Too many lives have been lost. Families, communities and nations have been devastated. … Our marathon effort has been a success, but the last mile may be the most difficult path.”
That was U.N. Secretary-General Ban Ki-moon in April 2015 speaking to world leaders about the Ebola crisis in West Africa. As President Joe Biden and his team asked heads of state and leaders of industry at a COVID-19 summit last week to make new commitments to end the latest pandemic, they all seemed to forget the very issue that Ban highlighted six years ago: the last mile.
The context for the two gatherings was quite different. In 2015 the question of how to strengthen health systems was an early focus in a hemorrhagic fever outbreak in a few countries that was deadly but relatively short-lived. Today, the world faces an active respiratory disease outbreak that after raging for almost two years is still killing more than 65,000 people a week.
Progress against the disease is limited largely because only 2% of people in the developing world have been vaccinated against COVID-19. At the same time, the rest of our health systems have been fundamentally disrupted. UNICEF and the World Health Organization have reported that disruptions in routine immunization have seen 23 million children missing standard vaccinations in 2020-21, the highest in a decade.
All of this means that most of our work to solve this pandemic is in front of us. Action is certainly and urgently needed on commitments of billions of doses, on therapies and oxygen to help save lives, and on the mechanisms to be put in place at the global level to support better future preparedness. But a crucial element is missing from the targets of last week’s summit: How will we actually vaccinate, save lives and improve preparedness to reach the billions of people not well connected to effective health care systems?
On global vaccinations, current priorities for the campaign are to get 2.4 billion doses to the developing world by the end of 2021 to vaccinate 40% of the world. Every day, global partners try to give hope with photos of vaccine doses sitting on airport tarmacs. Yet to date, 70% of all vaccinations have been given by only five countries.
COVAX, the organization coordinating the worldwide COVID-19 vaccine campaign, had to slash its vaccination plans by 30% in September. WHO has stated that more than a third of African countries have major gaps in the ability to deliver vaccines to the district level because of broken “last mile” delivery systems, just as the secretary-general cited in countering Ebola back in 2015.
More striking, we do not have the syringes to vaccinate the world. Current estimates are that we will be at least 5 billion syringes short across the life of the COVID-19 vaccination campaign. In 1999, a joint policy from WHO, UNICEF and the United Nations Population Fund called on all partners to finance “not only the vaccines, but the safe administration of the vaccines.”
Worryingly, most current donations to countries are being sent without syringes. Experts have estimated that if this syringe gap is not addressed, we could see 2 million to 3 million deaths from infections caused by syringe reuse.
Refocusing the world on the goal of “saving lives” now is also needed. Solutions to date have focused on the upstream purchase of commodities rather than the people providing care and vaccinating at the front line. If efforts to ramp up access to oxygen and personal protective equipment are going to have any effect, massive efforts must be made now at training and deployment of our front-line health workers. This must include finding ways to engage community health workers more integrally in vaccination efforts, while medical personnel support care for COVID-19.
Efforts to rebuild the disrupted systems are just starting. The debates started at last spring’s World Health Assembly and will continue after this summit. By far the most contentious topic is how to scale up manufacturing. Again, we are focused on “first mile” issues and ignoring downstream questions of how countries can really manage the end of the vaccine supply chain, namely filling, finishing and distributing vaccinations safely to their populations, even those hardest to reach.
In March 2015, we all made commitments we thought would help create a world where an Ebola outbreak could not happen again. We failed as a global community partially because we forgot the most important part, the last mile. Let’s not allow this summit’s commitments to do the same.
(David Heymann is a professor of infectious disease epidemiology at London School of Hygiene & Tropical Medicine. Ashish Jha is the dean of the Brown University School of Public Health. Edward Kelley is the chief global health officer of ApiJect Systems Corp., which focuses on injectable medicines.)
