Fair Doses: An Insider's Story of the Pandemic and the Global Fight for Vaccine Justice Seth Berkley Univ. California Press (2025)
Most people don't like getting vaccinated, much less seeing their children have needles stuck in their thighs and arms. But context can change that. Gripped by horrific outbreaks of paralytic polio and the specter of ventilators, many parents were glad to see their children receive the first polio vaccinations in the 1950s. Likewise, when I received my first COVID-19 vaccine, it instantly eased the sense of existential dread I had felt for nearly a year as the death toll rose.
A radical plan for vaccine equity
For many, traumatic memories of the pandemic are fading. But infectious disease epidemiologist Seth Berkley says the prospect future pandemics means that it is extremely important for us not to forget about the powerful impact of the COVID-19 vaccine. IN Fair doses is a riveting account of the race to distribute the drug around the world as it attempts to provide readers with the “extra shot” to restore public health awareness.
Berkeley is the perfect place to tell this story. In 2020, he was the executive director of Gavi's global health organization, the Vaccine Alliance. In the early months of the COVID-19 pandemic, Gavi co-founded the Epidemic Preparedness and Innovation Coalition and others COVAX is a worldwide initiative to access, procure and deliver billions of doses of safe and effective COVID-19 vaccines to those living in low- and middle-income countries (LMIC). The author rightly spends little time studying the vaccine or the disease itself. Instead, it aims to describe the complex and intertwined financial, legal, practical, ethical and political issues involved in securing and equitably distributing vaccines across more than 140 territories.
These complexities have led to a number of challenges for COVAX managers. As Berkley recalls, “I thought that this time, thanks to COVAX, we could address the pandemic with meaningful global commitments to justice. How wrong I was.”
Tremendous effort
COVAX's goal was extremely ambitious, especially given the world's abject failure to ensure equitable distribution of influenza vaccines a decade earlier during the 2009–2010 influenza pandemic. Berkeley notes that these flu vaccines have left low- and middle-income countries “at the back of the queue.” As he points out, the drugs arrived too late to prevent a significant burden of disease, and in some countries, in fact, did not arrive at all.
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On the contrary, COVAX has been successful in many ways. More than one billion COVID-19 vaccine doses had been distributed by the end of 2021, and two billion by the end of 2023. More than half (57%) of the population in the world's 92 lowest-income countries have ultimately received the one or two doses needed (depending on the vaccine brand) for primary protection, compared with a global average of 67%. The doses supplied by COVAX are estimated to prevent 2.7 million deaths in low-income countries by the end of 2022.
Berkeley details the challenge of raising the billions of dollars needed for the scheme from foundations and governments that have struggled to fund their own vaccination programs. It was the need to raise funds that prompted COVAX leaders to decide from the outset to invite high-income countries to participate in the initiative.
A major attraction for rich countries was that COVAX had secured supply contracts with a wide range of vaccine developers. By joining the initiative, these countries will be able to ensure access to the safest and most effective vaccines, rather than being dependent on a vaccine developer with whom they can strike a deal. While the decision to involve high-income countries was, in Berkeley's words, “one of the biggest controversies in the creation of COVAX,” it was successful, helping to raise enough funds in advance to purchase vaccines for the entire world.
Initiatives to equitably distribute vaccines during a pandemic could save many lives.Photo: Issam Rimawi/Anadolu Agency/Getty
One of the fundamental challenges COVAX officials faced when doses became available in early 2021 was deciding what equitable distribution would look like. Some countries lacked the infrastructure needed to handle large numbers of doses, and COVAX was reluctant to send vaccines to countries that couldn't properly store or transport them. As more doses became available throughout the year, some middle- and high-income countries that had signed up for COVAX doses were able to procure their own vaccines. This has led to a debate over whether they should continue to provide vaccines to COVAX that they may not need. Moreover, evidence has gradually emerged that many African countries appear to be less susceptible than others in the general population to the severe effects of COVID-19 disease. This phenomenon is still not fully understood, but it suggests that the need and demand for vaccines may be less than previously predicted.
Berkeley notes the impossibility of developing a transparent algorithm that could combine all these factors and create an equitable mechanism for distributing vaccines. Ultimately, and controversially, COVAX leaders decided from the outset that the initiative would aim to meet each country's total 20% of vaccine needs, regardless of other factors. Those goals were based on projections of how much vaccine could be produced by the end of 2021 and were later revised upward.
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Despite involving rich countries in its initiative, COVAX inevitably ended up competing directly for vaccine supplies with these countries, especially when supplies were initially limited as rich countries could pay higher prices and pay up front. Despite manufacturers' contractual obligations, COVAX has sometimes found vaccine orders delayed or depriority compared to offers from other buyers.
Some countries have gone from refusing to share any doses with COVAX (despite receiving far more than their populations need) to offering leftover vaccine doses that were about to expire. Some targeted their donations to specific “friendly” countries, despite the carefully planned COVAX distribution program, and demanded immediate acceptance of their publicly visible, politically sensitive “gifts,” regardless of countries’ willingness to receive them.
