It was heartwarming to see 90-year-old Briton Margaret Keenan becoming the first patient in the world to get the SARS-CoV2 vaccine in early December.

But there was a bitter sense of deja vu for many watching on television from Africa. Those of us who lived through the HIV pandemic of the 1980s and 1990s recalled the time when life-saving antiretroviral medicine was available in Western countries yet unaffordable for us. We knew that people we loved would die as a result.

Last week, a UK initiative called Arm-in-Arm was launched to encourage people who have been vaccinated against COVID-19 to donate to the WHO COVID-19 Solidarity Fund to help pay for vaccines for people in poorer countries. It is supported by the universities of East Anglia and Essex, as well as Sarah Gilbert, the co-creator of the Oxford/AstraZeneca vaccine.

Acts of solidarity involving ordinary people, particularly between the Global North and South, are always important, morally and psychologically. During the height of the worldwide struggle for access to effective HIV drugs, HIV-positive people in the north donated their medicines to those in the south. Activists, sympathetic flight attendants, and many others helped to smuggle these donated drugs to those who couldn’t afford them, and this undoubtedly saved lives.

But while people living with HIV in the US and Europe could get access to antiretroviral drugs from 1996, it took another ten years before these life-saving medicines were widely available in Africa.

The most fundamental stumbling block to vaccine access is that private pharmaceutical companies, motivated by profit, are in control, and rich countries are enabling them.

At times last year, it looked as if global solidarity against COVID-19 was possible. The World Health Organization (WHO), together with the vaccine alliance GAVI and the Coalition for Epidemic Preparedness, set up the COVAX Facility to “accelerate the development and manufacture of COVID-19 vaccines, and guarantee fair and equitable access for every country in the world”.

Why cash for COVAX won’t solve the problem

COVAX aims to vaccinate 20% of people in low- and middle-income countries by the end of 2021 – a modest ambition, to UK ears. Late last week, COVAX was boosted by additional donations from the US, UK and European Union. But COVAX and the low-income countries that depend on it are still on the back foot. Despite wealthy countries’ apparent support for COVAX, most have raced to clinch bilateral deals with pharmaceutical companies, “pre-ordering” vaccines even before efficacy trials had been completed – and there is a global shortage of vaccine stock.

The WHO director-general, Dr Tedros Adhanom Ghebreyesus, told the body’s recent executive board that 44 bilateral deals had been done in 2020 and a further 12 this year. Canada, for example, has pre-ordered nine doses per citizen. The US has pre-ordered 7.3 doses per citizen and the UK 5.7.

“Even as they speak the language of equitable access, some countries and companies continue to prioritize bilateral deals, going around COVAX, driving up prices and attempting to jump to the front of the queue. This is wrong,” said Tedros.

Most manufacturers, Tedros said, have prioritised regulatory approval in rich countries where the profits are highest, rather than submitting full dossiers to WHO to get emergency use listing approval. COVAX requires this approval before it can allocate vaccines to countries that need them.

Tedros slammed the fact that young people in wealthy countries were being vaccinated before vulnerable groups, including the elderly and health workers, in poorer countries.

Three-quarters of global vaccinations have taken place in only ten countries, while 130 countries don’t have access to a single vaccine, the UN secretary-general, António Guterres, told the UN Security Council meeting on 17 February. He described the goal of providing vaccines to all as “the biggest moral test before the global community”.

And it’s not just a moral test. Experts have pointed out that unless vaccines are equitably distributed to the most exposed and vulnerable across the globe, we risk increasing the circulation of the virus and the potential for further, more serious mutations.

Securing private bilateral deals directly with pharmaceutical companies is unaffordable for the least developed countries. Yet African and Latin American governments are desperately trying to secure vaccines, at the very least for their frontline health workers, before being hit by a third wave of infections.

Uganda, for example, is paying the Serum Institute of India $7 per dose for the AstraZeneca vaccine – triple the price paid by the European Union ($2.16). South Africa secured the same vaccine from the Serum Institute for $5.25 per dose for 1.5 million doses for its health workers, only to discover a few days later that the vaccine was ineffective in preventing mild and moderate infection of the variant that is prevalent in the country.

‘Vaccine diplomacy’

Meanwhile China and Russia are using vaccine donations to expand their influence in Africa and Latin America.

Although the Russian (Sputnik V) and Chinese (Sinopharm and Sinovax) vaccines have not yet received WHO emergency use approval, in January Guinea became the first African country to start COVID-19 vaccinations, using a donation of the Sputnik V vaccine. Five Latin American countries have also started vaccination programmes with the Russian vaccine, Sputnik V.

Last week, Zimbabwe started to vaccinate health workers with the Sinopharm vaccine thanks to a 200,000 dose donation from China. A number of other African countries are poised to follow.

Whose intellectual property?

One of the huge bottlenecks in vaccine distribution is the lack of manufacturing capacity of the pharmaceutical companies. The only thing that will change this is if more manufacturers are brought into the picture.

Aside from individual acts of solidarity like Arm-in-Arm, people in wealthy countries can pressurise their political representatives to support the proposal for a waiver on intellectual property rights on all COVID-19 products—from PPE to vaccines—so that more companies throughout the world are able to manufacture vaccines and sell them at locally appropriate prices.

South Africa, India and the majority of poor countries are pushing for such a waiver at the World Trade Organisation—as is the WHO itself—but wealthy countries, including Germany, the UK and US, are currently blocking it.

Demands from wealthy countries for protection of pharmaceutical monopolies ignore the fact that many of their vaccines have been developed with the help of government grants, not just company investments. “Public funding has driven most of the research and development for treatments and vaccines,” says Public Citizen.

“COVAX is one part of a global COVID-19 response, but charity is not a comprehensive public health strategy,” according to Asia Russell, executive director of Health GAP, which has campaigned for equitable access to medicines for over two decades. She calls on the US president, Joe Biden, to “break from Trump on this life and death issue, [and] drop US opposition to the TRIPS waiver request.” That, she argues, would be a way to keep his promise to share COVID-19 vaccine technologies with the world.

Russell, who is based in Uganda, told openDemocracy that no charity initiative can right that wrong of the skewed access to vaccines.

“The only solution is for vaccine manufacturers to share their technology so we can start to overcome artificial vaccine supply scarcity through easing monopoly restrictions,” said Russell. “Why is gross profiteering being tolerated, while front-line health workers in poor countries are dying waiting in line for access? Aren’t their lives worth as much as people in the UK or US?”

“Pharmaceutical companies must wake up. Donation schemes and feel-good initiatives won’t fix vaccine apartheid. They must relinquish their patents, share their know-how, and co-operate.”