Over 20 years ago, in July 2000, a group of activists, scientists, and clinicians gathered in Durban, South Africa, for the 13th International AIDS Conference. This was an AIDS conference like no other before it. Up until that summer—actually, winter in the Southern Hemisphere—no international AIDS conference had ever been held in the Global South, let alone a country in the region of the world that was the epicenter of the pandemic.

That July winter was historic too because at that moment, scientists, activists, clinicians, and politicians banded together to call out a singular and gross inequity. While powerful drugs had since 1996 transformed AIDS from a death sentence into a chronic manageable illness in richer countries, in poorer ones few had access to these medications. Well-known figures, including Nelson Mandela and Bill Clinton, stood at the podium to call on the world to redress this injustice.

But it was someone less well-known to Americans who made the clarion call to all of us. That week in Durban, Justice Edwin Cameron of the High Court of South Africa—who would later go on to become a justice of the highest court in the land, the republic’s Constitutional Court—came out to all assembled as an HIV+ gay man. But what he said that day was crucial:

If, without combination therapy, the mean survival time for a well-tended male in his mid-forties after onset of full AIDS is 30—36 months, I should be dead by approximately now. Instead, I am more healthy, more vigorous, more energetic, and more full of purposeful joy than at any stage in my life. In this I exist as a living embodiment of the iniquity of drug availability and access in Africa. This is not because, in an epidemic in which the heaviest burden of infection and disease are borne by women, I am male; nor because, on a continent in which the virus transmission has been heterosexual, I am proudly gay; nor even because, in a history fraught with racial injustice, I was born white. My presence here embodies the injustices of AIDS in Africa because, on a continent in which 290 million Africans survive on less than one US dollar a day, I can afford monthly medication costs of approximately US$400 per month. Amidst the poverty of Africa, I stand before you because I am able to purchase health and vigour. I am here because I can pay for life itself.

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I can pay for life itself. Edwin’s words set off a revolution as the call for access to antiretroviral therapy for AIDS swept the globe, out of Africa to Asia, Latin America, and the Caribbean, to the states of the former Soviet Union. Within a few years, millions would be receiving these precious AIDS drugs around the globe.

On March 7 of this year, I found myself sitting in front of my desktop on another Zoom call among dozens that week. I was giving the opening plenary of another AIDS conference, the Conference on Retroviruses and Opportunistic Infections, the premier scientific meeting on AIDS and related diseases, now integrating Covid-19 into its proceedings. The plenary was a conversation with another leading South African legal figure, and a dear friend of mine, the lawyer and human rights activist Fatima Hassan of the Health Justice Initiative. Fatima and I shared an office in Cape Town for several years in the early 2000s, when we were both working to address Justice Cameron’s challenge to us in 2000 to make AIDS drugs accessible in South Africa—despite the resistance of then-President Thabo Mbeki.

Now we were sitting thousands of miles apart, but telling a story, like Edwin’s, about today’s scandal, in some ways similar and some ways far worse than the one that held us spellbound two decades before in Durban.

As we in the United States and many other rich countries around the world await our turn in the vaccine line, worrying and fretting that we may have to wait weeks to be eligible for a jab, few in the poorest countries, even middle-income ones like South Africa, can expect to get vaccinated at all in 2021. In the poorer countries where most of the world’s population lives, people may even wait years, not weeks or months, to finally be immunized against SARS-CoV-2. As the United Nations Joint Programme on AIDS has said in a statement, “Rich nations are vaccinating one person every second, while majority of the poorest nations are yet to give a single dose.”

The arrival of multiple vaccines against SARS-CoV-2 in under a year after the virus’s emergence is nothing short of a miracle. But the absolute failure of the global community—wait, let’s be clear: donor nations, pharmaceutical and biotech companies, multilateral agencies—to mobilize, prepare for, and mount a global vaccination campaign is nothing short of medical apartheid. As my friend Fatima Hassan has said, it’s “black and brown to the back” of the line all over again.

Just think of this sitting in the United States: You would be told that your state is going to get only enough vaccine in 2021 to cover up to 20–30 percent of the population, but because of production delays in states that can pay more for the vaccine, you may have to wait even longer for these doses to arrive. Yet COVAX, an initiative led by the WHO, has essentially said this to low-income countries around the world: 20–30 percent coverage—if all else goes well and if rich countries get what they need first.

The worst thing is that the leadership of COVAX thought that this was something they could announce without any sense of shame or idea that this was morally repugnant. They’ll say, Well, this is what we could arrange with the companies; this is how far we could afford to push what rich nations have offered in terms of supporting our activities. This isn’t asking a lot. UNAIDS Executive Director Winnie Byanyima, along with the People’s Vaccine Alliance, have been crying out for a people’s vaccine since the fall.

It’s true that supplies of Covid-19 vaccines are lacking, and that pumping out more doses immediately is impossible with current constraints on manufacturing. But many have called for a massive scale-up of production capacity for the vaccines we have now to satisfy worldwide need. Where is the plan to do that? Nowhere. Rich countries would prefer to let industry set the pace of saving lives, let companies play God in a pandemic (and profit handsomely) than to think creatively and boldly about getting factories on line in the next six to 12 months in a way that could actually change the shape of the pandemic.

Doctors Without Borders and other such groups have called for companies to open their books and sell their vaccines at cost; instead, manufacturers are charging substantial sums for products invented and developed thanks to billions of American taxpayer dollars. Profiteering in a pandemic seems to be all well and good with our political leaders. Finally, low- and middle-income countries have asked for certain intellectual property and patent restrictions to be waived by the World Trade Organization to allow them to pursue their own measures to address their domestic epidemics, and to collaborate regionally to stem the tide of new infections. Guess who opposes these calls? The United States, European countries, and Australia. You’d think that in a global pandemic, the fate of billions of people around the planet would be the first priority of our governments, rather than catering to the pharmaceutical industry. But you’d be wrong.

Global Covid-19 policy is being written in boardrooms, driven by what companies are willing to do. It’s all well and good for the US government to throw billions at COVAX, but it’s like making a commitment to send water to a forest fire while telling those in the path of the conflagration to negotiate for fire trucks and fire equipment with the companies that make these things—after you’ve bought up most of those necessities yourself.

This is about power. But it is also about survival. Denying vaccines to billions of people around the world is a moral outrage for sure. It also means further spread of the virus and its variants, more sickness and death. Beyond the human and epidemiological costs of this abject surrender to industry, the economics of vaccine nationalism “could cost the global economy up to $1.2 trillion a year in GDP,” according to a report by Rand Europe, while “for every $1 spent on supplying poorer countries with vaccines, high-income countries would get back about $4.80.” It makes no sense at all to keep to the policy of vaccine apartheid, but here we are.

Many things have changed over the course of the past year or so in our pandemic-shaped lives. But sometimes it is same as it ever was. As we used to say back in the day: “AIDS is Big Business! (But Who’s Making a Killing?)” Who’s making a killing now? The vaccine manufacturers and the politicians who love them will have a lot to answer for when the story of this new pandemic is written. As another old ACT UP slogan goes, they have blood on their hands.