On April 15, 2020, I wrote a column in TIME magazine on the race to develop COVID-19 vaccines. The good news, I said, is that “ the time from ‘lab to jab’ could be as short as 12-18 months,” which has thankfully turned out to be true. Tomorrow, Britain becomes the first Western nation to start a mass immunization campaign.  But I also sounded a warning bell, saying:

“There’s no guarantee right now that when COVID-19 vaccines are ready, they will actually reach everyone who needs them. There’s a serious risk that rich countries will monopolize the vaccine, leaving poor countries behind. Such behavior by the rich world would not only be immoral but disastrous to their own health and recovery too, and the selfishness would upend our global efforts to shut down the pandemic once and for all.”

Why was I so nervous about this scenario? Because, as Shakespeare said, "What's past is prologue." The historical actions of rich nations during pandemics gave me a pretty good sense of how they would behave during COVID-19. During the 2009 swine flu pandemic, rich countries like the United States, Canada, and Australia entered into bilateral deals with vaccine manufacturers to secure huge advanced orders, which meant that poor countries received vaccines much more slowly and in smaller quantities.

And here we go again.  My worst fears have sadly come to fruition, and then some. Research conducted by my colleagues at Duke University has shown that almost 10 billion doses of COVID-19 vaccines have been reserved already, through advanced purchase agreements, and most of these were purchased by rich nations. Canada has bought enough doses to vaccinate its whole population six times over, and Britain and the US are not far behind, securing enough to vaccinate their populations four times over. Rich nations have flexed their market power to buy up over 80% of all doses of the first two vaccines that showed high efficacy in phase 3 trials—the Pfizer/BioNTech and Moderna vaccines. 

So where does that leave low-income and lower middle-income nations? When it comes to securing doses for these nations, all eyes are on the new COVAX Facility, a mechanism for pooling the purchase and procurement of vaccines.

High-income and upper middle-income countries can participate in the Facility as “self-funded” countries. When they join, they commit to buy enough doses from COVAX to vaccinate 10%–50% of their populations and they also make an upfront payment to support vaccine development and manufacturing. Low-income and lower middle-income countries are automatically enrolled as “funded” countries. By the end of 2021, COVAX hopes to be able to distribute two billion doses to these COVAX-funded countries, financed by official development assistance—enough to cover 20% of their populations (hopefully they will prioritize high-risk people such as health workers and the elderly). 

But Houston, we have a problem. COVAX has only secured 700 million doses so far. That's way too little to resemble anything close to global fairness, justice, and equity.

When I was thinking about how to redress this imbalance, one person came to mind: the South African activist Zachie Achmat. In 1998, Achmat went public with his HIV diagnosis and in an act of remarkable solidarity, he said he would refuse to take antiretroviral medications until all in South Africa who needed them had access to them.

In an era of COVID-19 vaccine nationalism, what might a similar act of solidarity look like?

In a global campaign for a “people’s vaccine,” one action inspired by Achmat would be for all governments worldwide to commit to prioritizing the vaccine for high risk people everywhere on the planet. Let’s say that the initial supply of vaccine is two billion doses in total, enough to vaccinate one billion people (assuming a two-dose regimen), or around 13% of the global population; an equitable approach would be to ensure that these doses go to high-risk people in all nations first. Then as the supply ramps up, doses would be allocated to lower risk groups.

Clearly, this is not what rich countries intend to do. They plan to vaccinate their entire populations as soon as possible.

But what if enough low-risk people in these rich countries stood up and said they would be willing to wait until vulnerable people in COVAX-funded nations have been vaccinated first?  Might this be enough of a signal to rich country governments to show that their citizens do care about global equity?  Perhaps it could send a message that no rich nation needs enough doses to vaccinate their whole populations four to six times over and that these unneeded doses should be donated to the COVAX Facility.

Clearly, President Trump would not listen. Today he signed an “America first” executive order that mandates that Americans get vaccinated first before any doses are sent outside the country.

But the incoming Biden administration is likely to return the US to a multilateral approach in global health. There is some hope that Biden may join COVAX and may realize that we need global vaccine herd immunity to end this pandemic.