pandem-ic

It is not too late to achieve global vaccine equity

Philip Schellekens — Thu, 24 Mar 2022 10:59:30 +0000

It is not too late to achieve global vaccine equity

March 24, 2022

A new, urgent push for global vaccine equity could help avert suffering and deaths, protect economies, and prevent new virus variants

This article was originally published in the BMJ and is reposted here with permission. Full set of authors: Gavin Yamey, Patricia Garcia, Fatima Hassan, Wenhui Mao, Kaci Kennedy McDade, Madhukar Pai, Senjuti Saha, Philip Schellekens, Andrea Taylor, and Krishna Udayakumar (affiliations at the bottom).

During the covid-19 pandemic, we have seen the best of international collective action and its limits. Global scientific cooperation drove the development of safe, highly effective covid-19 vaccines in under one year.¹ Yet we have also witnessed global vaccine inequity,² in which low and middle income countries have “limited supply and limited vaccine brand options.”³

With the omicron wave dissipating, several well vaccinated high income nations with stockpiles of covid-19 vaccines are rushing to declare the pandemic over, reminding us of how things unfolded with tuberculosis, malaria, and HIV/AIDS in the past. But the pandemic is not over and 2.8 billion people remain completely unvaccinated. Now is the time to recommit to, and further invest in, equitable and effective country led vaccination campaigns.

In this paper, we briefly examine how global vaccine inequity arose, lay out a renewed case for urgently ramping up our commitment to vaccine equity, and propose principles to ensure no one is left behind in the quest to vaccinate the world.

What caused global vaccine inequity?

Vaccination coverage varies starkly by country income level. Although over 11 billion vaccine doses have been administered, nearly 70% of them benefited high and upper middle income countries.⁴ As of 19 March 2022, 79% of people in high income countries had received at least one dose of a covid-19 vaccine, compared with just 14% in low income countries.⁴ Primary vaccination and booster coverage have been highly regressive (Fig 1).

Fig 1. Booster coverage of total population, by income. Country observations (centre points) of boosters per 100 people by income group and total population size (area) with group averages (lines). HIC=high income countries; UMIC=upper middle income countries; LMIC=lower middle income countries; LIC=low income countries. Source: https://pandem-ic.com/booster-coverage-of-population-by-country-income-and-population-size/

What caused such inequity? We use Wouter and colleagues’ framework to briefly summarise inequitable access to covid-19 vaccines across four dimensions: vaccine production, allocation, affordability, and deployment.⁵

Vaccine production

High income countries quickly pre-ordered huge numbers of doses from companies such as BioNTech/Pfizer that overcame early manufacturing scale-up challenges relatively quickly.⁶ In contrast, low and middle income countries, as well as the Covid-19 Vaccines Global Access (Covax) facility that purchased doses for distribution in these countries (Box 1), largely relied on initial purchases from Astra Zeneca, Janssen, and Novavax, which were slower to overcome manufacturing scale-up challenges.

BOX 1: Covax

The Covax facility was formally launched in June 2020, aiming to supply covid-19 vaccines to all countries worldwide. Covax hoped to be able to vaccinate all health workers, elderly people, and high risk populations in every country by the end of 2021, which would constitute about 20% of the global population.

Covax was “designed to stand on two legs.”⁷ The first was the self-financing leg: high income and upper middle income countries would buy doses through Covax for their own populations. Initially, they would be able to purchase enough doses to vaccinate 20% of their populations, though Covax later raised the ceiling to 50% to attract more high income and upper middle income country purchases. The incentive for these nations to buy doses from Covax, rather than only through bilateral deals with vaccine manufacturers, was as an insurance mechanism. If a high income country’s bilateral deals were unsuccessful (that is, the candidates failed in trials), the country would still have access to vaccine doses from the wide portfolio of around a dozen Covax candidates. The second leg was aimed at the 92 countries that are low income or lower middle income countries—doses for these nations would be paid for largely by donor funding through an advanced market commitment.

Covax hoped that a huge number of high and lower middle income countries would buy doses through the facility, which would have given Covax massive buying power to invest in research and development, fund manufacturing at risk, drive prices down through pooled purchases, and ensure that some of the supply would go to low income and lower middle income countries. However, in the end most high income and upper middle income nations largely bypassed Covax: “About 3 dozen rich nations ended up buying most of their doses by way of direct deals with vaccine companies rather than through the Covax pool.”⁸ Its supply projections were overly optimistic. It was not transparent about the contracts it made with companies and the prices it paid.⁷ Most high income and upper middle income nations that pledged to donate doses to Covax have not met their pledges. An independent review of Covax found “insufficient inclusion and meaningful engagement” of low and middle income countries and civil society in developing the mechanism.⁹ Nevertheless, Covax has to date delivered nearly 1.2 billion doses to the 92 nations participating in the Covax advanced market commitment.

Additionally, low and middle income countries did not have manufacturing capacities in place at the beginning of the pandemic, with notable exceptions (for example, China, Cuba, and India).¹⁰ While there has been some investment in vaccine manufacturing in low and middle income countries since the pandemic began—such as the US Development Finance Corporation investment in Biological E in India and the Carlos Slim Foundation’s investment in vaccine manufacturing in Mexico and Argentina—these take time to stand up manufacturing capabilities and cannot solve the immediate crisis. Vaccine companies and high income nations were reluctant to share vaccine patents and technology with vaccine manufacturers in less wealthy countries and with multilateral initiatives that aim to boost vaccine equity, though there has been some voluntary licensing to manufacturers in low and middle income countries.

Allocation

To try to ensure fair global vaccine allocation, Gavi, the Vaccine Alliance, the Coalition for Epidemic Preparedness, and the World Health Organization launched Covax, a “first-of-its kind ‘buyers pool’ in which richer nations can collectively purchase vaccines, fund vaccine development and manufacturing and ensure that some of the supply will go to poorer countries.”⁸ Covax also uses foreign aid to buy doses for distribution to 92 lower middle income and low income countries.

Covax has undoubtedly procured vaccines for people who would otherwise not have had access, but as an allocation mechanism it faced an array of challenges, some of its own making and others outside its control (Box 1). High income and upper middle income nations largely bypassed Covax, buying huge numbers of doses directly from vaccine companies, and Covax struggled to raise necessary financing, leaving it at the back of the queue when it came to purchasing doses.⁸

The case of Latin America illustrates the allocation problems faced by low and middle income countries.¹¹ Even with resources to buy vaccine doses, the lack of capacity for negotiations caused delays in vaccination (for example, Peru was able to start vaccinating only in March 2021). High public trust in vaccines has allowed the region to catch up,¹² but the delays caused a huge number of deaths that could have been averted.

Affordability

The wide variation and lack of transparency in vaccine prices across countries and companies contributed to inequity.¹³ In 2021, when the European Union was paying $3.50 (£2.70; €3.20) per dose of the Oxford-AstraZeneca vaccine, South Africa was being charged $5.25 and Uganda was being charged $7. Many low and middle income countries had to take out loans to procure vaccines for their populations while high covid-19 vaccine prices have led to huge profits for industry.¹⁴ The lack of transparency around vaccine prices and terms of contracts, including indemnity, has been a barrier to countries being able to negotiate and buy vaccines even when resources were available—a problem that was particularly acute for Latin America.¹⁵

Deployment

Cross country differences in health systems, including vaccine supply chains, data infrastructure, and health workforce, contributed to global vaccine inequity. For example, many covid-19 vaccines need ultra-cold chains and expire quickly once removed from storage.⁵

Vaccine hesitancy also varied across countries.¹⁶ While vaccine uptake is high in many regions of low and middle income countries, complex social factors drive hesitancy for some communities. For example, “a history of colonial medical and vaccine research abuse in Africa diminishes trust in current vaccines.”¹⁷ Scarcity and unpredictability of vaccine supply also complicated building vaccine confidence.^17,^18,¹⁹

Renewed case for vaccine equity

Covid-19 vaccines are very safe and effective, particularly at reducing hospitalisation and death. Nations with high vaccine coverage have greatly weakened the link between cases and death. It is unjust that people in high income and upper middle income nations have been protected from illness, hospitalisation, and death while those in low and lower middle income countries are being left behind. While the global omicron surge led to large numbers of people worldwide getting infected and surviving, leaving them with a degree of immunity, infection induced immunity is not as robust and durable as being up to date with vaccination; nor does it provide the same protection against future variants.^20,^21,^22,^23,²⁴

It is a myth to believe that high income countries have been harder hit by the pandemic and thus “deserve” to have hoarded the lion’s share of the vaccine supply. Figure 2 shows that estimates of excess deaths per capita have been substantial worldwide, with lower middle income countries—not high income countries—having the highest rates. In terms of share, low and middle income countries currently account for 63% of cumulative reported covid-19 mortality. When under-reporting and other factors are considered, excess mortality estimates suggest this share could be as high as 87%.²⁵

Fig 2. Cumulative estimated excess deaths since the start of the pandemic per 100 000 people. HIC=high income countries; UMIC=upper middle income countries; LMIC=lower middle income countries; LIC=low income countries. Mid-point estimates of excess death model by The Economist. Source: https://pandem-ic.com/cumulative-estimated-excess-deaths-per-capita-by-income/

Low and middle income countries also bear the highest burden of endemic infectious diseases, such as HIV and tuberculosis, and have had to redirect resources usually used to tackle these diseases towards covid-19 control. The pandemic is hindering progress towards controlling these other diseases in addition to worsening social determinants such as poverty.²⁶

Vaccinating everyone in low and middle income countries could avert a huge number of deaths. Savinkina and colleagues estimate that giving two doses of mRNA vaccine to everyone in low income countries and lower middle income countries would cost $35.5bn and avert 1.3 million deaths from covid-19.²⁷ Three doses would cost $61.2bn and avert 1.5 million deaths from covid-19. To put these costs into perspective, the International Monetary Fund estimates the economic losses caused by covid-19 will be $13.8tn from 2020 to 2024.²⁸

Global vaccine inequity undermines the economic recovery and social and political stability of low and middle income countries. Sub-Saharan Africa will suffer the greatest economic losses from covid-19 as a proportion of gross domestic product.²⁹ An April 2021 analysis by the United Nations Development Programme found that if vaccination rates in low income countries had been the same as those in high income countries, low income countries would have added $38bn to their gross domestic product forecast for 2021.³⁰ A United Nations Counter-Terrorism Committee study concluded: “Pandemic-related economic hardships (including rising unemployment, poverty, growing inequality, and food insecurity) are potential drivers for an increased terrorist threat.”³¹

Given the economic interdependency of countries, high income nations are also harmed economically by their own vaccine nationalism. Çakmakli and colleagues estimate that high income countries will bear 13-49% of the global economic losses arising from vaccine inequity, through factors such as interruption of global supply chains and reduced exports to low and middle income countries.³²

Achieving global vaccine equity is an urgent priority to reduce the risk of future SARS-CoV-2 variants. The uncontrolled spread of SARS-CoV-2 in unvaccinated populations is a risk factor for new variants, as seen with the emergence of the delta and omicron variants.²⁹ The recent delta/omicron surge led to a huge escalation in cases compared with previous surges (fig 3), creating fertile ground for the development of new variants. Vaccination reduces the risk of infection and transmission, even against the highly transmissible omicron variant. For example, with a booster dose, vaccine efficacy against infection with omicron approaches 70%, akin to the efficacy of influenza vaccines.³³

Fig 3. Ratio of the peak in cases and mortality rates for the current omicron/delta surge versus previous waves prior to 1 November 2021. Peaks calculated for daily weekly trailing averages of newly confirmed cases and deaths per 100 000 people. HIC=high income countries; UMIC=upper middle income countries; LMIC=lower middle income countries; LIC=low income countries. Source: https://pandem-ic.com/the-severity-of-the-omicron-surge/

We cannot assume the next variant will be less severe than omicron. Preventing the emergence of new variants is our best strategy, requiring equitable access to vaccines, new antiviral drugs, and rapid tests. Equitable access to vaccines must mean equitable access to a full course, including boosters. Since vaccine effectiveness wanes around 4-6 months after completing two doses of an mRNA vaccine or one dose of J&J vaccine,³⁴ the best protected are those who had a booster—they are considered “up to date” on vaccination. For high risk populations, further boosters will probably be needed.

Equity among different populations within countries of all income levels is increasingly important. In the United States, for example, black and Hispanic populations have been vaccinated at lower rates compared with the white population,³⁵ and vaccination coverage is much lower in rural than in urban areas.³⁶ These types of sub-national disparities are common worldwide.

How we can vaccinate the world and be better prepared

The world is not on course to reach the WHO target of 70% of people in all countries vaccinated by mid-2022. Yet vaccine equity remains critical to end the pandemic. How can it be achieved?

Firstly, empowering national sovereignty so that countries determine their own priorities and targets is a critical dimension of the path forward in vaccinating the world. Such national sovereignty is embedded in recent guidance on boosters issued by both Africa CDC and WHO’s Strategic Advisory Group of Experts on Immunization.^34,³⁷ For many nations, reaching the highest risk groups, including marginalised populations, is their key priority. They may prioritise vaccinating all older people and health workers for full vaccination (including boosters).

Secondly, in the short term, there is an important role for more bilateral donations (provided the doses are not close to expiration) and donations to Covax. The COVID GAP project estimated in November 2021 that at the end of 2021, the Group of 7 (G7) and EU countries had 834 million excess doses, even after accounting for boosters, child vaccinations, and contingencies; these should have been donated or diverted well before the end of the year.³⁸

Hundreds of millions of doses were delivered to low and middle income countries in November and December 2021, as donor countries scrambled to meet their donation targets. Unfortunately, more than 100 million of these doses were rejected by recipient countries in December alone, primarily because the expiration dates were too close to allow for in-country distribution.³⁹ In addition to accelerating pledged donations, G7 and EU countries should also “queue shift” expected deliveries—that is, defer delivery of contracted vaccine doses to prioritise delivery to the African Union, Covax, and countries with unfulfilled bilateral contracts. Covax has shifted from delivering doses to Africa once they are available to delivering them timed with when the country wants them, which should also help to support country led vaccination campaigns.⁴⁰

Thirdly, urgent, intensified financial and operational support to low and middle income countries is needed for their own national vaccination programmes. Vaccine supply must be made “consistent and predictable.”⁴¹ Donors, multilateral banks, and others must also tackle health systems bottlenecks, including political context, in-country planning and financing, health workforce, supply chain constraints, and data systems.

Fourthly, a trickle-down charity model—in which high income and upper middle income nations donate doses to lower middle income and low income nations—is not a fair or sustainable way to achieve vaccine equity. We need a revitalised push towards vaccine self-reliance and decentralised bottom-up manufacturing worldwide, which would be accelerated by the sharing of vaccine intellectual property and technology transfer, financing, workforce development, and regulatory support. The case of Latin America has also shown how critical it is to strengthen capabilities for negotiation and improve transparency on prices and contracts.

WHO’s covid mRNA vaccine hub in South Africa is one potential way forward. The hub is a partnership between Afrigen (a biotech company), Biovac (a vaccine manufacturer), universities, Africa CDC and WHO. It recently announced it had developed “its own version of an mRNA shot, based on the publicly available data on the composition of the Moderna covid-19 vaccine, which will be tested in the coming months.”⁴² Six African nations have been tapped to receive mRNA vaccine technology from the hub.⁴³

Many other efforts are under way to manufacture mRNA vaccines in sub-Saharan Africa—for example, the Kenyan government is partnering with Moderna to build a vaccine manufacturing facility,⁴⁴ a South African company (NantSA) is launching a vaccine plant,⁴⁵ and Moderna plans to ship modular mRNA vaccine factory kits.⁴⁶

Some low and middle income countries, such as China, Cuba, and India, have invested in their own covid-19 vaccine development and production and have achieved impressive vaccination coverage. In Cuba, for example, as of 19 March 2022, 94% of the population had received at least one dose of a home grown vaccine, 87% were fully vaccinated, and 54% were boosted (several Chinese and Indian vaccines have WHO emergency use listing, unlike Cuba’s vaccines).^4,⁴⁷ South-South collaborations and technology transfer could pave the way for current and future pandemic responses.

Fifthly, regional initiatives will become increasingly important in increasing vaccine coverage in low and middle income countries. Examples include the African Union African Vaccine Acquisition Trust, which is leading pooled procurement efforts for member states, and the Asia Pacific Vaccine Access Facility.

Finally, work is ongoing to develop new variant specific vaccines and nasal vaccines that could potentially provide sterilising immunity. Unless we take steps now to ensure a fair, transparent global allocation process, global inequities will continue for access to these tools, as they have for new covid-19 treatments, such as monoclonal antibodies and tablets such as Paxlovid.

We are at a pivotal moment in the covid-19 pandemic. Without a recommitment to global equity for vaccines and other covid-19 counter measures, coupled with stronger actions and accountability, many more people will die needlessly, and all countries will increase their own future health and economic risks. Prematurely “moving on” from the pandemic, however attractive the short term implications, would be a moral failure from which the world will not easily recover.

Key messages

Covid-19 vaccine access is inequitable: around 8 in 10 people in high income countries have received at least one vaccine dose compared with just 1 in 10 in low income countries
Such global inequity has been caused by vaccine development and production being concentrated in high income nations, hoarding of doses by such nations, high vaccine prices, and challenges in deploying vaccines in resource poor settings
Even as rich nations are “moving on” and declaring the pandemic over, the public health, moral, and economic case for vaccine equity, including to reduce the chances of future waves or variants, remains powerful and undiminished
We can vaccinate the world through more robust donations, timed specifically to when low and middle income countries request them; strengthened capabilities for distribution, delivery, and demand generation; and decentralised “bottom-up” manufacturing worldwide, accelerated by shared vaccine intellectual property and technology transfer

Note: Gavin Yamey is professor of global health and public policy at Center for Policy Impact in Global Health, Duke Global Health Institute and Duke University (Durham NC, USA), Patricia Garcia is professor at School of Public Health of Universidad Peruana Cayetano Heredia (Lima, Peru), Fatima Hassan is director at Health Justice Initiative (Cape Town, South Africa), Wenhui Mao is senior research and policy associate at Center for Policy Impact in Global Health, Duke Global Health Institute and Duke University (Durham NC, USA), Kaci Kennedy McDade is policy associate at Center for Policy Impact in Global Health, Duke Global Health Institute and Duke University (Durham NC, USA), Madhukar Pai is professor of epidemiology and global health at School of Population and Global Health, McGill University (Montreal QC, Canada), Senjuti Saha is director and scientist at Child Health Research Foundation (Dhaka, Bangladesh), Philip Schellekens is senior advisor at World Bank Group (IFC, Washington DC, USA), Andrea Taylor is assistant director of programs at Duke Global Health Innovation Center, Duke Global Health Institute and Duke University (Durham NC, USA), and Krishna Udayakumar is founding director at Duke Global Health Innovation Center, Duke Global Health Institute and Duke University (Durham NC, USA). Competing interest: see BMJ article. This article is part of a series commissioned by The BMJ for the World Innovation Summit for Health (WISH) 2022. The BMJ commissioned, edited, and made the decisions to publish. The series, including open access fees, is funded by WISH.

Disclaimer: Posts by the Center for Global Development reflect the views of the authors, drawing on prior research and experience in their areas of expertise. CGD is a nonpartisan, independent organization and does not take institutional positions. Likewise, views expressed do not necessarily reflect those of the United Nations, the United Nations Development Programme, its programmes/projects or governments. The designations employed do not imply the expression of any opinion whatsoever concerning the legal status of any country, territory or area, or its frontiers or boundaries.

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It is not too late to achieve global vaccine equity

COVID-19 is a developing country pandemic

For greater vaccine equity, first fix these misconceptions

Data is essential to navigating an era of pandemics

COVID-19 mortality in rich and poor countries: A tale of two pandemics?

Ignore the global surge at your own peril

Visuals

COVID-19 is a developing country pandemic

Philip Schellekens — Thu, 27 May 2021 10:15:03 +0000

COVID-19 is a developing country pandemic

May 27, 2021

New estimates of excess mortality suggest this is now - and has for along time been - a developing-country pandemic

This blog was originally published at Brookings and later at OECD and is reposted here.

“Has global health been subverted?” This question was asked exactly a year ago in The Lancet. At the time, the pandemic had already spread across the globe, but mortality remained concentrated in richer economies. Richard Cash and Vikram Patel declared that “for the first time in the post-war history of epidemics, there is a reversal of which countries are most heavily affected by a disease pandemic.”

What a difference a year makes. We know now that this is actually a developing-country pandemic—and has been that for a long time. In this blog, we review the officially published data and contrast them with brand new estimates on excess mortality (kindly provided by the folks at the Economist). We will argue that global health has not been subverted. In fact, compared to rich countries, the developing world appears to be facing very similar—if not higher—mortality rates. Its demographic advantage of a younger population may have been entirely offset by higher infection prevalence and age-specific infection fatality.

Official data: Developing countries account for half of global mortality

The statement that this is a developing-country pandemic is not self-evident when we look at the official statistics (Figures 1 and 2). When it comes to per capita mortality, the official data suggest that the pandemic has been most intense in high-income countries (HICs). Cumulative mortality rates and—with a few exceptions—daily mortality rates have been higher for richer countries. Most people don’t look any further and decide that HICs have suffered more.

But it is necessary to also consider mortality shares. Mortality rates measure intensity, which highlights country performance, but they do a poor job in reflecting the contribution to global mortality. Given that the developing world is both younger and more populous than the HICs, we would expect its mortality rates to be lower and its mortality shares to be higher. Official data indeed show that the developing-country share in cumulative mortality is high: slightly above 50 percent (Figure 3).

This wasn’t always the case: The global mortality distribution has seen big swings since the onset of the pandemic. One upper-middle-income country (UMIC) dominated the global death toll initially: China. Soon after, outbreaks in HICs lifted their share in global mortality to almost 90 percent. A shift to UMICs followed, then quickly to lower-middle-income countries (LMICs). When winter came to the northern hemisphere, a new wave drove up the HIC share. More recently it has again started to recede. Throughout the period, the reported share of low-income countries (LICs) remained negligible.

The daily mortality distribution puts into sharper focus the most recent trends (Figure 4). The good news is that, in part thanks to vaccines, HIC mortality rates have plummeted. The bad news is that rates have spiked in LMICs and remain at high levels in UMICs. As a result, 2021 saw a complete shift in the daily mortality distribution: The LMIC share rose from 7 to 42 percent; the UMIC share from 33 to 42 percent; and the HIC share dropped from 59 percent to 15 percent—a trend that may become more pronounced in coming months.

Excess mortality estimates: The share of developing countries may be as high as 86 percent

The Economist has just published new estimates of excess deaths. Excess deaths measure the difference between observed and expected deaths throughout of the pandemic. Previously confined to mainly the richer countries, excess deaths are thanks to the new estimates available for the entire world. A gradient-boosting machine-learning algorithm helped fill the data gaps on the basis of 121 predictive indicators that are comprehensively available. With this method, global excess deaths are estimated at 7 million to 13 million, with 10 million as the midpoint.

Figure 5 shows the detailed results by World Bank income classification. Two patterns are striking.

First, excess mortality rates for the developing world are much higher than what reported COVID-19 mortality data suggest: 2.5 times higher for UMICs, 12 times more for LMICs, and 35 times greater for LICs. For HICs they are practically the same—actually about 3 percent lower. To see this, compare the dashed and solid lines, which represent the population-weighted averages for each income group (see also Figure 6 for the time series).

Second, non-reported COVID-19 deaths and other excess deaths are much larger than reported COVID-19 deaths especially in poorer countries (compare the darker and lighter shades of each bar). The small gap for HICs may reflect the opposite effects of inadequate testing and “general equilibrium” impacts of the pandemic (such as the vanished flu season).

Perhaps the most striking result is the compression of mortality rates across income groups (Figure 6). Mortality rates in LMICs are the highest (157), then UMICs and HICs (both 118) and then LICs (98). But relative to the dispersion seen in the reported COVID-19 mortality rates (Figure 1), one could say they’re “about the same.” These estimates are subject to uncertainty, but the 95% confidence intervals are considerably above the reported COVID-19 mortality rates, particularly among UMICs and LMICs (which together represent 75 percent of the world’s population).

The midpoint estimates entail a completely different mortality distribution (Figure 7). If the midpoints hold true, the developing world may account for 86 percent of global mortality (as of May 10). This compares to a share of 55 percent using officially reported data. The biggest increases are in the share of LMICs and LICs.

While virtually all developing countries are contributing to the rise (see Figure 5), rising mortality rates in the developing world’s most populous countries will produce the largest absolute impact on global mortality. We can see this very vividly in Figure 8, which shows the cumulative death toll in millions of souls. The tragedy that continues to unfold in India has claimed a very large death toll of close to 3 million. While considerable uncertainty surrounds these estimates, alternative methods suggest they are in the ballpark.

Demographic advantage squandered

It is useful to do a thought experiment (Figure 9). Imagine all countries—rich and poor—faced the same epidemiological odds; that is, suppose that everyone has the same chance of getting infected and everyone faces the same age-specific fatality rates. Under these conditions, we would capture the pure effect of demography on the mortality distribution and obtain an estimate of the demographic advantage of the developing world.

In such a scenario, we expect the developing-world share in global mortality to be around 69 percent (Figure 9, middle bar in red). Applying common epidemiological parameters to the developing world boosts their share in global mortality because of the large absolute numbers of elderly. Though developing countries are younger, they are much more populous. As a result, the 60+ population of the developing world is 2.4 times larger than its counterpart in HICs. India alone, for example, counts 140 million people over 60; this is three times the number in Japan, which has the world’s oldest population after Monaco.

The generally younger age distributions of the developing world were believed to protect against a pandemic that discriminated against older people. The fact that the excess mortality shares (Figure 9, dark blue bar on the right) are significantly higher suggests that developing countries have likely squandered their demographic advantage as mortality is higher than demography alone would indicate. In other words, developing countries likely face worse epidemiological odds in the form of higher infection prevalence and/or more elevated age-specific infection fatality risk.

We can think of many structural reasons why that would be the case. Infection prevalence has likely been fueled by environmental factors such as urban density as well as poverty and informality, which complicate physical distancing. Over 1 billion people, mostly in developing countries, live in slums. Flattening the curve will therefore be more difficult in many developing countries, meaning that preexisting health capacity constraints will become binding more quickly.

Age-specific infection fatality rates are also likely more elevated than in HICs. Comorbidities are highly prevalent in the developing world. Of the 1.1 billion people with hypertension, two-thirds live in developing countries. Over the last decade, the number of cases and prevalence of diabetes has risen most quickly in the developing world. Moreover, limited access to quality health care in developing countries would mean that many ailments would be left untreated or undertreated, heightening vulnerability.

Official data point to a big shift in the mortality distribution to the developing world in recent months. Excess death estimates suggest that developing-country shares have been much higher than previously thought. Regardless of what the precise channels have been, one conclusion is clear: This is now—and has for a long time been—a developing-country pandemic.

Note: Indermit Gill is Chief Economist of the World Bank Group and Nonresident Senior Fellow at Brookings. Philip Schellekens is Senior Economic Advisor at IFC – World Bank Group. The authors are grateful to Sondre Solstad, who produced the excess death estimates at The Economist, for making additional results by World Bank income groups available to us.

It is not too late to achieve global vaccine equity

COVID-19 is a developing country pandemic

Data is essential to navigating an era of pandemics

For greater vaccine equity, first fix these misconceptions

COVID-19 mortality in rich and poor countries: A tale of two pandemics?

Ignore the global surge at your own peril

Visuals

Data is essential to navigating an era of pandemics

Philip Schellekens — Sun, 10 Sep 2023 07:08:23 +0000

Data is essential to navigating an era of pandemics

Sep 14, 2023

A rebranded data analytics initiative by CGD and UNDP to support equitable pandemic preparedness and protection

COVID-19 is fading from public discussion, countries’ investments in health are in retreat, and hopes for a safer and fairer future are being dashed by potentially watered-down political commitments. Yet people around the world continue to feel the impacts of COVID-19 every day, other infectious disease threats have not magically gone away, and the next pandemic is nearer than we’d like to think.

Consider that, more than three years on, COVID-19 remains the third leading cause of death (over the week prior to this post). COVID-19 has claimed close to 4 million lives in the past 12 months and continues to disrupt the health and development landscape. In the wake of the pandemic, countries and communities are enduring economic downturns alongside cost-of-living and debt crises. This has put a stranglehold on health and development financing, including to prevent, prepare for, and respond to future pandemics.

These effects are not being felt equally. Some of the highest and more persistent spikes in excess deaths are in developing countries, home to the vast majority of people unvaccinated against COVID-19, and where health systems are typically less resilient to shocks (Figure 1).

At the same time, the world is yet to fully face another harsh truth: the next pandemic is coming, whether we are ready for it or not. Recent modeling forecasts a 47-57% chance of another pandemic akin to COVID-19 in the next 25 years. Climate change, continued urbanization and, more generally, the way humans interact with nature are all exacerbating pandemic risks.

We have all freshly borne witness to how a novel virus can exploit a lack of preparedness to upend lives and livelihoods. Efforts in understanding and responding to COVID-19 must ultimately be building blocks of a world more capable of tackling any and all infectious disease threats of pandemic potential in an equitable way. That means analyzing, not just COVID-19 trends, but also what future pandemics might look like, and figuring out how we can connect the dots to better prepare and protect everyone, equally.

Reliable data and actionable insights

To drive these insights and generate the political will necessary for sustained investment and action, we first need good, actionable data.

For instance, data on all-cause excess mortality and other vital statistics to support adequate surveillance efforts are sparsely available, with fewer than half of all countries providing regular information. This means that capturing the true toll of COVID-19 has been difficult. Data on pandemic risk and financing are also grossly insufficient, especially for preparedness.

Enter Pandem-ic, which started as a passion project of Philip Schellekens and has become an authoritative source of data and insights on pandemic inequities during the COVID-19 pandemic. Pandem-ic has focused on inequalities across countries (hence, the “ic” suffix) with respect to pandemic severity, the Omicron escalation, and global vaccine equity. Underpinning these themes is a commitment to tracking inequalities and uncovering struggles that would otherwise remain under the radar, as with excess mortality for example (Figure 2).

Philip has now donated Pandem-ic to the Center for Global Development (CGD) and the United Nations Development Programme (UNDP) and will remain in an advisory role. CGD and UNDP are delighted to partner on the next phase of Pandem-ic. By leveraging the cutting edge of data analytics, we will expand beyond COVID-19 to provide actionable insights on global health equity across infectious disease threats of pandemic potential, including how to move evidence and data into action and policy.

Pandem-ic is a collective effort focused on dissecting inequalities by providing accessible and relevant data with dynamic visualizations, policy insights and recommendations that help make sense of where we are and how to move forward. All website visitors are free to browse the data, insights, and articles to explore these topics further and understand how we might better – and more equitably – address the pandemics of the future.

Commitment to equity

Even the best data is not enough to save us without a substantive commitment to equity. How is data being generated? Who is that data being shared with? Are countries equally equipped to act on the insights generated by that data?

Monitoring and evaluation tools for emerging outbreaks at the global level, for instance, have been constrained by “top-down approaches, inadequate financing, and inequalities between countries that have limited their ability to evaluate country preparedness comprehensively.” As such, past experiences show that even the current understanding of pandemic preparedness could be skewed toward high-income country experiences, limiting the effectiveness and adaptability of data-driven interventions.

Our promise is that Pandem-ic will remain the converse of that. Above all, it will contribute to a more robust understanding of what pandemic preparedness and response means and requires for countries at all development levels.

If the “post-COVID” picture of the world has taught us anything, it is that “post” is a relative description. As the G20 High-Level Independent Panel on Financing the Global Commons for Pandemic Preparedness and Response clearly stated, we are in an era of pandemics and that will not change anytime soon.

What we can change, however, is how we improve global cooperation and choose to learn from the past – how we generate, share, and act on quality data to prepare for, and respond to health threats and save lives.

* * *

Note: Mandeep Dhaliwal is Director of the HIV and Health Group at UNDP. Javier Guzman is Director of Global Health Policy at CGD. Philip Schellekens is Chief Economist for Asia and the Pacific at UNDP, Non-Resident Fellow at CGD and creator of Pandem-ic. The authors are grateful to Victoria Fan, Roy Small and Sara Viglione.

It is not too late to achieve global vaccine equity

COVID-19 is a developing country pandemic

Data is essential to navigating an era of pandemics

For greater vaccine equity, first fix these misconceptions

COVID-19 mortality in rich and poor countries: A tale of two pandemics?

Ignore the global surge at your own peril

Visuals

For greater vaccine equity, first fix these misconceptions

Philip Schellekens — Fri, 02 Apr 2021 10:15:05 +0000

For greater vaccine equity, first fix these misconceptions

Philip Schellekens

Published on

April 2, 2021

Asides from various practical constraints, three misconceptions stand in the way of greater vaccine equity

This blog was originally published at Brookings and later at OECD and is reposted here.

As we start to see the light at the end of the pandemic’s dark tunnel, inequities in the distribution of vaccines across countries are coming under intense scrutiny. Unequal vaccine distribution is not necessarily unfair—after all, some population groups are more vulnerable than others. Yet relative to sensible metrics of need, the current inequality is excessive. Efforts to boost and balance deployment have galvanized under the clarion call for #VaccinEquity, but progress has been slow and marred by bottlenecks.

In addition to the various practical constraints—including financing, logistics, manufacturing, and patent rights—three misconceptions stand in the way: the view that COVID-19 is mainly a “rich-country disease”; a focus on herd immunity that detracts from the pressing goal of protecting the global priority group; and a belief that fixing vaccine hoarding in rich countries will fix vaccine equity on its own.

A global snapshot of vaccine inequity

Competing interests in diplomacy, economics, and global health shape the international distribution of vaccines, but overshadowing them all are universally recognized ethical principles that center on “need” and “priority for the disadvantaged.” Needs encompass a fuzzy spectrum. They include the burden of morbidity (e.g., long COVID), broader health effects (e.g., undermanaged illnesses), and wider socioeconomic effects (e.g., food security and poverty). But as long as this pandemic rages on, needs will first and foremost be defined by the vulnerability to premature death—which not only is devastating but also irreversible and hence hard to compensate for.

Quantifying needs is easier said than done. Trade-offs battle trade-offs. Prioritize those with high risk of death once infected or those most likely to infect or be infected? Prioritize on the basis of expected years of life left? If so, how to compare 60-year-olds from Niger with an average of two years left to live with those in Norway with 23 years left? And should we prioritize places with high R values (the reproduction number)? If so, do we distinguish between situations of poor infection control due to structural factors (e.g., informality) or discretionary ones (e.g., low compliance with mask rules)?

The vaccine equity trackers on the website pandem-ic.com examine the massive needs of the developing world through the lens of income classification. They focus on the “global priority group,” which includes vulnerable seniors older than 60 and those in the medical profession, and thus combine notions of intrinsic and extrinsic vulnerability (age and exposure). The measure could be widened by including comorbidities such as diabetes and hypertension that are prevalent in developing countries too. They could also control for R, though limited testing and the likelihood of new variants would pose a challenge. The advantage of our approach is that the data are comprehensively available.

Figure 1 then shows the disconnect between vaccine distribution and global needs. High-income countries account for 51 percent of doses administered globally—almost twice their share in the global priority group. Developing countries account for 71 percent of the global priority group but have administered 49 percent of vaccines. The contrasts are greater for lower-income countries. Demography drives some of these results. Developing countries are younger on average, but they count more seniors because their populations are collectively much larger.

Figure 2 shows the unequal capacities to protect the priority group across the income classification. It measures whether countries can theoretically cover the priority group given the single doses administered thus far, with full coverage at 200 percent. The inequality is huge: High-income countries have had capacity to inoculate 95 percent of the priority group with a single shot; in the developing world, that share is just 39 percent. Even starker, within the developing world, upper-middle-income countries have covered 44 percent, whereas low-income countries only 2 percent.

Don't penalize developing countries for a "less visible" pandemic

The idea that the pandemic has passed the developing world, including the poorest countries, is a myth reliant on poor data. The reported data underestimate reality by a vast margin. Demography alone suggests the developing country share in the global death toll should hover around 70 percent, not 50 percent. All countries struggle with data quality, but more limited testing and weaker vital registration systems compound the challenges in the developing world. Just 1 in 4 deaths from malaria are detected globally; in some low-income settings, it can be 1 in 20. Unsurprisingly, a recent post-mortem surveillance study in Zambia found that, among the deceased in a major morgue, 1 in 5 tested positive, even though none did so antemortem. When it comes to new variants and “new new variants,” let’s also not forget that we may all be vulnerable and in need of protection.

Prioritize the global priority group, worry about universal coverage later

A second misconception relates to vaccine equity itself. Vaccine equity is desirable on account of basic notions of morality. Many have also appealed to externality arguments: Vaccine equity helps dampen international transmission and muzzle new variants. It is therefore in everybody’s interest. After all, the pandemic isn’t over until it’s over everywhere.

But universal or quasi-universal coverage to reach global herd immunity should not be equated with vaccine equity. Global herd immunity as a final outcome may be compatible with vaccine equity if everyone is equally protected relative to their need. But we should also practice vaccine equity along the trajectory toward global herd immunity.

An appeal to externality arguments (namely, infection risk) may incentivize people to practice greater solidarity across borders. But even with the support of enlightened self-interest, we should still make sure that the global priority group gets vaccinated first. Elderly diabetics in developing countries deserve priority over healthy youngsters in high-income countries. The alternative scenario where we sequence herd immunity across the income ladder would result in countless deaths globally.

In practice, this means that we should fill the gaps in Figure 5 as a matter of first priority (see pandem-ic.com for a dynamic visualization). The figure shows where we stand on vaccine equity with respect to the global priority group, by country and income classification. The vertical axis shows the intensive margin of vaccine equity: the capacity of countries to fully cover the priority group of elderly and medical personnel with single doses, with full coverage at 200 percent (technical details are available here). The circular axis shows the extensive margin: the participation of countries in the vaccination process. As the predominantly blank chart shows, much progress is needed in both dimensions. But it is not a Utopian ideal—it is well within our collective reach.

Connect vaccine equity to a broader development agenda

A final misconception relates to vaccine equity more broadly. It is worth remembering the world’s performance against the Millennium Development Goals. We met the goal of reducing income poverty five years ahead of time. But the progress on all other goals—the non-income dimensions of development including health, education, sanitation, and others—were much more incomplete and heterogeneous. These dimensions represented the persistent development bottlenecks that left countries behind and motivated the broader 2030 agenda

For at least three reasons, the call for #VaccinEquity needs to be connected to this broader development agenda. First, because fixing vaccine hoarding in rich countries and distributing them more equitably across countries will not be sufficient to fix vaccine inequity on its own. Inequities and deficiencies across the broader supply chain across and within borders need to be considered. Second, the vaccine equity movement must call attention to and extend greater solidarity with other inequities in global health and development. Third, since pandemics are likely to occur again, we must seize the opportunity to break the cycle of panic and neglect and scale up pandemic preparedness.

Note: Philip Schellekens is Senior Economic Advisor at IFC – World Bank Group. Helpful comments from Jorge Araujo, Luis Benveniste, Indermit Gill, Anthony Leonardi, Magnus Lindelow, Andrew Mayeda, Alfred Watkins, David Wilson, and Shahid Yusuf are gratefully acknowledged.

It is not too late to achieve global vaccine equity

COVID-19 is a developing country pandemic

Data is essential to navigating an era of pandemics

For greater vaccine equity, first fix these misconceptions

COVID-19 mortality in rich and poor countries: A tale of two pandemics?

Ignore the global surge at your own peril

Visuals

COVID-19 mortality in rich and poor countries: A tale of two pandemics?

Philip Schellekens — Fri, 01 May 2020 20:13:58 +0000

Ignore the global surge at your own peril

Philip Schellekens — Tue, 27 Apr 2021 20:58:45 +0000

This chart describes the distribution across the income classification of, respectively, the global total of doses administered thus far, the global population and the global population that is part of the priority group.

Definitions of the priority group of people who should be vaccinated first vary across countries. To arrive at a globally consistent concept, the tracker includes all people aged 60+ as well as medical workers (specifically physicians, nurses and midwives on the basis of the WHO’s Health Workforce Accounts) who are under 60 (to avoid double counting). Various refinements are possible to include those with pre-existing conditions.

The left and middle bars can be interpreted as proxies for global vaccination needs either in terms of the full population (without regard for who might get vaccinated first) or the priority group part of the population. Both measure the weight of the country income group in global needs. The right bar expresses how vaccines have been de facto distributed thus far. This is based on actual vaccinations.

Vaccine equity in this particular context would be obtained when the distribution of vaccines corresponds to the distribution of global needs whether these needs are based on a full-population criterion or the more restrictive subset of the global priority group.

The chart shows the following:

Developing countries have a much higher population share than high-income countries. However, their share in the priority group population is smaller. This reflects the fact that there are many more elderly people in absolute terms in the developing world than in high-income countries even though relative to their own population pyramids the developing countries are much younger.
Even though needs based on priority group populations are smaller than needs based on the full population in developing countries, the collective priority group need is about twice as high in developing countries compared to high-income countries.
We would expect inequality in vaccine distribution in the sense that the priority group share of high-income countries by far exceeds their population share. Yet, the observed inequality is excessive. The share of high-income countries in vaccines is twice their share in the global priority group.
Conversely, while the priority group needs in developing countries are lower than their population share would suggest, the share in vaccines is falling well short of that.
Within the developing world, there is considerable variation. Vaccination in UMICs is progressing much more proportionately in line with priority group needs than in LMICs and LICs. The largest discrepancy is observed in LMICs.
The low shares of vaccine distribution towards lower-income countries reflects the fact that many of them have yet to start vaccinating as well as the fact that among those that have started vaccination coverage for the total population and priority group remains low.

The unreal dichotomy in COVID-19 mortality

Philip Schellekens — Tue, 05 May 2020 10:15:06 +0000

The unreal dichotomy in COVID-19 mortality

Philip Schellekens

and

Diego Sourrouille

Published on

May 5, 2020

The gap between rich and poor countries is partly unreal, but for the most part it reflects the incomplete spread of the virus

This blog was originally published at Brookings and later at OECD and is reposted here.

Here’s a striking statistic: Low-income and lower-middle income countries (LICs and LMICs) account for almost half of the global population but they make up only 2 percent of the global death toll attributed to COVID-19. We think this difference is unreal.

Views about the severity of the pandemic have evolved a lot since its outbreak in Wuhan. First, we thought it was just China. But in a matter of weeks, 3.5 million people in 210 countries and territories had become infected. A local epidemic became a full-scale pandemic, entire countries were locked down, and now the world faces the prospect of the worst economic downturn since the Great Depression.

Will we soon have to adjust our views again? Will the burden of COVID-19 mortality soon travel in a different direction? Will new epicenters emerge outside of the high-income world? Is this just the beginning for the developing world? To begin addressing these questions, it is useful to first analyze the reported data and get a better feel for the contrasts and inequalities.

Tracking the severity of the mortality burden

In a recent paper, we present an alternative way of tracking the global distribution and progression of the pandemic based on an indicator of “relative severity.” The indicator is both globally comprehensive and country-specific because it compares the mortality burden of COVID-19 across countries to pre-pandemic mortality patterns of individual countries. Deviations from these patterns indicate pressure points, most notably on health systems. And comparisons like these can help us understand the dimensions of the crisis better by referring to typical mortality patterns and common causes of death.

Using the World Health Organization’s 2016 Global Health Estimates on causes of death, we compare COVID-related deaths to pre-pandemic deaths for all causes and country-specific top causes. We draw the specific causes from a list of 123 disease families (third level of ICD-10). We focus on 70 countries that have data and have registered at least 50 deaths.

A still small global burden, shared unevenly

On April 30, the global death toll due to the coronavirus was 230,000. That’s only about 1.5 times the number of deaths the world expects on an average day. The number would not seem large were it not for the fact that it is highly unevenly distributed. Just five high-income countries (HICs)—the United States, Italy, the United Kingdom, Spain, and France—account for 70 percent of global deaths.

Figure 1 gives a sense of the unequal distribution of the severity of the mortality burden over the entire period of the outbreak, which also differs across countries. Belgium and Spain stand out. COVID-19 exceeds their first, second, and third causes of death combined (the bars). Ireland, the U.K., and France exceed their first and second causes, while Italy, Luxembourg, Netherlands, and Sweden their first ones. Only three developing countries are in these notorious lists. Ecuador exceeded its second cause of death, whereas Iran and Peru passed their third cause.

Emerging and receding pressures

Switching from cumulative to daily data, we can see how severity evolves over time and how the progression relates to the typical cause of death on a daily basis. Daily numbers are naturally noisier, but they still display clear patterns. Globally, we saw a steep rise followed by some leveling off. COVID-19 exceeded Alzheimer’s disease as the fifth cause of death by the end of March. A few weeks later it surpassed chronic obstructive pulmonary disease as the third cause.

We see huge variations at the country level (Figures 4 and 5 at the end of this blog). The cumulative severity observed in Belgium and Spain is mirrored in a sustained high level of daily severity. The contrasts between Italy and the U.S. are also instructive. Germany and South Korea are often hailed as success stories, but there too we see marked differences.

The patterns among developing countries are more muted, with some exceptions. Populous nations such as China and India report minimal severity at the level of the entire country; that obviously masks the severity in particular areas if the reported outbreak is more localized (think of China versus Hubei). Severity is still low in Indonesia, Russia, and South Africa, even though deaths in Russia are rising fast. Turkey has managed to keep severity below its second cause of death, but Brazil is registering sustained increases and COVID-19 has recently broken the threshold of the first cause of death.

An unreal dichotomy, explained partly by data quality

For a disease that has spread so extensively and so rapidly, it is surprising that the distribution of the reported mortality burden is so unevenly tilted towards HICs. There are various reasons why we believe this is unreal. One culprit is data quality.

Demographic diversity confounds the numbers—most notably, the elderly are more vulnerable to the virus. But the developing world has been aging at breakneck speed and its population is huge, meaning there are many older people. In fact, developing countries count twice as many 60+ people as high-income countries.

As Figure 3 suggests, proper accounting for age- and COVID-specific mortality patterns would tell us a radically different story (see paper for methods). We calculate that the share of HICs in total COVID-19 deaths could be three times lower on account of demography alone. The share for upper middle-income countries is likely three times higher. Those for LMICs and LICs would be, respectively, 14 and 39 times higher.

Comorbidities are another reason why the death toll in the developing world should be higher. A global meta-analysis highlights the importance of hypertension (21 percent), diabetes (10 percent), cardiovascular disease (8 percent), and respiratory system disease (1 percent) in severely infected patients. These are highly prevalent in the developing world. Two-thirds of the 1.1 billion people with hypertension live in developing countries. Diabetes has been increasingly rapidly.

Environmental factors such as temperature, population density, and sanitary conditions will matter too, in different ways, as does the availability and quality of health care. Furthermore, the policy response will have to differ across countries. Informal and self-employment will pose a particular challenge as will urban density. Some 65 percent of urban populations in LICs and 27 percent in middle-income countries live in slums.

Data quality—accuracy, completeness, consistence, timeliness, and validity—is likely the main culprit why the true death toll is not reflected in the statistics. Where testing has been limited or untimely, data quality will suffer—as the experience in high-income countries has demonstrated.

Death may be better measured than infection, especially in HICs, but even so there is ample evidence that COVID-19 deaths are being misattributed to different causes. By some estimates, reported death rates in selected countries could be underestimated by 60 percent.

While better data quality is obviously desirable, it is an even taller order for poorer countries than that evidenced in the struggles in the richest countries in the world. Where vital statistics were poorly reported before the pandemic, measurement of COVID-19 mortality will inevitably be much worse.

COVID, quo vadis?

We argue that the dichotomy in the mortality stats between high-income and developing countries is likely very significantly overrepresented. This will apply to the static comparison across countries and also the dynamic progression over time.

COVID-19 has been described as a heat-seeking missile speeding toward the most vulnerable in society. That metaphor applies not just to the vulnerable in the rich world; the vulnerable in the rest of the world are not more immune. They may actually be easier targets.

Developing countries may of course be at earlier stages of the pandemic than high-income countries. If true, this would bring however only temporary respite. The virus has already traveled the world over and structural features of developing countries may make them more susceptible to contagion.

As the pandemic unfolds, there will be a great need for understanding the anomalies over time and dissimilarities between countries. The method we propose provides a simple way to capture and dimension the severity of the crisis relative to well-understood pre-pandemic patterns of mortality.

It lends itself to comprehensive dashboards that provide progressive layers of granularity in many dimensions, such as age groups, comorbidity patterns, socioeconomic status, or economic geography. It could provide a clearer understanding of this deadly disease, without which effective medical and economic remedies will always be out of reach.

Note: Philip Schellekens is Senior Economic Advisor at IFC – World Bank Group and Diego Sourrouille is an Analyst at the World Bank.

It is not too late to achieve global vaccine equity

COVID-19 is a developing country pandemic

For greater vaccine equity, first fix these misconceptions

Data is essential to navigating an era of pandemics

COVID-19 mortality in rich and poor countries: A tale of two pandemics?

Ignore the global surge at your own peril

Visuals

Welcome

Philip Schellekens — Sat, 26 Mar 2022 12:04:30 +0000

Welcome

Introducing Pandem-ic, a comprehensive data analytics platform shedding light on pandemic inequality across countries (ic). With an initial focus on COVID-19, it offers insights into three themes: the hidden mortality crisis in developing countries, the underestimated Omicron escalation, and the urgent call for global vaccine equity.

This platform is a collaborative effort between the Center for Global Development and the United Nations Development Programme. It dissects inequalities across countries by income level, region and subregion. By exploring the relations within the epidemiological triad (between agents, hosts and environment), Pandem-ic examines how development levels and pandemic outcomes interact. Specifically, its dynamic content consists of three parts:

Trackers: Visualizations of COVID-19 data by income, region, and subregion.
Insights: Short data-oriented analyses of pandemic severity, the Omicron escalation, and global vaccine equity.
Articles & Blogs: Other longer pieces and perspectives.

We have great plans for pandem-ic. Soon we will be giving the site a fresh coat of paint. We’re planning to expand beyond COVID-19 and cover global health inequity more generally with respect to other infectious diseases. Also in the making are effort to examine what the likely future is of pandemics and how we can better prepare for the inevitable next one.

We are committed to keeping our content fresh and accessible, with daily updates of all trackers and most insights before 8am EST. In addition to a few insights that are not updated, the only static content on this site are the articles and blogs.

Be sure to explore also our other about pages, including a synthesis of the main themes of the site, the back story of pandem-ic along with a list of acknowledgements, and finally the testimonials of others on this platform.

We hope you find the content useful and welcome your comments and suggestions!

Three themes

Philip Schellekens — Sat, 26 Mar 2022 12:04:25 +0000

Three themes

Pandem-ic currently covers three themes: pandemic severity, the scale of the Omicron escalation, and global vaccine equity.

The first theme delves into the understated severity of the pandemic in developing countries, highlighting the gap between official data and the reality of excess mortality. Pandem-ic addresses pressing questions on how COVID-19 compares to pre-pandemic mortality patterns, the impact of population outliers, and why this remains a developing country pandemic.

The second theme explores the unprecedented scale of the Omicron escalation, examining the latest global patterns on newly confirmed cases and its unequal impacts across countries. Pandem-ic provides insights on the implications of the sheer scale of the escalation for the future course of the pandemic.

The third theme focuses on the unmet need for global vaccine equity, emphasizing the persistent gaps in vaccine coverage, particularly in lower-income countries. Pandem-ic asks critical questions on how to think conceptually about global vaccine equity, the latest status on primary and booster vaccination, and how well the global priority group is protected.

Theme #1: Pandemic severity

Delve into the reality of the pandemic’s understated severity in the developing world, as official data on pandemic mortality has failed to paint the full picture. Initially, the claim was made that COVID-19 would leave the developing world “unscathed,” and later that the pandemic had been “mild” in countries with young populations, leading to the belief that vaccines were unnecessary. However, a broader examination reveals the true impact of the pandemic, especially in developing countries.

By using the concept of excess mortality, we can take a comprehensive look at the true and total impact of the pandemic. The chart above reveals our best guess of the per capita mortality impact on the developing world. Middle-income countries – both lower and upper middle – have been hit hard despite having much younger populations than high-income countries, whereas low-income countries have much higher rates than the official numbers suggest.

Our posts on pandemic severity tackle critical questions to deepen our understanding of the pandemic’s impact:

What is the latest on COVID-19 and excess mortality across countries and over time?
How is the gap between the two mortality concepts evolving and what does this mean?
How does COVID-19 compare to pre-pandemic mortality patterns?
How do we assess pandemic severity across richer and poorer countries?
What is the impact of population outliers on pandemic severity?
Why are poorer countries, despite their younger populations, disproportionately affected by the pandemic?
Why has the pandemic been a developing country pandemic, and has it always been this way?

Stay up-to-date with the latest developments on pandemic severity by checking out our most recent posts, almost all of which are updated daily:

COVID-19 did not subvert global health

Global mortality trends in the last 12 months

The demographics of excess mortality

The global picture of excess deaths is disturbing

Four perspectives on pandemic severity

Pandemic exceeds top causes of death in most countries

Japan and US are worlds apart on pandemic mortality

A life lost is a life lost

One world, two pandemics?

How population outliers distort COVID severity rankings

Excess death counts reveal pandemic’s true tragedy

Demography rules in this age-discriminating pandemic

We’ve also compiled a selection of external articles and blogs on pandemic severity that have been republished on our platform. These resources provide additional perspectives and insights, helping to broaden our understanding of the pandemic’s impact:

COVID-19 is a developing country pandemic

COVID-19 mortality in rich and poor countries: A tale of two pandemics?

The unreal dichotomy in COVID-19 mortality

Theme #2: Scale of Omicron escalation

Discover the previously unseen scale of the Omicron escalation, the second theme of our platform. Since mid-December 2021, Omicron has swept across the globe, leading to an unparalleled surge in the number of confirmed cases, initially accompanied by Delta. Pandem-ic documents this escalation and sheds light on its unequal impact on countries. We explore the implications of the sheer scale of the escalation, offering insights into the future course of the pandemic.

The chart above vividly portrays the scale of the Omicron escalation. It illustrates the ratio of the latest peak in cases and deaths per capita compared to the earlier peak before November 1, 2021. We can see that the surge in cases has been extraordinary, and the impact on mortality, while not as severe as before, is still significant. It’s worth noting that if we could count all infections accurately, the scale of the escalation would be even more striking.

In light of the stark reality of the pandemic’s impact, we are left with several questions:

What are the latest global patterns on newly confirmed cases?
Where are the new hotspots, and what do they reveal about the pandemic’s ongoing impact?
How do we measure and understand the differences across countries and over time?
What are the implications of the scale of infection for the future course of the pandemic, and how can we best prepare for what’s to come?

We explore these critical questions in the following posts:

Wake us up before you go, Omicron!

The severity of the Omicron surge

South Korea defies pandemic records

The surge in East Asia and the Pacific

The pandemic across US states

COVID waves: Europe and US compared

Theme #3: Global vaccine equity

The third theme of our platform is the urgent need for global vaccine equity, which has been a key focus since our inception. Despite some progress, the road to achieving vaccine equity remains long and challenging, as persistent gaps in coverage continue to highlight. Lower-income countries continue to suffer the greatest shortfalls in primary vaccination. Meanwhile, booster programs are being rolled out globally, yet they seem to follow the same patterns of inequality that marked the primary vaccination campaign.

The unvaccinated world is huge – as of today, 2.2 billion people have not yet received a single COVID-19 vaccine shot. Our cartogram above depicts where the unvaccinated live, with land masses distorted to represent the headcount of those without vaccines. This illustrates the main challenge in achieving global vaccine equity in the absolute: Sub-Saharan Africa and South Asia. However, in per capita terms, the challenge is most intense in Sub-Saharan Africa, as the colors of the chart suggest.

At our platform, we explore the issue of global vaccine equity, tackling a range of questions, including:

How can we accurately compare vaccination progress across countries?
What are the conceptual frameworks for understanding global vaccine equity?
What is the latest status on primary and booster vaccination?
How well are global priority groups protected?
What are the characteristics of countries that perform well or less well in vaccine distribution?

Check out our daily updated posts on the global vaccine equity:

Mapping our unvaccinated world

The unfinished business of COVID-19 vaccination

Vaccine equity needs a boost

The global booster rollout is slow and unequal

Excess mortality and vaccination

Local vaccine manufacturing pays off

The 50 least vaccinated countries of the world

Cuba, one of the most-vaccinated countries

Elderly vaccination is poorly targeted globally

We’re in the dark on vaccination by age

A new indicator to compare vaccination across countries

Extreme poverty and vaccination

See also the following articles on global vaccine equity published originally elsewhere and republished here:

It is not too late to achieve global vaccine equity

For greater vaccine equity, first fix these misconceptions

A parting note

We believe that a deep understanding of the interconnectedness of global health issues is important to navigating this pandemic and beyond. Our three thematic areas – pandemic severity, Omicron escalation, and global vaccine equity – may seem separate at first glance, but they are inextricably linked. Our posts explore these connections, highlighting for instance how the need for vaccine equity is accentuated by the severity of the pandemic in the developing world, and how the transmissibility of Omicron has highlighted the importance of global collaboration in managing the virus.

We invite you to explore our platform and join the conversation. Your comments and suggestions are welcome!

Visuals

What others say

Philip Schellekens — Sat, 26 Mar 2022 14:26:13 +0000

What others say

The gripping visuals at pandem-ic are beacons that point to much-needed action. WHO greatly appreciates your dedication and contribution to the pandemic response.

An excellent website visualizing the pandemic and its inequalities

Pandem-ic has been my go-to resource on cases, deaths and vaccinations by country income group - totally vital for policy making and financing

Philip Schellekens is an economist by day, super-hero by night. During this pandemic it has been difficult to find ongoing, reliable information on the pandemic and its global scale; comparative analyses on deaths, infections, vaccinations by regions and countries and; smart, data-driven commentaries on the common misconceptions we have about COVID-19 from coverage of vaccination worldwide to mortality in the developing world. Pandem-ic fills an important gap in keeping us all up-to-date and informed about what matters around the planet during this plague. The fact that it is a labor of love, a volunteer effort, makes Dr. Schellekens a hero in my book. So many people have gone the extra mile (or kilometer) over these past two years to help others and Dr. Schellekens is one of them.

Pandem-ic has been the single most important visualization platform to understand and track global equity during COVID-19. Where a flood of data has so often served to obscure what’s really going on in this pandemic, hiding the stark realities of unequal vaccine access and avoidable mortality, Philip Schellekens has given us a set of tools with which to see the world as it is. Ironically it has become the public good that our vaccine efforts aspire to be. While I hope it is soon made redundant, this work has shown the value of social science in global pandemic response.

Terrific visualisations that drive home the many aspects of the huge, and continuing, inequality in access to vaccines across country income groups. Important reminder of what remains to be done to bring this pandemic under control.

For those fighting for global vaccine equity, pandem-ic has been an invaluable, easily accessible, frequently updated resource. It has exposed inequities with great clarity and helped raise awareness about what the world needs to do, if we want to end this pandemic

An enormously valuable source of data on the COVID-19 pandemic, exceeding in value the work of many institutions on this topic

Some of the most compelling data analytics on #VaccinEquity

Powerful data visualizations showing the extreme inequities in the global vaccine campaign

The gripping visuals at pandem-ic are beacons that point to much-needed action. WHO greatly appreciates your dedication and contribution to the pandemic response.

An excellent website visualizing the pandemic and its inequalities

Pandem-ic has been my go-to resource on cases, deaths and vaccinations by country income group - totally vital for policy making and financing.

An enormously valuable source of data on the COVID-19 pandemic, exceeding in value the work of many institutions on this topic

Some of the most compelling data analytics on #VaccinEquity

Powerful data visualizations showing the extreme inequities in the global vaccine campaign

An enormously valuable source of data on the COVID-19 pandemic, exceeding in value the work of many institutions on this topic

Some of the most compelling data analytics on #VaccinEquity

Powerful data visualizations showing the extreme inequities in the global vaccine campaign

The gripping visuals at pandem-ic are beacons that point to much-needed action. WHO greatly appreciates your dedication and contribution to the pandemic response.

An excellent website visualizing the pandemic and its inequalities

Pandem-ic has been my go-to resource on cases, deaths and vaccinations by country income group - totally vital for policy making and financing.

pandem-ic

It is not too late to achieve global vaccine equity

It is not too late to achieve global vaccine equity

Contents

What caused global vaccine inequity?

Vaccine production

Allocation

Affordability

Deployment

Renewed case for vaccine equity

How we can vaccinate the world and be better prepared

References

COVID-19 is a developing country pandemic

COVID-19 is a developing country pandemic

Contents

Official data: Developing countries account for half of global mortality

Excess mortality estimates: The share of developing countries may be as high as 86 percent

Demographic advantage squandered

Data is essential to navigating an era of pandemics

Data is essential to navigating an era of pandemics

Reliable data and actionable insights

Commitment to equity

For greater vaccine equity, first fix these misconceptions

For greater vaccine equity, first fix these misconceptions

Contents

A global snapshot of vaccine inequity

Don't penalize developing countries for a "less visible" pandemic

Prioritize the global priority group, worry about universal coverage later

Connect vaccine equity to a broader development agenda

COVID-19 mortality in rich and poor countries: A tale of two pandemics?

Ignore the global surge at your own peril

The unreal dichotomy in COVID-19 mortality

The unreal dichotomy in COVID-19 mortality

The gap between rich and poor countries is partly unreal, but for the most part it reflects the incomplete spread of the virus

Tracking the severity of the mortality burden

A still small global burden, shared unevenly

Emerging and receding pressures

An unreal dichotomy, explained partly by data quality

COVID, quo vadis?

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Visuals

Welcome

Welcome

Three themes

Three themes

Theme #1: Pandemic severity

Theme #2: Scale of Omicron escalation

Theme #3: Global vaccine equity

A parting note

What others say

What others say