Distributing the COVID Vaccine Will Be the 21st Century’s Greatest Challenge

The race is on to develop an effective COVID-19 vaccine. We’re nearing the finish line with encouraging results from three leading candidates so far: Pfizer, Moderna and AstraZeneca. But our most difficult challenges still lie ahead. Getting a vaccine through research and development isn’t even half the battle. We still have to deliver that vaccine around the world. And it’s here that our best medical efforts to end the COVID-19 pandemic meet the realities of the world’s limited infrastructure and often capricious bureaucracies.

For more than 35 years, I have built and operated health infrastructure to and throughout the developing world for global organizations like USAID, the Global Fund and the United Kingdom’s Department of International Development, and I have worked in concert with various U.N. organizations like UNICEF. From Russia, Saudi Arabia and Iraq to Africa, India and most of Asia, I’ve been on the ground battling the everchanging bureaucratic hurdles, challenging logistics infrastructure and limited financial resources that can present an impenetrable blockade to vaccine and medicine delivery. Today my company manages hundreds of millions of kilos of medicines and supplies to over 80 developing countries. We are most likely doing more than any other company in the logistics industry.

Based on my experience, I believe delivering the COVID-19 vaccine to the billions of people living in the developing world may be the greatest public health challenge we’ve ever faced as a global community and is most certainly the biggest challenge of the 21st century. We have to get it right, but the time to prepare is limited.

So, what is it that we need to do to deliver the vaccine? Let me take a 10,000-foot view of a few of the most pressing challenges we face.

First, there’s the vaccine itself. Leading vaccine candidates from Moderna and Pfizer need to be stored at sub-zero temperatures — much colder than the 2 to 8 degrees Celsius that is standard for the flu vaccine. These temperature requirements will present serious challenges here in the United States and Europe; those challenges may become insurmountable for the developing world. Shelf life is also a critical consideration. A vaccine like AstraZeneca’s is much more ideal. It is cheaper and, even more importantly to distribution, can be kept at standard refrigerator temperatures for up to six months.

The challenge here is well-documented: The developing world has big issues with cold chain storage and transport. Even if we were to focus on shipping a vaccine like AstraZeneca’s, there is still very limited cold-storage infrastructure, and that limitation starts right at the airports. I can’t think of a single airport in Africa that has the 2-8C capacity to store the number of doses we need for this pandemic. But we need more than airport storage; we also have to extend the strict cold chain throughout each country in the developing world in order to reach designated inoculation sites.

Now, there do exist implementable, cost-effective solutions, but putting them into practice will take a herculean organizational effort. And who will be in charge of that effort? The COVAX consortium was launched to be that platform, but it is unclear how the poorest countries will be able to maximize their inoculation capability. The United States’ likely return to the World Health Organization should add a very powerful, capable and willing player to COVAX. But in my opinion we still lack an expert distribution plan with detailed and proven cold-chain methodologies customized for the developing world.

The cost of failing to organize and plan effectively can be enormous. The recent problem with government officials in Kenya misusing $2 billion in COVID relief funding is a grim reminder of how quickly corruption, inefficiency and organizational failure can derail our best efforts if we lack sufficient coordination and oversight.

Now, let’s even assume we succeed in buttressing the developing world’s logistics infrastructure to handle simple refrigeration and in establishing the right organizational structure. Are we in the clear? Is that enough? Not even close.

First and foremost, we still have to get through the governmental red tape and bureaucracy that must be dealt with in each and every developing country individually. No cargo is more strictly regulated than medicines and vaccines; the processes of testing, inspecting and authorizing shipments in every country can be very time-consuming and can often involve as many as four different government ministries. Approval in various African countries for the “game-changing” TLD antiretroviral regimen for HIV positive patients took more than a year. And I’ve seen vital medical supplies such as malaria nets used as a political power play in various countries. Any potential COVID-19 vaccine will be a magnet for self serving political agendas and misuse.

But even after we get a country’s approval for the vaccine, we still have to face the daunting transportation and environment challenges of the developing world. We will have to meet these challenges on a country-by-country basis; a cookie-cutter approach simply won’t work. We have to plan for each country’s unique road infrastructure, terrain and weather. After the 2016 Ebola crisis in Sierra Leone, my company rebuilt the medical infrastructure to over 2000 hospitals and dispensaries, and many of those medical facilities are located in regions that are only accessible by canoe. In parts of South Sudan and the Democratic Republic of Congo, the rainy season makes large parts of each country completely inaccessible for weeks at a time. We have to prepare for unique conditions such as these.

These challenges can all be conquered. There are solutions, but the organizational planning and expert capacity to implement them must be built — now. The cold-chain infrastructure network, country-by-country regulatory coordination and private-public partnerships so necessary to succeed in this massive, global distribution effort take time to develop.

If we don’t start now, the developing world will be left behind in the race to global inoculation. Without a significant part of the developing world vaccinated, herd immunity may not be achievable for many years.

Ron Cruse is founder and CEO of Logenix International, one of the leading supply-chain services companies in the developing world, working with USAID and the Global Fund, among others; Cruse is also the author of “Lies, Bribes & Peril,” updated edition available fall 2020.

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