The COVID-19 pandemic has hit the world hard, and countries around the globe are anxious to get their hands on a vaccine as soon as possible in the hopes that it will bring a return to normalcy

Those vaccines are expected to be in short supply when they first hit the market, meaning not everyone will have access initially. Within countries, some groups will be prioritized for vaccination.

But what about globally? Which countries will get the vaccines first?

Many wealthier nations are already making bets on vaccines still in relatively early stages of development, with no guarantee that they will ever perform well enough to gain approval or protect their populations.

That has many concerned about “vaccine nationalism,” where countries look out for their own interests at the expense of others.

Here’s a closer look at what wealthier countries are doing to ensure supplies for their own citizens, how that might affect other countries, how Canada might fare and what efforts are being made to distribute a vaccine more fairly.

There are a few different ways wealthier countries can try to ensure their own supplies:

In previous pandemics, such as an H1N1 outbreak in 2009, wealthier nations were able to buy up the first batches, leaving no supply for lower-income countries.

And even some richer countries, including Canada, weren’t always first in line if they didn’t have their own manufacturing facilities. During the swine flu outbreak in 1976, for example, the U.S. decided to vaccinate its entire population before it would allow vaccine producers to export their products to Canada.

The U.S. has a program called Operation Warp Speed, which aims to produce a vaccine faster than anyone else. President Donald Trump has said he hoped it would be available before the end of the year.

The program has already announced that it’s providing more than $6 billion US to pay for development, manufacturing and preorders or reservations for hundreds of millions of doses of promising vaccine candidates from U.S.-based Johnson & Johnson, Moderna, Novavax, Pfizer and Merck, along with U.K.-based AstraZeneca.

Similarly, the European Commission has a plan to use an emergency fund worth €2.4 billion (almost $3.7 billion Cdn) to buy up to six vaccines in advance for 450 million people.

Germany, France, Italy and the Netherlands have also signed a deal with AstraZeneca for over 300 million doses of its vaccine, which they say all EU members can participate in. 

Meanwhile, the United Kingdom has preordered nearly 200 million doses from AstraZeneca, BioNTech/Pfizer  and France-based Valneva.

There are concerns such preorders could reduce the initial availability of vaccines in the rest of the world, which has happened in previous pandemics  

The European Commission has specifically said it will not buy vaccines produced exclusively in the U.S. over concerns that might delay supplies to Europe.

The federal government has created a $600 million fund to support vaccine clinical trials and manufacturing in Canada.

It is also “closely monitoring vaccine development efforts — domestically and internationally — and will work quickly to negotiate advanced purchase agreements with vaccine manufacturer(s) to secure supply for all Canadians as soon as it is feasible,” Geoffroy Legault-Thivierge, a spokesperson for the Public Health Agency of Canada, told CBC News in an email.

However, as of July 30, it hadn’t yet announced any such agreements.

The government has also announced it is ordering enough equipment, such as syringes, alcohol swabs and bandages, to give at least two doses of a vaccine to every Canadian when one becomes available.

Still, experts warn that Canada currently doesn’t have much manufacturing capacity for vaccines, even those developed in this country — many of which would be manufactured elsewhere and some of which would likely be licensed to foreign companies for manufacturing. 

Quebec City-based Medicago is the first Canadian vaccine candidate to begin clinical trials. But CEO Bruce Clark has said that his company’s main manufacturing plant is in the U.S., meaning there’s no guarantee that a supply would reach Canada in a timely manner.

“‘Guarantee’ is a strong word,” Clark told The Canadian Press in July. “Strange things happen to borders in the context of a pandemic.”

Dr. Noni MacDonald, a professor of pediatrics and infectious diseases at Dalhousie University and the IWK Health Centre in Halifax, said Canada is a very small market.

“And we will not have a vaccine if the manufacturer doesn’t apply for approval,” said MacDonald, who has done research on ethical issues surrounding vaccines.

In the past, some manufacturers have not prioritized Canada, she said. For example, the manufacturer of the chicken pox vaccine didn’t apply for approval in Canada until it had already been available in the U.S. for five years.

Because it’s a global pandemic and our world is interconnected, outbreaks in any country have the potential to travel to other countries and cause outbreaks there, MacDonald said. “For you to be safe … your country needs to be safe and all other countries need to be safe.”

That’s even the case if the entire population is vaccinated, she said, as a given vaccine usually doesn’t work for everyone. 

Due to manufacturing and distribution constraints, when a vaccine first becomes available, there isn’t expected to be enough of it to vaccinate the entire populations of even countries wealthy and lucky enough to have preordered it. That means most of their populations could remain at risk for a long time if the pandemic isn’t under control in other parts of the world.

Outbreaks also tend to be worse and harder to control in poorer countries, posing a higher risk to both their own populations and the world.

Dr. Joel Lexchin, a professor emeritus at York University in Toronto who has studied pharmaceutical policy, said many wealthier countries such as Canada are able to do a pretty good job of controlling the virus without a vaccine through such measures as physical distancing, frequent handwashing, mask wearing and temporarily shutting down certain businesses and services. 

Meanwhile, lower-income countries where many people live in crowded conditions — some of them with limited access to things like clean water and soap — are struggling with both controlling the epidemic and treating those who have fallen ill.

“I think you need to look at where the outbreak is still the greatest threat to public health and also where the medical care resources are the lowest,” Lexchin said.

“You can make the case that however much we need a vaccine in Canada, there they need it much more than we do.”

There are some, but perhaps the biggest is the COVAX Facility, an initiative of the World Health Organization; Gavi, the Vaccine Alliance, which is a public-private partnership founded by the Bill & Melinda Gates Foundation that vaccinates children against deadly diseases; and the Coalition for Epidemic Preparedness Innovations, which aims to develop vaccines to stop future epidemics.

COVAX is pooling money from dozens of countries to invest in vaccine candidates around the world, with a goal of delivering two billion vaccine doses globally by 2021. 

The program is designed to connect developing and developed nations, with all partners getting enough doses of a successful vaccine for 20 per cent of their populations, initially prioritizing health-care workers. So far, it’s signed on 75 higher-income countries — including Canada but not the U.S. — to partner with 90 lower-income countries that together represent more than 60 per cent of the world’s population. It’s also joining forces with vaccine manufacturers.

The program includes investment in production facilities and incentives to scale up through preorders.

Because most vaccine candidates are not expected to succeed and make it to market, COVAX is designed to get higher-income countries to participate by improving the chance that they’ll invest in a successful vaccine.

“This is an initial opportunity for a wealthy country to kind of hedge their bets and protect their own interests and also contribute to a global effort to secure vaccine for people living in countries where the resources are not there to do it on their own,” said Prof. Ruth Faden, founder of the Johns Hopkins Berman Institute of Bioethics in Baltimore.

“It’s very smart.”

Prime Minister Justin Trudeau has spoken in favour of and co-authored an op-ed article with leaders of other countries calling for equitable access to a COVID-19 vaccine when it’s ready. Canada has already pledged $850 million to Global Coronavirus Response and $120 million toward the broader initiative that COVAX is part of, called the Access to COVID-19 Tools Accelerator.

Gavi, the Vaccine Alliance, says it has raised $600 million US from higher-income countries and the private sector to provide an incentive for manufacturers to make enough vaccine to ensure access for developing countries.

York University’s Lexchin said it’s not clear if vaccines will be fairly distributed. He noted in an article in The Conversation that even for COVAX, rich countries will get the vaccine before poorer countries. And all countries will only be able to vaccinate their highest-priority groups, including health-care workers — just 20 per cent of the population through the program, limiting its influence.

At least one humanitarian group has expressed concern that the program doesn’t stop rich countries from buying up all the supply in advance, limiting what can be distributed to the rest of the world.

Lexchin said in an interview that middle-income countries such as Brazil and Mexico sometimes fall through the cracks, as they’re not poor enough to take advantage of lower prices offered by manufacturers, who set the prices.

He said he thinks leaders, including Canada’s, need to step up as well, by requiring that vaccines and treatments be made available at affordable prices to low- and middle-income countries if government funding was received for their development.

Still, MacDonald of Dalhousie University is cautiously optimistic.

“We’re in better shape to be more equitable about a COVID-19 vaccine globally than we were for the influenza pandemic,” she said.

“Do I think we’re going to get it right? … I hope we’ll get it more right.”

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