Vaccine Diaries is a series of dispatches exploring the rollout of COVID-19 immunizations.
I weep with relief when I hear Anthony Fauci announce that the COVID-19 vaccine is imminent for health care workers. As a doctor taking care of patients with COVID-19, I’ve watched more people die this year than ever before—and it was only October. Alone in the kitchen of my Boston apartment, I want to share the good news. I call my mother back home in Zimbabwe.
“I’m getting the vaccine!” I say.
She is happy for me; I am her son, after all. But my own relief is displaced with a pang of guilt. It will be a long time, maybe years, before my mother gets a COVID-19 vaccine—if she is ever offered one at all.
My mother is in her mid-60s and has diabetes. If she were in the U.S., she’d be next in line after health care workers and nursing home residents. She is not an essential worker, but her work is essential. Zimbabwe has neither Social Security nor stimulus checks, not even paltry ones. My mother, who runs a small business selling solar panels, must go to work and interact with customers in order to afford her bills and food.
Zimbabwe, like much of sub-Saharan Africa, has skeletal health services. There are fewer than 100 ventilators for a country of 14 million people; there are twice as many ventilators in my Boston hospital alone. A man with whom I went to high school in Harare, the country’s capital, died of COVID while his family searched for a ventilator. I worry about what would happen to my mother if she needed one.
Similar inequities are laid bare with vaccines. The world’s supply of COVID-19 vaccines has been dominated by high-income countries which, in order to put their citizens first in line, have bought out large amounts from manufacturers to the exclusion of people in poor countries. Bioethicists call this vaccine nationalism. Since not all vaccines will be developed at the same speed, and some will fail, rich countries are incentivized to reserve far more doses than they will need. The United States, for example, has prepurchased more than 1 billion doses—enough to vaccinate its population several times over. The EU, Canada, and the U.K. have made similar investments.
But when rich economies take more than they need just to be safe, they deplete the global supply. They take away from countries like Zimbabwe, where people are already on the verge of famine and the government can’t afford hunger relief for its citizens, let alone millions of doses of a new vaccine at $5 to $50 per dose.
Instead, low-income countries must rely on COVAX, the global alliance for a more equitable distribution of COVID-19 vaccines. The alliance consists of governments (rich and poor), international organizations like the World Health Organization, vaccine manufacturers, and philanthropists which are working together to fund the research, development, and fair distribution of COVID-19 vaccines. (It does not include the U.S.; Trump refused to join, and Joe Biden has yet to commit to joining.) Rich countries subsidize poor ones in return for higher global immunity rates, reducing the risk of future pandemics. COVAX has 700 million doses at the moment, far from its 2 billion dose goal. Even if COVAX reaches this goal, it will only be enough to vaccinate 20 percent of people in low-income countries: medical workers and vulnerable populations. This is not nearly enough to achieve herd immunity, which means that people in those countries will be at risk for years to come. If a government like Zimbabwe’s wants to vaccinate the rest of its population, it will be up to it alone to find the funding. According to a recent report, only 1 in 10 people in many African countries will get a vaccine in the upcoming year. My mother, a small-business owner, will likely not be one of them.
“I grew up in the dusty streets of Harare (Zimbabwe),” writes a Pfizer scientist in a viral post on LinkedIn. He is proud “for being part of the team that delivered this great Christmas present to the world.” Most Zimbabweans I know are congratulatory. But some question whether his efforts will ever touch the lives of those still living in the “dusty streets” of Harare.
“I’m not sure a vaccine will work in Zimbabwe,” my mother says to me.
It’s the middle of a hot summer in Zimbabwe. There are power outages for hours each day. The food in my mother’s freezer spoils in the heat. Even if by some miracle the government could pay for the vaccine, how will they keep it cool? How will they deliver it to rural areas where most Zimbabweans live and where, even in many clinics, reliable refrigeration is a luxury?
Living in Zimbabwe, my family is accustomed to limited medical resources. For example, it took 10 years after a devastating cholera epidemic in 2008 to vaccinate 10 percent of the Zimbabwean population against the disease, even though effective vaccines for cholera have existed for a long time. My mother has been taught that some things, like the COVID vaccine, may never reach her. “I prefer not to expect too much of the world,” she says, “that way I won’t be disappointed.”
The day the U.S. Food and Drug Administration approves the Pfizer vaccine, I’m sleeping off the previous night’s shift on the COVID ward. I wake up, restless, as I have been throughout the pandemic. I reach for my phone in the darkened room and scroll through emails. Another hospitalwide message: COVID-19 Employee Vaccination Program. I go from sleepy to wide awake. My heart races as I scroll the details. I am in Wave A, under “Inpatient and Observation units.” I feel relieved. Then I read on. At first, there won’t be enough for all of us in Wave A. If we are likely to be in contact with COVID-19 patients, we should step forward first when the booking system goes live. I feel a twinge of Darwinian competition strike up in me. I want my place in that line, but for now all I can do is wait.
Over the next few days, our hospital beds fill with patients from the Thanksgiving surge and we keep opening new wards. In between seeing COVID-19 patients who struggle to breathe, I refresh my email over and over, searching for a sign as to when I might be getting a vaccine. I hear of dermatologists who work from home planning to angle for a spot at the front of the line. Jealousy and panic creep in. I am barely sleeping.
Economists have shown that scarcity affects our “bandwidth” and just thinking that we may not have enough destroys our mental health. Although I know there will eventually be enough to go around, I recall the early days of the pandemic, when there wasn’t enough PPE. That’s when I last felt like this: on edge, desperate. Speaking with colleagues, I learn that I am not the only one with insomnia.
When the online booking system opens, so many health care workers try sign up in the first hour that the system crashes. I call my mother in tears. She puts things into perspective. “You might not be the first person,” she says, “but you’ll get it before most of the world.”
Suddenly, I feel embarrassed. I think about my friends who are doctors in Zimbabwe: They work in hospitals without adequate pay or PPE, and in some places without running water. A vaccine seems far away for them. As I refresh my email hoping for news that I can finally book a spot, I feel like I am no better than the American government trying to secure vaccines for its citizens. I hate this feeling—the desire to put my life ahead of others. It’s not something I knew I had in me, and it goes against everything we stand for as health care workers.
A day later, I’m able to make a walk-up appointment. An expansive, sunlight-filled lobby has been repurposed as the vaccine clinic. Yellow circles on the floor keep employees safely apart as we approach volunteers armed with syringes and Band-Aids. An adjacent area accommodates giddy people posting selfies during the 15-minute observation period, required after one gets the shot just in case of a reaction. I move from one yellow circle to the next, and in a few minutes, I am seated getting my shot. After, I turn to the nurse. “You sure it all went in?” I ask.
“I’m sure,” she smiles.
Update, December 29th: This article was updated to note that effective cholera vaccines have existed for a while (specifically, the oral cholera vaccine was developed in the 1990s). The original text specified that cholera vaccines have existed for more than a century; while that’s true, they were rudimentary.