It’s Time For A Biden Plan To Help Vaccinate The World Against COVID—And End This Pandemic For Good. Here’s What It Should Include.

On April 28, President Biden gave his first major address before a joint session of Congress, reflecting on his first 100 days in office and his administration’s major legislative priorities ahead. Much of his speech predictably focused on the COVID-19 pandemic, sparking optimism about a quick American recovery given the more than 200 million vaccine doses already administered at the time. But to many listening around the world, one issue was conspicuously absent from President Biden’s remarks: a bold American plan to help vaccinate the global population and bring an end to the pandemic still claiming over 10,000 lives each day globally.

Behind the scenes, there has been considerable debate among Biden-Harris administration officials about precisely when to allow other countries to tap into US vaccine supplies, and how. According to latest projections, the US will have a surplus of several hundred million vaccine doses by July—an enormous stockpile that might swell to 1 billion by end of the year. Meanwhile, other countries—many of which have yet to receive a single vaccine dose—have been clamoring for access to these vaccines with limited success to date.

In recent weeks, however, the Biden-Harris administration has signalled a shift in strategy, likely given that nearly two-thirds of American adults have already received a shot. First, President Biden announced that the US would share up to 60 million doses of the AstraZeneca vaccine with the international community after a federal safety review. On May 17, the White House pledged an additional 20 million doses, this time from its domestic supply of Pfizer, Moderna, and J&J vaccines. And in perhaps the most surprising move yet, the administration announced it would support a temporary waiver of COVID-19 vaccine patent protections under the World Trade Organization’s modified Trade-related Aspects of Intellectual Property Rights (TRIPS) agreement—a policy shift widely praised by humanitarian organizations, health experts, and political leaders around the world.

These decisions highlight the Biden-Harris administration’s intent to take on a growing leadership role in the global crisis response. However, the White House has yet to publish a comprehensive strategy and implementation timeline for its global vaccination effort, beyond a brief statement and factsheet released this week. Administration officials have only shared allocation details for a small portion of the 80 million doses pledged to date—and there is still considerable uncertainty about exactly how and when the bulk of American vaccines and related technology will reach other countries. Meanwhile, negotiations to formalize the TRIPS waiver may drag on for months, delaying large-scale vaccine production in low- and middle-income countries (LMICs) to 2022 or later.

The Time To Respond Is Now

The time is now for decisive action to release more of the US vaccine stockpile and commit to a clear strategy for global vaccination. The US will likely have enough doses of the Pfizer and Moderna vaccines on hand by mid- to late June to fully vaccinate the entire American population—without even having to resort to other vaccines in its expanding portfolio. Meanwhile, there are clear epidemiological and ethical imperatives to accelerate the pace of vaccine shipments abroad.

The US delayed response to the ongoing surge of cases in India is an example of too little, too late in terms of mobilizing US resources. Immediate deployment of the US vaccine surplus will help limit future transmission and avert further surges of the virus. Notably, policymakers must also consider that the protection offered by existing vaccines will decrease over time as the virus mutates and new variants emerge—which is why researchers are working on new vaccines and boosters for the current vaccine. Vaccines on hand should be deployed as soon as possible. The example of the virus’s resurgence in Brazil, with growing transmissibility and mortality, highlights the need for an accelerated pandemic response that prioritizes equitable vaccine allocation.

The humanitarian and diplomatic implications of how quickly the US begins sending shots abroad are just as profound as the epidemiological situation. So far, populations in the 29 lowest-income countries have received just 0.3 percent of all vaccines administered worldwide. This translates to fewer than 1 in 500 people vaccinated in these nations, compared to roughly 1 in 2 in the US. Monopolization of global vaccine manufacturing by high-income countries is driving this shocking inequity; for example, the US, UK, Canada, and EU have so far ordered roughly 4 or more vaccine doses for every one of their residents—forcing poorer countries to wait even longer for their turn. South African President Cyril Ramaphosa has called it “tantamount to vaccine apartheid » for “populations of advanced, rich countries [to be] safely inoculated while millions in poorer countries die in the queue.” Meanwhile, Russia and China have both produced their own vaccines, either selling or donating them widely for diplomatic and economic gain—and the EU is racing to start its own vaccine-exporting effort. By taking quick, decisive action to resolve the vaccine crisis, the Biden-Harris administration stands to not only solve a looming humanitarian and diplomatic catastrophe, but also demonstrate principled leadership on the world stage after years of isolationism and waning global influence under the Trump administration.

A Plan For Global Progress

We call on the Biden-Harris administration to immediately release a detailed plan for how the US will manufacture, distribute, and license COVID-19 vaccines to the world on a massive scale in order to bring a swift end to the pandemic. Similar in size and scope to the Marshall Plan that rebuilt Europe after World War II, this plan would entail a landmark commitment of US vaccine resources and expertise to the world in order to stop COVID-19’s spread, restore global economic activity, and rebuild international institutions to better secure global health in the post-pandemic world.

We believe that this “Biden Plan” should include the following components:

A Commitment To Begin Sharing At Least Half Of America’s COVID Vaccine Surplus With The World By Early Summer

While the White House has floated several cautious targets over the last few weeks, the time is now for a bold, verifiable, and sustained commitment. A bipartisan CSIS commission studying available policy options recently suggested that the US begin by donating 10 percent of surplus stock over the summer, then gradually ramp this share up to 50 percent by the end of 2021. A more aggressive timeline is appropriate, considering that the US has already offered vaccines to the entire US adult population and is now expanding access to adolescents aged 12–15 years old—a move that World Health Organization (WHO) Director General Tedros Ghebreyesus urged wealthier nations to postpone in order to first vaccinate high-risk populations abroad. Releasing at least half of US vaccine production to LMICs within the next few weeks is an ethical and epidemiological imperative. Moreover, this strong start will be necessary to get the world on pace for immunization targets recently announced at the World Health Assembly, including 10 percent coverage of every country’s population by September, and 30 percent by end of year.

Importantly, the US government should make all vaccines in its portfolio available as part of this commitment, given their varying indications, handling requirements (i.e. cold-chain), dosing schedule, and performance characteristics. For example, it is important that the US government make available vaccines that are epidemiologically appropriate to countries given regional differences in predominant variants of concern. Preliminary data suggest the mRNA Pfizer and Moderna vaccines are both effective in the real world and efficacious against recently reclassified variants of concern, while the AstraZeneca vaccine also appears efficacious against at least some of these variants. However, evaluation of these and other vaccines continues as new variants continue to emerge, including a recently detected strain in Vietnam that is a hybrid of two known variants of concern first identified in India and the UK.

An Equitable Allocation Framework For Donated Vaccines, Considering Humanitarian, Diplomatic, And Epidemiological Risks And Benefits

Given the enormous unmet global demand for COVID-19 vaccines, the Biden-Harris administration will no doubt face difficult decisions about where to send doses as they become available. While emerging epidemiological and diplomatic considerations will likely hold significant weight, the administration should maximize technical objectivity by leveraging and helping to strengthen operational aspects of multilateral efforts like the Gavi COVAX Facility wherever possible. We strongly support the administration’s pledge to allocate at least 75 percent of vaccine doses to the COVAX multilateral pool, which will help ensure fair allocation to all countries.

The administration should simultaneously make clear the principles guiding any bilateral or other ad hoc vaccine-sharing arrangements, grounding them in transparent global health system strengthening and humanitarian frameworks. So far, the White House has indicated it will reserve the remaining quarter of its vaccines for direct donation—instead of through COVAX—prioritizing health care workers and the US’s closest neighbors, among other groups. As Dr. Agnes Binagwaho, the former Rwandan Minister of Health, has declared, we must be careful not to allow COVID vaccine distribution to perpetuate discrepancies in “the valuation of human life solely based on where an individual lives.” Numerous recent proposals by bioethicists could serve as a template to help redress this issue in vaccine allocation plans. Importantly, the US must ensure that migrants, refugees, and other vulnerable populations are not left behind in such a framework.

A Roadmap For How The US Can Support Global Vaccine Manufacturing, Especially In Lower-Income Countries And Territories

Meeting global demand for COVID-19 vaccines will depend on manufacturers around the world working together to expand supply. However, waiving patent protections through the TRIPS agreement is unlikely to expand global vaccine access by itself in the short term. Manufacturers will still need the raw materials, proprietary know-how, and facilities to scale-up production even once they have the vaccine blueprints in hand.

To address upstream bottlenecks in the existing supply chain, the US can source and ramp up manufacturing of key raw materials and reagents (e.g., glass vials, cell culture media, other organic reagents), including through the Defense Production Act. To overcome facility bottlenecks, particularly in the area of fill-and-finish (loading the vaccine into glass vials and packaging it for distribution), the US can help negotiate innovative industry partnerships, as exemplified by recent deals between rivals to accelerate production. Notably, the US will also need to exert its influence and expertise to ensure that manufacturers around the world meet strict quality standards, maintain safety and efficacy, and root out counterfeits as part of any solution.

However, to sustainably scale up production capacity, perhaps the most important measure is for the US to accelerate critical technology transfer to global manufacturers. This can be accomplished in a synchronized, multilateral fashion through the WHO Access to COVID-19 Tools (ACT) Accelerator, which aims to establish a centralized technology transfer hub for mRNA vaccines and other vital innovations, according to WHO official Dr. Martin Friede. Numerous leading COVID-19 vaccine manufacturers have relied on federal funding or intellectual property; Moderna, alone, has received approximately $1 billion of US taxpayer money to help develop and test its vaccine. The US government can use its leverage over these companies to encourage them to participate in tech transfer initiatives and other licensing agreements as may be needed. Furthermore, as recommended by the WHO-commissioned Independent Panel for Pandemic Preparedness & Response, the US can request tech transfer and a commitment to voluntary licensing in future deals with vaccine developers receiving public funding. These agreements can also include measures to cap price at a certain level of manufacturing costs in sales to LMICs.

Additional Support For Multilateral Initiatives Like The Gavi COVAX Facility

The global fair-access COVAX Facility was established as a safety net to ensure vaccine coverage for low-income countries and prioritize high-risk populations globally. We welcome the Biden-Harris administration’s steps so far to join and support the COVAX Advance Market Commitment, including $4 billion in pledged funding through 2022. As America’s vaccine supply expands, it will be important for the administration to lend increasing support to COVAX. In addition to donating an increasing share of surplus vaccines to the COVAX pool, the US can offer additional logistical, financial, and technical support towards scale-up and sustainability.

Support For Vaccine Campaign Planning, Execution, And Monitoring

While COVID-19 vaccines are in short supply, it’s important to acknowledge that vaccines themselves don’t save lives—vaccinations do. To quickly scale up immunizations and monitor vaccine campaigns moving forward, appropriate technical expertise, logistics capabilities, community engagement, and financial resources will be crucial. The US can help provide this support through multilateral and community-based partnerships. To ensure sustainability, it will be important to integrate these health security investments into primary and emergency health care systems, as well as health information systems. An example of this is how Mongolia has taken a successful “diagonal” approach in its COVID-19 response—achieving disease-specific “vertical” results through investments in “horizontal” health care system infrastructure.

A Call To Strengthen International Institutions To Better Protect Health Security, Including By Negotiating A New Comprehensive Pandemic Treaty To Complement The International Health Regulations

Under the terms of the IHR, a legally binding international treaty, countries are obligated to improve their capacity to prevent, detect, and respond to disease outbreaks, while also reporting such outbreaks to WHO in a timely manner. While many countries have shown progress over the last decade through initiatives like the Global Health Security Agenda, the COVID-19 pandemic has made clear how significant gaps in outbreak surveillance, response, and data quality and transparency persist. The WHO, with an annual programming budget comparable to that of a New York City hospital system, still lacks resources and authority to enforce compliance with the IHR or act in a timely, independent fashion during emergencies. And in the absence of stronger legal, economic, and political incentives, countries will continue to neglect vital investments in health security.

While some experts have suggested continued IHR revisions, we call on President Biden to join global leaders in proposing a new comprehensive pandemic treaty to complement the IHR based on the lessons learned from the current crisis including recent recommendations from the WHO-commissioned Independent Panel for Pandemic Preparedness & Response. This agreement will need to address topics including, but not limited to: protecting access to future vaccines as a global public good, financing of preparedness activities at the national level, strengthening WHO’s outbreak investigation capabilities, and sustaining high-level political attention to disease threats. In contrast to the IHR, which largely assumes that outbreaks are inevitable, this agreement should devote substantial focus to upstream prevention of outbreaks, including through a proactive One Health approach to disease surveillance, hotspot identification, and reduction of zoonotic spillover events. The US can take a leadership role in negotiating such a framework through action at the upcoming G7 Summit and by helping convene a special session of the UN General Assembly in September 2021 focused on charting a way forward.

Enacting the above plan will require significant resources: Producing enough vaccines to meet global demand is likely to cost $25 billion by one recent estimate. However, in comparison to President Biden’s $1.9 trillion American Rescue Plan—or the estimated $16 trillion cost of the pandemic to the American economy—this is a modest sum.

It is time for the US to participate in a global rescue plan, not just an American one. In this effort to help the world “build back better,” expanding the global COVID-19 vaccine supply must be the administration’s top priority. UNICEF Executive Director Henrietta Fore has urged the world’s leading economies to act quickly, noting that the ongoing crisis in India, a global hub of vaccine production, threatens to derail vaccines available to LMICs even further. The US has clear moral, epidemiological, and geopolitical incentives to advance a global solution. With more than 8 in 10 high-risk Americans having already received a shot—and millions of high-risk individuals still suffering unprotected abroad—the time to act is now.