“We know that we live in a highly unequal world, and it hasn’t become less unequal during the pandemic,” said Saad Omer, director of the Yale Institute for Global Health, at the start of the Y-RISE conference on vaccine inequity and the COVID-19 pandemic on April 28.
The conference featured speakers from a range of sectors—including academia, government, and philanthropy—as well as from countries including Bangladesh, Nigeria, and Sierra Leone, who discussed the ways in which the social, geographic, and economic inequities alluded to by Omer have fueled vaccine inequity in developing countries. They also shared lessons to be learned from the COVID-19 pandemic response about achieving equity through the implementation of better access and delivery models.
In the day’s first panel, Omer and Nobel Laureate Michael Kremer of the University of Chicago discussed how misperceptions about low- and middle-income countries (LMICs) have furthered vaccine inequities. For example, Omer said, perceived vaccine hesitancy in (LMICs) has been used to justify the de-prioritization of equitable global vaccine distribution. However, a study conducted between June 2020 and January 2021 of vaccination attitudes in 10 LMICs showed that baseline vaccine acceptance rates were higher in the LMICs than they were in the U.S. “Anyone with a half-decent set of instruments said that there was some softness in vaccine demand in the U.S., but we never used that as an excuse to decide on the number of doses that were ordered,” said Omer. “It wasn’t even part of the conversation.”
In the conference’s second session, researchers from the Yale School of Management, Stanford, and the University of California, Berkeley shared findings from a large-scale study on mask delivery in Bangladesh that was coauthored by Yale SOM professors Jason Abaluck and Mushfiq Mobarak. Since its publication, the study has driven policy changes and targeted interventions aimed at reducing health inequity during the pandemic.
Later in the day, Mobarak, who serves as faculty director of Y-RISE, addressed another factor in global vaccine inequity: “Access problems are real,” said Mobarak. “Even after you set up big development and distribution mechanisms, you actually need to solve very practical challenges to get vaccines in the arms of people.”
Mobarak offered a glimpse into his ongoing research on scalable and cost-effective treatment interventions for last-mile delivery of vaccines in rural Sierra Leone. He was joined by his study co-author, Dr. Desmond Kangbai of Sierra Leone’s Ministry of Health, and Niccolo Meriggi from the International Growth Centre.
On average, Mobarak said, it takes three hours each way to get to a vaccination center, and the trip costs $6.50—about two weeks’ salary. As a result, “people aren’t vaccine hesitant, but they’re also not vaccine eager,” he said.
The study in Sierra Leone adapted interventions from the model developed in the Bangladesh mask study and brought vaccines and administering nurses directly to remote communities, often on motorbike, where vaccine clinics would be set up for 48 hours. The delivery of the vaccine to the communities was complemented either by door-to-door outreach or small-group outreach to encourage community members to get the vaccine during the 48-hour period.
The research team tested the effects of these interventions using a randomized controlled trial. With door-to-door outreach, vaccination rates went from 7% up to 35%, and up to 32% with small-group outreach.
“If you don't send vaccine doses, then governments don’t have an opportunity to engage in the learning-by-doing and experimentation that’s needed to set up the last-mile delivery systems,” said Mobarak. “We really should not be using hesitancy as an excuse to withhold vaccines from anyone.”
In the final session of the conference, Hakeem Belo-Osagie of Harvard Business School moderated a discussion on healthcare access and equity in Africa.
Panelist H.E. Mallam Nasir El-Rufai, governor of Kaduna State in northern Nigeria, pointed to “limitation in vaccine availability” as a “major problem” in combatting vaccine inequity. “When we mobilize for vaccination and people come out for vaccines and then we run out, trust issues arise. People become despondent that maybe this is all a game.”
Chikwe Ihekweazu, assistant director general of the World Health Organization, said it is important to look at the larger picture when considering issues of vaccine inequity. “It is more a consequence of a deeper issue than an input factor. It really depends on how we look at health, healthcare, and education. Do we look at these things as something the wealthy deserve to have or as a global public good to which every citizen deserves access?” said Ihekweazu.
In his closing remarks, Belo-Osagie sounded the alarm for action to tackle systemic inequity.
Thanks to the speed at which vaccines were developed by the medical and pharmaceutical communities, Belo-Osagie said, “we escaped the worst fears of COVID, but we did so in a manner that left millions if not billions of people unprotected and large groups of the world excluded because of costs. We are left with a critical need to reconnect as a world so that the worst possibilities do not occur in the future.”