The world counts 2.3 billion people unvaccinated against COVID today. A staggering 89% live in the developing world and 70% in the poorer half of the world. Tracking the unvaccinated across countries rich and poor, this post highlights the regressive outcome of the global vaccination campaign so far. It argues why this outcome is deeply problematic by debunking often-heard claims against vaccinating the world. It concludes with references to the late Paul Farmer, who described situations like these “failures of imagination”.
Let us start off by characterizing how the unvaccinated are distributed across income groups. We use the World Bank income classification of countries, which divides the world into high, upper-middle, lower-middle and low income countries (HICs, UMICs, LMICs and LICs). The developing world consists of UMICs, LMICs and LICs – in other words, the world minus the group of HICs.
The sheer inequality across income groups is best illustrated with a cartogram. This is a map that distorts the geometry of countries so that land mass becomes proportional to the absolute count of the unvaccinated. The colors indicate the income groups that countries belong to. The labels are shown for the ten countries that have the largest unvaccinated populations in the world and thus contribute the most to the total. In addition, we label Australia and New Zealand, which otherwise are more difficult to locate.
The visualization conveys the following messages:
The Top 10 countries with the most unvaccinated people make up 57% of the global total. Unsurprisingly, most of the top 10 countries for the unvaccinated are LMICs and LICs.
Let us now make these statements more precise by showing the actual numbers. The chart below plots the global distribution of the unvaccinated by income group and vaccination status. It lists the number of people who are not yet vaccinated (red bars), have been vaccinated with at least 1 dose (dark blue bars) and have been fully vaccinated as per the primary cycle (light blue bars). Our interest is in the red bars, but the other ones are useful to show the flip side of the picture, illustrating the progress that has been made so far.
The chart shows us:
The poorer half of the world claims 1.6 billion (70%). Note that the poorer half of the world consist of the LMICs and LICs, which together represent just over 50% of the global population.
The importance of Africa and South Asia could already be derived from the earlier cartogram. As the labels indicated, may of the countries that have the 10 largest unvaccinated populations in the world belong to these regions. But there is an important twist.
While the two regions contribute vast numbers to the global total, vaccination progress is quite different between them. To see this consider the cartogram below where colors indicate now the share of people not yet vaccinated in the total population of each country. So we get two perspectives combined: the absolute perspective (land mass showing the tally of the unvaccinated) and the relative one (colors indicating the share of that number in population).
This cartogram confirms that:
In relative terms, there are important relative differences between the two main contributing regions. Relative to their population, South Asia comes out much better than Africa. The challenge of reaching the unvaccinated is much more intense in the latter region.
Let us now proceed with the numbers and look at the distribution across geographical regions. We use the World Bank’s regional classification divides the world into seven regions: East Asia & Pacific (EAP), Europe & Central Asia (ECA), Latin America & Caribbean (LAC), Middle East & North Africa (MNA), North America (NAM), South Asia (SAR) and Sub-Saharan Africa (SSA). Note that Africa is split up into SSA and part of MNE.
The chart shows that:
SSA is the only region in the world that counts still (many) more unvaccinated than vaccinated people. This again illustrates the extremely low vaccine coverage of the region.
If you are interested to know which countries are driving the results by region, check out these two additional visualizations for more country-level detail. They show the headcount of the unvaccinated and their share in total population by World Bank region and a discussion of these charts can be found in this post.
The regressive outcome sometimes attracts the reaction of “so what?”. Many arguments have been made to justify the current state of affairs. But most of them have been false. In what follows, we highlight six different reasons why.
It needs to be said that the pandemic is not over, despite wishful thinking and declarations to the contrary. The virus is still widely circulating among us and provoking outburst that present large risks to vulnerable populations, including the unvaccinated and undervaccinated. So vaccination is needed. And not just primary vaccination (as this post has focused on), but also booster vaccination. We continue to face important coverage gaps on both. Vaccination remains an important instrument to protect individuals from the risk of severe COVID in the present context.
But vaccines not only limit the risk of severe COVID. They also have proven to be effective in limiting the spread of the virus. Yes, vaccine effectiveness (VE) against infection/transmission is lower than VE against severe COVID, but that does not mean VE against infection/transmission is negligible. The public health benefits of vaccination are considerable particularly when people are fully up-to-date on their shots. That conclusion was reached in a recent study of VE among adolescents in Singapore, which suggested that VE against infection with Omicron was 25% for primary vaccination and 56% for booster vaccination.
The claim goes like this: “Developing countries don’t need vaccines because infection fatality risk is low thanks to young demographics”.
In other words, undervaccination – whatever the underlying reason – need not worry us since the developing countries are naturally hedged thanks to their predominantly young demographic structures. The pandemic has passed most of the developing world without much of a stir as the officially published data on COVID-19 mortality also suggest.
Unfortunately these observations could not be further from the truth. Developing countries, including the poorer ones, have been dealt a very serious blow during the pandemic. Much of the material on this site serves to debunk the myth of a mild development country pandemic. See for example this post on why COVID did not subvert global health. Indeed, once we take a broader look and estimate excess mortality, the conclusion is clear: this is still mainly – and has in fact always been – a developing country pandemic.
Why? This is not just so because developing countries account for the vast majority of the global mortality toll. That is true even for officially reported COVID-19 mortality and not at all unexpected. After all, developing country populations outnumber those of rich countries by a large margin. As a result, while the developing world is young as a share in population, it counts many more elderly in the absolute than the rich countries. So we would expect more fatalities even after accounting for age structure differences.
But the sad reality – as shown in the above chart – is that the mortality picture in developing countries is worse even on a per capita basis. Excess mortality rates are far higher for LMICs than for HICs and those of UMICs and LICs are remarkably similar to those of HICs. Pandemic mortality has also exceeded the leading causes of death prior to the pandemic in most of the world, including many of the poorest countries.
Controlling for age, developing countries generally do not face favorable epidemiological odds. One reason why excess mortality rates have been high in developing countries is that age-adjusted infection fatality rates are much higher. Once you get infected and controlling for age, you are much more likely to succumb from COVID in the less-resourced settings of especially the poorer countries. Another reason is that infection prevalence tends to be higher in countries that are less able to mitigate the spread due to poverty, informality and generally dense living conditions. These points are discussed in greater detail here and here.
It is often heard that low vaccination is simply the result of people not wanting to get vaccinated. And the point is often made that this applies especially to developing country populations which are thought to be more prone to vaccine hesitancy. However, the reasons why people are not unvaccinated are complex. They do not fit simple one-size-fits-all narratives.
Conceptually, we can make a distinction between supply- and demand-side factors. On the supply side, constraints such as limited access to global vaccine supplies or in-country logistical bottlenecks may be the factors inhibiting those interested in vaccination to be vaccinated. On the demand side, the reasons may be related to perceptions about the efficacy and safety of vaccines. They may also be related to broader views about the severity of COVID and the need to get vaccinated in the first place.
Demand-side factors that contribute to hesitancy play a role everywhere. But hesitancy does not offer a convincing explanation for the extremely low vaccination levels in the poorer countries. As the chart below shows, while many countries around the world remain very poorly vaccinated, the poorer low- and lower-middle income countries have fared the worst. In these countries, it continues to be common for the the unvaccinated to represent over 75% of the population. In some countries, this number is still close to 100%. It is hard to imagine that hesitancy could ever explain such high numbers.
We should also keep in mind that the conceptual distinction between supply- and demand-side factors is moot in practical terms as supply and demand interact with each other in several ways.
Consumer interest may in turn be affected by supply conditions. Think of cases where vaccines were delivered that were close to their expiry date. Similarly, limited take-up may be motivated by consumer selectivity if the vaccines available are consider to be of lower efficacy than the alternatives not presently available.
Whatever the underlying reasons – demand or supply – they should not be used to dismiss the fact that the inequality in vaccination that we continue to observe across countries reflects an outright ignominy. The fact that 89% of the unvaccinated population live in the developing world and 70% in the poorer half of the world illustrates the utterly regressive nature of the global vaccination campaign.
Next it is often claimed that a renewed drive to vaccinate the unvaccinated is too late as developing country populations are already mostly infected and have built their own immune defenses.
It is true that the pandemic has spread more extensively in the developing world than one might have expected to. We can think of many structural reasons that support that conclusion. 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.
But it is one thing to say that infection prevalence is high and another to then use this as a justification against vaccination. As we recently argued in an article titled “It is not too late to achieve global COVID-19 vaccine equity” (BMJ, 2022):
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.
The final claim that is often heard is that developing countries have other pressing health needs that require prioritization. That is of course true, but the conclusion that COVID needs to be ignored does not follow naturally.
The COVID-19 pandemic has put immense pressure on national health systems. It has also disrupted the prevention and treatment of a host of other diseases. Vaccination programs against other pathogens were interrupted. Some facilities were closed. Medical workers were redeployed to battle the pandemic. Medical supplies were harder to get by. People delayed treatment for various reasons.
By the time the critical phase of the pandemic has passed, some degree of normalization should set in as these pressures recede. Yet, we already know that COVID is here to stay so resources will need to continue to flow into battling this disease. Importantly, this will involve continued efforts to make sure that those who were previously vaccinated remain up-to-date on vaccination with respect to the most prevalent variants expected to be in the community.
COVID will need to be attended to as part of a holistic strategy that must also make up for ground lost on the prevention and treatment of other diseases. But it doesn’t have to be “either-or”. Ensuring that polio vaccination is back on track need not come at the expense of promoting COVID vaccination.
Moreover, there are various things countries can do that will be beneficial across a variety of public health objectives. The crisis has for example demonstrated the importance of placing primary health care at the core of health systems, both to manage an unexpected surge of demand and to maintain continuity of care for all. Strengthening primary health care will also be to the benefit of the management of other diseases.
How about those who are not yet vaccinated – the ones that as of today have not received a single shot of any COVID-19 vaccine? Should it be the goal to reach the very last person and vaccinate the entire world, including the youngest age cohorts? Clearly, this will become progressively more difficult as diminishing returns set in. The remaining population will become ever harder-to-reach and ever harder-to-convince. The goal may reflect a laudable aspiration but implementation may stand limited chance of success.
That is true but there is also the political economy of health to consider – and this is why we keep on highlighting the regressive nature of the global vaccination campaign. The reality is this: A groundswell has been underway to push for greater global vaccine equity. Pulling the plug on the momentum right now means that the political opportunity to push this through during a time of heightened awareness will evaporate. After all, we all know that political energy cannot be so easily shifted from one issue to the next.
Yes, we need to “fix” everything else, but vaccines can be thought of as what Paul Farmer, the late American medical anthropologist and physician, calls our “battle-horse”. The vaccination campaign can be used to stoke momentum for bigger things and move the whole public health agenda forward. So again it is not “either-or”.
Finally, there is also an important forward-looking aspect to consider. The virus continues to mutate. New variants are finding ways to escape immunity of existing vaccines. No one has a crystal ball but in the spirit of better safe than sorry it would be short-sighted not to prepare against the downside risk of a more lethal pathogen.
The current state of global vaccination progress however serves as a sobering reminder of what could happen in the future if a more dangerous variant were to emerge. COVID vaccines have been developed quickly and compared to vaccines for other diseases they have been rolled out comparatively fast, except for the lower-income countries.
However, the global scale of infection is unprecedented and Omicron continues to circulate and mutate. As part of our preparedness efforts, we need to invest more in efforts to address the demand- and supply-side bottlenecks to vaccine uptake, so that if a downside contingency were to occur we can respond even more rapidly and especially more inclusively with respect to the poorer countries.
This post has surveyed where the unvaccinated live, how their numbers are distributed across countries rich and poor and how they are spread across geographical regions. As we have shown, the outcome is highly regressive: 2.3 billion people have yet to receive their first shot, 89% of them live in the developing world and 70% in the poorer half of the world. Across regions, we found that Sub-Saharan Africa makes up 33% of the world’s unvaccinated and South Asia 21%.
Why this regressive outcome is an ignominy is perhaps best explained by referring again to the work of Paul Farmer, who sadly passed away recently. He was of the view that all people deserve care (“every person is a person”), but clinical and public health deserts are all too common as are easily preventable deaths (“stupid deaths”). But with struggle and effort, it is possible to bend the arc and overcome the “failures of imagination”.
It is apt to conclude with a quote from Paul Farmer’s book “Pathologies of Power“, where he famously noted: “If access to health care is considered a human right, who is considered human enough to have that right?”. His observation, unfortunately, remains highly relevant today.
Note: Thanks to Gregg Gonsalves, Peter Hotez, Anthony Leonardi and Anne Sosin for insightful suggestions on this post and thanks to Pierre-Andre Cornillon and Florent Demoraes for helpful coding and technical advice on the cartogramR package, which produced the cartograms in this post. Any remaining errors remain all mine.