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Fifteen months ago, the SARS-CoV-2 virus unleashed Covid-19. Since then, it’s killed more than 3.8 million people worldwide (and possibly many more). Finally, a return to normalcy seems likely for a distinct minority of the world’s people, those living mainly in the United States, Canada, the United Kingdom, the European Union, and China. That’s not surprising. The concentration of wealth and power globally has enabled rich countries to all but monopolize available vaccine doses. For the citizens of low-income and poor countries to have long-term pandemic security, especially the 46 percent of the world’s population who survive on less than $5.50 a day, this inequity must end, rapidly—but don’t hold your breath.

The Global North: Normalcy Returns

In the United States new daily infections, which peaked in early January, had plummeted 96 percent by June 16. The daily death toll also dropped—by 92 percent—and the consequences were apparent. Big-city streets were bustling again, as shops and restaurants became ever busier. Americans were shedding their reluctance to travel by plane or train, as schools and universities prepared to resume “live instruction” in the fall. Zoom catch-ups were yielding to socializing the old-fashioned way.

By that June day, new infections and deaths had fallen substantially below their peaks in other wealthy parts of the world as well. In Canada, cases had dropped by 89 percent and deaths by 94 percent; in Europe by 87 percent and 87 percent; and in the United Kingdom by 84 percent and 99 percent.

Yes, European governments were warier than the United States about giving people the green light to resume their pre-pandemic lifestyles and have yet to fully abolish curbs on congregating and traveling. Perhaps recalling Britain’s previous winter surge, thanks to the B.1.1.7 mutation (initially discovered there) and the recent appearance of two other virulent strains of Covid-19, B.1.167 and B.1.617.2 (both first detected in India), Downing Street has retained restrictions on social gatherings. It’s even put off a full reopening on June 21, as previously planned. And that couldn’t have been more understandable. After all, on June 17, the new case count had reached 10,809, the highest since late March. Still, new daily infections there are less than a tenth what they were in early January. So, like the United States, Britain and the rest of Europe are returning to some semblance of normalcy.

The Global South: A Long Road Ahead

Lately, the place that’s been hit the hardest by Covid-19 is the Global South, where countries are particularly ill-prepared.

Consider social distancing. People with jobs that can be done by “working from home” constitute a far smaller proportion of the labor force than in wealthy nations with far higher levels of education, mechanization, and automation, along with far greater access to computers and the Internet. An estimated 40 percent of workers in rich countries can work remotely. In lower- and middle-income lands, perhaps 10 percent can do so and the numbers are even worse in the poorest of them.

During the pandemic, millions of Canadians, Europeans, and Americans lost their jobs and struggled to pay food and housing bills. Still, the economic impact has been far worse in other parts of the world, particularly the poorest African and Asian nations. There, some 100 million people have fallen back into extreme poverty.

Such places lack the basics to prevent infections and care for Covid-19 patients. Running water, soap, and hand sanitizer are often not readily available. In the developing world, 785 million or more people lack “basic water services,” as do a quarter of health clinics and hospitals there, which have also faced crippling shortages of standard protective gear, never mind oxygen and ventilators.

Last year, for instance, South Sudan, with 12 million people, had only four ventilators and 24 ICU beds. Burkina Faso had 11 ventilators for its 20 million people; Sierra Leone 13 for its eight million; and the Central African Republic, a mere three for eight million. The problem wasn’t confined to Africa either. Virtually all of Venezuela’s hospitals have run low on critical supplies and the country had 84 ICU beds for nearly 30 million people.

Yes, wealthy countries like the United States faced significant shortages, but they had the cash to buy what they needed (or could ramp up production at home). The Global South’s poorest countries were and remain at the back of the queue.

India’s Disaster

India has provided the most chilling illustration of how spiraling infections can overwhelm health care systems in the Global South. Things looked surprisingly good there until recently. Infection and death rates were far below what experts had anticipated based on the economy, population density, and the highly uneven quality of its health care system. The government’s decision to order a phased lifting of a national lockdown seemed vindication indeed. As late as April, India reported fewer new cases per million than France, Germany, the United Kingdom, or the United States.

Never one for modesty, its Hindu nationalist prime minister, Narendra Modi, boasted that India had “saved humanity from a great disaster by containing Corona effectively.” He touted its progress in vaccination; bragged that it was now exporting masks, test kits, and safety equipment; and mocked forecasts that Covid-19 would infect 800 million Indians and kill a million of them. Confident that his country had turned the corner, he and his Bharatiya Janata Party held huge, unmasked political rallies, while millions of Indians gathered in vast crowds for the annual Kumbh Mela religious festival.

Then, in early April, the second wave struck with horrific consequences. By May 6th, the daily case count had reached 414,188. On May 19, it would break the world record for daily Covid-19 deaths, previously a dubious American honor, recording almost 4,500 of them.

Hospitals quickly ran out of beds. The sick were turned away in droves and left to die at home or even in the streets, gasping for breath. Supplies of medical oxygen and ventilators ran out, as did personal protective equipment. Soon, Modi had to appeal for help, which many countries provided.

Indian press reports estimate that fully half of India’s 300,000-plus Covid-19 deaths have occurred in this second wave, the vast majority after March. During the worst of it, the air in India’s big cities was thick with smoke from crematoria, while, because of the shortage of designated cremation and burial sites, corpses regularly washed up on riverbanks.

We may never know how many Indians have actually died since April. Hospital records, even assuming they were kept fastidiously amid the pandemonium, won’t provide the full picture because an unknown number of people died elsewhere.

The Vaccination Divide

Other parts of the Global South have also been hit by surging infections, including countries in Asia which had previously contained Covid-19’s spread, among them Malaysia, Nepal, the Philippines, Sri Lanka, Thailand, and Vietnam. Latin America has seen devastating surges of the pandemic, above all in Brazil because of President Jair Bolsonaro’s stunning combination of fecklessness and callousness, but also in Bolivia, Columbia, Chile, Paraguay, Peru, and Uruguay. In Africa, Angola, Namibia, South Africa, and the Democratic Republic of the Congo are among 14 countries in which infections have spiked.

Meanwhile, the data reveal a gargantuan north-south vaccination gap. By early June, the United States had administered doses to nearly half the country’s population, in Britain slightly more than half, in Canada just over a third, and in the European Union approximately a third. (Bear in mind that the proportions would be far higher were only adults counted and that vaccination rates are still increasing far faster in these places than in the Global South.)

Now consider examples of vaccination coverage in low-income countries.

In the Democratic Republic of the Congo, Ethiopia, Nigeria, South Sudan, Sudan, Vietnam, and Zambia it ranged from 0.1 percent to 0.9 percent of the population.

In Angola, Ghana, Kenya, Pakistan, Senegal, and South Africa, between 1 percent and 2.4 percent.

In Botswana and Zimbabwe, which have the highest coverage in sub-Saharan Africa, 3 percent and 3.6 percent respectively.

In Asia (China and Singapore aside), Cambodia at 9.6 percent was the leader, followed by India at 8.5 percent. Coverage in all other Asian countries was below 5.4 percent.

This North-South contrast matters because mutations first detected in the UK, Brazil, India, and South Africa, which may prove up to 50 percent more transmissible, are already circulating worldwide. Meanwhile, new ones, perhaps even more virulent, are likely to emerge in largely unvaccinated nations. This, in turn, will endanger anyone who’s unvaccinated and so could prove particularly calamitous for the Global South.

Why the vaccination gap? Wealthy countries, none more than the United States, could afford to spend billions of dollars to buy vaccines. They’re home as well to cutting-edge biotechnology companies like AstraZeneca, BioNTech, Johnson and Johnson, Moderna, and Pfizer. Those two advantages enabled them to preorder enormous quantities of vaccine, indeed almost all of what BioNTech and Moderna anticipated making in 2021, and even before their vaccines had completed clinical trials. As a result, by late March, 86 percent of all vaccinations had been administered in that part of the world, a mere 0.1 percent in poor regions.

This wasn’t the result of some evil conspiracy. Governments in rich countries weren’t sure which vaccine-makers would succeed, so they spread their bets. Nevertheless, their stockpiling gambit locked up most of the global supply.

Equity vs. Power

Tedros Adhanom Ghebreyesus, who leads the World Health Organization (WHO), was among those decrying the inequity of “vaccine nationalism.” To counter it, he and others proposed that the deep-pocketed countries that had vacuumed up the supplies, vaccinate only their elderly, individuals with pre-existing medical conditions, and health care workers, and then donate their remaining doses so that other countries could do the same. As supplies increased, the rest of the world’s population could be vaccinated based on an assessment of the degree to which different categories of people were at risk.

COVAX, the UN program involving 190 countries led by the WHO and funded by governments and private philanthropies, would then ensure that getting vaccinated didn’t depend on whether a person lived in a wealthy country. It would also leverage its large membership to secure low prices from vaccine manufacturers.

That was the idea anyway. The reality, of course, has been altogether different. Though most wealthy countries, including the United States following Biden’s election, did join COVAX, they also decided to use their own massive buying power to cut deals directly with the pharmaceutical giants and vaccinate as many of their own as they could. And in February, the US government took the additional step of invoking the Defense Production Act to restrict exports of 37 raw materials critical for making vaccines.

COVAX has received support, including $4 billion pledged by President Joe Biden for 2021 and 2022, but nowhere near what’s needed to reach its goal of distributing 2 billion doses by the end of this year. By May, in fact, it had distributed just 3.4 percent of that amount.

Biden recently announced that the United States would donate 500 million doses of vaccines this year and next, chiefly to COVAX; and at their summit this month, the G-7 governments announced plans to provide one billion altogether. That’s a large number and a welcome move, but still modest considering that 11 billion doses are needed to vaccinate 70 percent of the world.

COVAX’s problems have been aggravated by the decision of India, counted on to provide half of the 2 billion doses it had ordered for this year, to ban vaccine exports. Aside from vaccine, COVAX’s program is focused on helping low-income countries train vaccinators, create distribution networks, and launch public awareness campaigns, all of which will be many times more expensive for them than vaccine purchases and no less critical.

Another proposal, initiated in late 2020 by India and South Africa and backed by 100 countries, mostly from the Global South, calls for the World Trade Organization (WTO) to suspend patents on vaccines so that pharmaceutical companies in the Global South can manufacture them without violating intellectual property laws and so launch production near the places that need them the most.

That idea hasn’t taken wing either.

The pharmaceutical companies, always zealous about the sanctity of patents, have trotted out familiar arguments (recall the HIV-AIDS crisis): Their counterparts in the Global South lack the expertise and technology to make complex vaccines quickly enough; efficacy and safety could prove substandard; lifting patent restrictions on this occasion could set a precedent and stifle innovation; and they had made huge investments with no guarantees of success.

Critics challenged these claims, but the biotech and pharmaceutical giants have more clout, and they simply don’t want to share their knowledge. None of them, for instance, has participated in the WHO’s Covid-19 Technology Access Pool (C-TAP), created expressly to promote the voluntary international sharing of intellectual property, technology, and knowhow, through non-restricted licensing.

On the (only faintly) brighter side, Moderna announced last October that it wouldn’t enforce its Covid-19 vaccine patents during the pandemic—but didn’t offer any technical assistance to pharmaceutical firms in the Global South. AstraZeneca gave the Serum Institute of India a license to make its vaccine and also declared that it would forgo profits from vaccine sales until the pandemic ends. The catch: It reserved the right to determine that end date, which it may declare as early as this July.

In May, President Biden surprised many people by supporting the waiving of patents on Covid-19 vaccines. That was a big change given the degree to which the US government has been a dogged defender of intellectual property rights. But his gesture, however commendable, may remain just that. Germany dissented immediately. Others in the European Union seem open to discussion, but that, at best, means protracted WTO negotiations about a welter of legal and technical details in the midst of a global emergency.

And the pharmaceutical companies will hang tough. Never mind that many received billions of dollars from governments in various forms, including equity purchases, subsidies, large preordered vaccine contracts ($18 billion from the Trump administration’s Operation Warp Speed program alone), and research-and-development partnerships with government agencies. Contrary to its narrative, Big Pharma never placed huge, risky bets to create Covid-19 vaccines.

How Does This End?

Various mutations of the virus, several highly infectious, are now traveling the world and new ones are expected to arise. This poses an obvious threat to the inhabitants of low-income countries where vaccination rates are already abysmally poor. Given the skewed distribution of vaccines, people there may not be vaccinated, even partially, until 2022, or later. Covid-19 could therefore claim more millions of lives.

But the suffering won’t be confined to the Global Gouth. The more the virus replicates itself, the greater the probability of new, even more dangerous, mutations—ones that could attack the tens of millions of unvaccinated in the wealthy parts of the world, too. Between a fifth and a quarter of adults in the United States and the European Union say that they’re unlikely to, or simply won’t, get vaccinated. For various reasons, including worry about the safety of vaccines, anti-vax sentiments rooted in religious and political beliefs, and the growing influence of ever wilder conspiracy theories, US vaccination rates slowed starting in mid-April.

As a result, President Biden’s goal of having 70 percent of adults receive at least one shot by the Fourth of July won’t be realized. With less than two weeks to go, at least half of the adults in 25 states still remain completely unvaccinated. And what if existing vaccines don’t ensure protection against new mutations, something virologists consider a possibility? Booster shots may provide a fix, but not an easy one given this country’s size, the logistical complexities of mounting another vaccination campaign, and the inevitable political squabbling it will produce.

Amid the unknowns, this much is clear: For all the talk about global governance and collective action against threats that don’t respect borders, the response to this pandemic has been driven by vaccine nationalism. That’s indefensible, both ethically and on the grounds of self-interest.