptop screen in front of him, colleagues from UNICEF based in Panama and Haiti.
Schreiber discusses his "headache” for the day: two countries where progress has stalled. Referring to one, a nation that is difficult for outsiders to access, he says, "It’s not clear how things are going.” In the other, Haiti, a first potential shipment of vaccine has been delayed. The vaccination team seems to be ready, but political and social problems are blocking the shipment. Fuel in Haiti is expensive, roads are poor, budgets were miscalculated. Many Haitians also distrust Western aid and some don’t believe in COVID-19 in the first place. So, what now?
Schreiber has conversations like this every day. On a small scale, they often involve questions about the right way of cooling a vaccine, about finesse in dealing with governments. But the core issue is always global justice.
The novel coronavirus has spread to every continent and infected at least 128 million people worldwide. It has wrecked economies and destroyed families. A global health emergency has been in effect for over a year now.
But even as the first citizens in several industrialized countries are finally getting protection from the virus, many people in Africa, Asia and Latin America are still waiting for vaccination to get underway.
So far, nearly 600 million doses of vaccine have been administered around the world. But nearly two-thirds of them were given in only six countries. About 60 percent of Israelis have been vaccinated at least once, just under half of all Brits and one in 10 Germans. In Namibia, which has a population of over 2 million, less than 1,500 have received jabs. In other African countries, no one has been given a shot yet.
Earlier this year, Tedros Adhanom Ghebreyesus, the head of the World Health Organization (WHO), warned of a "catastrophic moral failure.”
An attempt is being made to prevent this failure: a project called COVAX, a kind of international buyer's club to purchase and distribute COVID-19 vaccines. The World Health Organization (WHO) founded the initiative a year ago, and the vaccine alliance called GAVI and the Coalition for Epidemic Preparedness Innovations (CEPI) are also participating, as is nearly every country in the world.
The goal is for the 92 poorest members to receive as many vaccines as quickly as the 98 richest. The rich countries pay more money into the initiative and the poorest are meant to get discounted or free jabs, with the aim of allowing each country to vaccinate one-fifth of its population by the end of the year. Schreiber’s employer, UNICEF, is tasked with ensuring the vaccines reach their destination.
It represents nothing less than an attempt to equitably vaccinate all of humanity regardless of race or wealth. COVAX wants to make it possible for everyone to help themselves from one pot.
It is a project on a scale matched perhaps only by the fight against climate change. And as with climate change, time is of the essence.
The virus is constantly mutating. Most of the changes have no effect on the danger posed by the virus, but some – like the ones that emerged in Brazil and the United Kingdom – do. And the greater the number of countries that go through uncontrolled outbreaks, the more likely it becomes that the world will have to deal with further mutants, even one that might one day evade current vaccine protection. Even if all German adults are vaccinated by the end of the year, the virus could return one day even more dangerous than before.
So, how is it possible to vaccinate those who are most threatened – the elderly, the sick, health care workers – around the world? How can COVAX still achieve its ambitious goals?
A team of DER SPIEGEL reporters followed the vaccines on their way around the world. They traveled to the vaccine factories in India. To the warehouse in Copenhagen where the shipping of the vaccines are managed. All the way to the final destination: to the health care workers in Malawi, who received their first injections in March. And they observed how a German in a nursery in the United States is planning the distribution of the vaccine.
U.S.: Questionnaires Against COVID-19
While Schreiber conducts his video calls with people from all over the world from his wooden home in Connecticut, his young daughters are scrambling around him. His wife Priya, who is nine-months pregnant, occasionally stops by.
Schreiber, who doesn’t seem like someone who is easily ruffled, sits down at the kitchen counter. He has worked at UNICEF for eight years. He says the biggest challenge last year was to "prepare the countries” in a short time.
COVAX’s proclaimed goal is to ship about 2 billion doses by the end of 2021, which represents around 850 tons of vaccine per month and 1 billion syringes. Thousands of cooling boxes will have to be brought to the most remote corners of the world by Jeep, boat, drone and donkey cart.
Even in normal years, UNICEF vaccinates almost every second child in the world. But the children’s aid organization has yet to face a global pandemic.
Vaccination campaigns are usually planned years in advance, but this time there were only a few months. The recipient countries are highly varied. Some have booming economies and others are failed states. Some have a few hundred thousand inhabitants, others more than a billion.
The countries were asked to explain in writing to UNICEF how they planned to manage the logistics of vaccination – which part of the population they wanted to vaccinate and how they planned to distribute the vaccine from the airports to the rest of the country.
Schreiber read more than 100 of these lengthy plans, most of them twice. He tweaked them and made recommendations for improvements. Most of the time it went well, but sometimes it didn’t work at all. The governments of Tanzania, Eritrea and Madagascar still dispute to this day that COVID-19 is a dangerous disease. And at the moment, nobody knows who is in power in the Central African Republic.
But the effort has been worth it. On Feb. 24, the first COVAX delivery landed in Ghana. The first delivery for Haiti has also now been planned. By the end of March, UNICEF had delivered 20 million doses to 47 countries.
India: The Power of the Manufacturers
Most of the vaccine doses come from a country that itself isn’t wealthy, but is extraordinarily important when it comes to global vaccine production: India. The Serum Institute of India has its headquarters in Pune, in the west of the country. The biggest vaccine factory in the world, it currently produces 2.4 million doses of coronavirus vaccines each day.
This is where the vaccine that is meant to reach large parts of the world is produced, at a price that in all likelihood cannot currently be replicated anywhere else.
A company worker puts on a white protective suit, a hair net and gloves before opening the airlock door to the lab. The valuable cargo rolls by behind protective glass. Fully automated nozzles fill the vaccine into glass vials. They measure only a few centimeters, but they could save entire economies.
Of the more than 39 million vaccine doses COVAX has shipped so far, 28 million have come from laboratories in Pune. The Indians are the main suppliers for COVAX. At the moment, they are mostly producing the British-Swedish AstraZeneca vaccine.
For a while, planes were taking off almost every day with vaccines destined for places like Djibouti, Brazil or Moldova. But in late March, India’s government cut vaccine exports to a minimum.
The numbers of coronavirus cases in India are rising faster than they have in months and millions of citizens in the country of almost 1.4 billion inhabitants are to be vaccinated in the coming weeks, so the government in New Delhi has decided to stockpile vaccines. For COVAX alone this means a delay in delivering 90 million doses to 63 recipient countries.
The bottleneck could last until May. A supplier in South Korea that could help is dealing with production problems. Right now, there is no other alternative to production in India.
About a year after the beginning of the pandemic, the development the international community wanted to prevent has now happened: The world is splitting in two, between countries that are vaccinating their citizens and others that are unable to do so and can only watch as the richer nations get their jabs.
"Nobody is safe until everyone is safe.” That claim that could often be heard in the early stages of the vaccine efforts, including from German Chancellor Angela Merkel, from European Commission President Ursula von der Leyen, from doctors and helpers. It was a nice idea, that when facing the virus, we are all equal.
But the closer the first vaccinations got, the more nervous political leaders became, and the more anxious their citizens also grew. Instead of working together, the rich countries independently ordered vaccines, sometimes twice or four times as many as necessary. COVAX and low-income countries had to make do with what was left. It was no longer about every person’s right to being protected, but about the survival of the strongest. To this day, that power dynamic has changed little.
The egotism of this period is also the reason why people like Mounir Bouazar are now managing shortages.
Copenhagen: The Logistics Center
Bouazar, the head of COVAX logistics in Copenhagen, sprints up the metal steps of a staircase on a March morning. The 39-year-old has a dimpled chin and a subtle sense of humor. "Three to four months” – that’s how long he had to prepare for the start of the first deliveries. He says he hasn’t slept much in the past year. "I don’t really count the number of hours. For me personally, it’s not just a job.”
He is standing above the world’s largest humanitarian warehouse. The 20,000-square-meter (215,000-square-foot) storage complex contains tens of thousands of pallets holding goods for the world’s poorest people. Robot cranes drive the crates from one corner to the other: medication, soccer balls, school notebooks, products for water purification, special food for starving children and, as of recently, syringes for use in vaccinations.
Forklifts hum amid the cranes. Aid leaves the Copenhagen logistics center when a catastrophe happens somewhere in the world, like a war, an earthquake – or a pandemic.
By the end of 2020, Bouazar had ensured that half a billion syringes were distributed to UNICEF’s four warehouses in Copenhagen, Dubai, Panama and Shanghai. Now, with COVAX up and running, thousands of vaccines need to reach their destination every day, ideally at the same time or a shortly after the syringes used for injections arrive.
The pandemic complicates Bouazar’s task. There are few or no flights because of the travel restrictions. The global flight schedule has been thinned out and none of the dozen-and-a-half airlines that have pledged to help UNICEF, for example, fly to East Timor or the Pacific Islands. Vaccines and syringes headed to war-torn Yemen, for instance, must be transported via Nairobi, where Bouazar charters a flight carrying nothing more than a few thousand vials and syringes. This logistical tour de force is a financial disaster. But Bouazar says that "no doses should be lying around, no matter how small.”
Bouazar hopes to ship more vaccine in the second half of the year. "If we have bigger shipments, you could find charter solutions.” If not, he will continue sending lots of small packages on big, empty planes.
There’s one idea that might make Bouazar’s job easier, one that is currently being heatedly debated among politicians and activists: suspending intellectual property rights for vaccines in a manner limited to the duration of the pandemic.
India and South Africa have filed a request with the World Trade Organization to suspend patents on COVID-19 vaccines and drugs, supported by 100 countries. Other companies would then also be able to produce the vaccines.
This happened during the AIDS pandemic, when 2 million people were dying of AIDS every year in southern Africa at the turn of the millennium. At the time, Indian generic drug companies broke international patent law and saved millions of lives with affordable drugs.
The big pharmaceutical companies argue that, unlike then, there is currently a lack of raw materials and expertise and that the request is in vain.
Team leader Lucy Kakowa in Nganja, Malawi: "Looking at Europe gives me goose bumps.”Foto: Thoko Chikondi / DER SPIEGEL
It’s true that there can be no innovation without a return on investment, but it’s also true that few people have thought about how to give the global South the tools necessary to fight the pandemic. Not even the initiators of COVAX.
The biggest criticism of the initiative remains that it turns financially weaker countries into supplicants and doesn’t empower them in any way to help themselves.
Malawi: Fragile Hope
On March 5, the first 360,000 doses were unloaded onto the tarmac at the airport in Lilongwe, the capital of Malawi, from an Emirates aircraft. Malawi’s health minister pointed to the white cardboard boxes with the COVAX stickers and said: "That is hope. Hope for the children, hope for the health authorities, hope for us all.”
Most of the approximately 20 million inhabitants of Malawi live as farmers. The country made it through the first wave of the virus better than many expected. But the second hit hard. Hospitals were overloaded, there were oxygen shortages and a soccer stadium and presidential residence were turned into emergency hospitals.
Twelve days after the first doses arrived, vaccination expert Steve Macheso is standing in a turquoise UNICEF T-shirt in a warehouse in Lilongwe. Ten cold storage rooms stand next to one another. The remains of the COVAX shipment are in the rearmost one, in the eastern end of the warehouse. Refrigeration units rumble inside. Two of the trucks that will transport the vaccines to the country’s hospitals and health centers are parked outside.
AstraZeneca’s vaccine only needs to be refrigerated to 2 to 8 degrees Celsius (36 to 46 degrees Fahrenheit), which makes it attractive to many countries, but for a poor country like Malawi, even that can be a problem. Some parts of the country have only spotty electricity and there is, for example, a shortage of spare parts for thermometers. Now, during the rainy season, roads often turn into mud. The day before, a car carrying vaccine was stuck in the mud for six hours. Doses of vaccine have gone bad before.
To address the problem UNICEF, has acquired a fleet of motorcycles. "We are also looking into boats right now,” says Macheso.
It’s already clear in some countries that not everyone has the same opportunities. City dwellers are vaccinated before rural inhabitants. The elite before the slum dwellers. There are also countries like Syria, where militias are in charge in places where the government isn’t. Others prioritize the military over health workers.
UNICEF tries to quietly influence distribution, but it’s up to the countries to decide what they want to do with their share of the vaccines. COVAX’s jurisdiction ends at the airport. In truth, though, UNICEF workers, including 40-year-old Macheso, often accompany the vaccine further.
On his way to a health center in Njanja in central Malawi, his Landcruiser passes cornfields, markets and villages. Macheso knows that vaccinating the health workers is the easy part. The harder part comes after: in getting the jabs to the rest of the population. "That’s where we expect some resistance,” Macheso says as he tries to access the real-time system on his laptop that tells him how many people have already been vaccinated. A moment later he says: "Data has been entered by just under half of the districts. Some 4,377 people have been registered as vaccinated there.” He sounds happy.
But increasingly negative reports about the AstraZeneca vaccine have been circulating online recently. "We support the government in awareness campaigns. But looking at Europe gives me goosebumps,” Macheso says. That’s because Malawi committed to only one vaccine: AstraZeneca, which has spurred distrust after reports of deadly thromboses.
Macheso’s car turns into a narrow dirt road and stops in front of a low brick building. Health center employees sit on cement benches. Fourteen men and women are to be vaccinated. Five employees didn’t show up.
Lucy Kakowa, the team leader, tells those present about possible side effects, like headaches and fever. "We are happy to be vaccinated now,” she says, explaining that the health workers’ fears have also grown amid the second wave. Then the nurses roll up their sleeves and, as the rain pelts on the tin roof, a colleague in a blue coat readies the syringes.
"First, we vaccinate the people in the health system and social workers, then people with pre-existing conditions, then the elderly,” Kakowa explains. The week after next, she says, they will begin the awareness campaigns in the villages.
Malawi needs 7.6 million doses to fully vaccinate 20 percent of its population. They expect 900,000 more doses from COVAX soon, but Macheso doesn’t know exactly when they will arrive. There should be enough vaccine for the approximately 60,000 employees of the health sector, but, at this point, not much more.
Some experts are already warning that the populations in many poorer countries won’t be vaccinated until 2024. WHO chief Tedros recently asked richer countries to donate doses – 10 million vaccine doses for 20 countries that have yet to receive a single delivery from COVAX.
Germany has provided almost 1 billion euros for the COVAX initiative, and is thus one of the biggest donors. But Berlin doesn’t want to give up its own vaccine either, much like the European Union and the U.S. There, President Joe Biden has said, "If we have a surplus, we’re going to share it with the rest of the world. But we’re going to start off making sure Americans are taken care of first.”
Nevertheless, the vaccines, which are currently a scarce commodity, could soon pile up. Estimates suggest that between nine and 12 billion doses of vaccine could be available by the end of the year. Global herd immunity would then be within reach, but only if the doses can be distributed evenly across the globe.
This would mean that many Africans, Asians and Latin Americans would be vaccinated before many Italians, French or Germans. It would mean that countries would need to share – countries where citizens’ frustrations are already great and the pressure on those in power is growing. On top of that, Germany will elect a new parliament and chancellor in the fall.
The industrialized nations’ vaccination policy has consequences that extend beyond people’s health. Developing nations are once again learning who they can rely on and who they cannot.
At the start of this year, aid workers in Nepal lugged cooling boxes with vaccine to mountain villages in the Himalayas. India had sent its neighbor a million doses of vaccine early on. In early March, a modest delivery from COVAX followed. After that, the flow stopped. And on March 17, the government suspended its vaccination program.
Last week, there was once again reason for the Nepalese to celebrate. A shipment of 800,000 vaccine doses arrived at the airport in Kathmandu, a gift from a friend whom many suspect of having ulterior political motives. The gift didn’t come from COVAX, the EU or the U.S. It came from China.