“Fair Doses,” a recent book by Dr. Seth Berkley, reflects on the introduction of the COVID-19 vaccines to determine how we might be in a better position for the subsequent pandemic.(Image credit: Bloomberg via Getty Images)ShareShare by:
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Months prior to the formal declaration of COVID-19 as a pandemic, leaders in public health were examining the initial data emerging from China, bracing for the worst.
Dr. Seth Berkley — a well-known epidemiologist specializing in infectious diseases and former chief executive of Gavi, a worldwide organization focused on increasing children’s access to vaccines — was among such leaders. In January of 2020, Berkley and his associates were striving to build a framework so that, if and when researchers developed vaccines for this new virus, the doses would not be amassed by affluent nations and withheld from less wealthy ones.
Presently, Berkley has launched a new publication — “Fair Doses: An Insider’s Story of the Pandemic and the Global Fight for Vaccine Equity” (University of California Press, 2025) — which details the progression of that effort and the insights gained throughout, while highlighting why the greater battle for fairness in vaccine distribution is far from concluded.
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On January 23, 2020, I was present high in the Swiss Alps in Davos, participating in the World Economic Forum (WEF). My attendance at Davos was in my capacity as the CEO of Gavi, the Vaccine Alliance, the foremost purchaser of vaccines globally, committed to supplying novel and underutilized vaccines to children in developing countries — nations housing approximately half the world’s children. As was typical, I was engrossed with thoughts on enhancing our global defenses against both emergent and established diseases using vaccines. Simultaneously, there were growing whispers about a potential respiratory ailment outbreak caused by a fresh coronavirus strain in China.
At the Hard Rock Hotel’s bar, my spouse, Cynthia [a medical academic and consultant], and I connected with Richard Hatchett, CEO of the Coalition for Epidemic Preparedness Innovations (CEPI). While enjoying nachos and beverages, we embarked on a discussion regarding the likely progression of the novel coronavirus, later designated as COVID-19. Discourse on the ailment hadn’t yet escalated to significant political levels and wasn’t officially part of the Davos agenda, yet worry was on the rise, and many individuals during that week requested our perspectives.
The initial point of discussion revolved around assessing whether this was merely a concerning localized outbreak or the “Big One” that epidemiologists had previously cautioned about. Up to that juncture, official verification only confirmed a confined outbreak, stemming from animals at the Wuhan live animal market and transferring to humans. Nevertheless, specialized infectious disease and epidemic forums were already abuzz with conversations about potential human-to-human transmission, a major warning signal in our line of work. We came to a consensus on the substantial likelihood of extensive propagation of the novel virus. Regardless of whether it qualified as the “Big One,” readiness was essential.
Such a prospect presents hurdles for all nations, including those possessing vaccine access. Nonetheless, my predominant apprehension centered on the inequity inherent in affluent countries’ self-serving priorities. Individuals in emerging nations devoid of vaccine access had historically been at higher risk of disease and susceptible to complications upon falling ill. Their access to basic medical services was already constrained.
Improving the administration of current vaccines and reinforcing delivery infrastructure stands as the optimal strategy for timely outbreak identification, readying communities for disease outbreaks, preventing health systems from being overwhelmed during crises, and bolstering our reserves against epidemics.
If creating vaccines against the ailment proved feasible — a prospect far from certain at the time — we anticipated swift acquisition of stocks by the wealthiest nations. Consequently, it was reasonable to anticipate that a significant portion of the global populace, particularly those in lower-income developing nations, would be excluded from agreements, consequently denied access to the available vaccine resources.
That was the area where we believed we could contribute. So, Richard, Cynthia, and I delved into a preliminary strategy to guarantee equitable access to prospective COVID-19 vaccines, outlining the potential roles of diverse entities — including CEPI, Gavi, UNICEF, and WHO — alongside pharmaceutical firms, in materializing that objective.
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Placing ourselves in the roles of government officials, we foresaw an incentive for them to engage with a framework that minimized risk by executing upfront acquisition pledges for a diverse array of vaccine candidates. Their involvement could enable us to unify demand, producing sufficient economies of scale to stimulate escalated production and negotiate the most favorable pricing for everyone. We aspired to cultivate unity, advocate for and address the needs of lower-income nations, and ignite a prompt, robust international movement towards fair access.
Richard departed from Davos back to London, conferring with the CEPI team, while I returned to Geneva, consulting with the Gavi team and our Alliance partners, WHO and UNICEF, thereby initiating our partnership. That cooperative endeavor evolved into COVAX [COVID-19 Vaccines Global Access, a venture aimed at ensuring equitable COVID-19 vaccine access].
Our modest team dedicated to COVAX embarked upon what I consider the most ambitious public health undertaking of the 21st century thus far. The inaugural COVAX dose reached a COVAX-supported nation 39 days following the first administration in the United Kingdom. Because of the duration required for WHO vaccine prequalification, the first doses were administered in Africa 43 days later, in Ghana and Côte d’Ivoire. After an additional forty-two days, COVAX vaccines had reached 100 countries. Multiple delays were attributed to export embargoes, vaccine nationalism, and manufacturing slowdowns. Nevertheless, nearly 1 billion doses were distributed by the conclusion of 2021; by the close of 2022, COVAX had provided over 1.6 billion doses to populations in the world’s most impoverished countries and was assessed to have averted 2.7 million deaths in those regions. That signified the swiftest distribution of vaccines to developing nations on record.
WHO estimates that approximately 16 million individuals perished during the initial two years of the pandemic; we are currently in the process of gathering data, and this figure will undeniably increase. Furthermore, COVID-19 is far from the sole infectious threat: Presently, roughly one in seven deaths, equating to upwards of 7 million individuals yearly, is attributable to infectious diseases. Millions succumb to ailments for which we currently possess vaccines.
Quantifying the mortality averted through vaccination poses a challenge, yet certain projections indicate that vaccines have preserved in excess of half a billion lives spanning the past 70 years, the period during which they have been commonly available. This encompasses solely the approximate 30 vaccines we have against over 300 infectious diseases recognized to afflict humanity.
The imperative remains to develop improved and expanded vaccine options, particularly for prominent causes of mortality such as tuberculosis, malaria, and HIV, and ideally, additional cancers. Concurrently, the risks posed by infectious diseases are undergoing transformation.
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Even those among us with years of involvement in the sector were taken aback by the world’s deficient state of readiness for a crisis of such proportions. Moreover, we navigated the challenges of vaccine nationalism, vaccine diplomacy, and the occasionally egocentric conduct exhibited by producers and global leaders. From the outset, it was apparent that impeccable execution would be unattainable. Nevertheless, we committed ourselves to performing our utmost, and I’ve endeavored to record both our achievements and the modifications I wish we could have implemented, with the objective of gleaning insights from our experience.
As the world advances in its recovery from the acute stages of the pandemic, the prospect of confronting another pandemic may not be appealing. We grapple with apathy, exhaustion, and an increasing wariness of scientific pursuits and institutions alike, fueled by deliberate misinformation that spreads rapidly via digital channels. Conversely, we possess the chance to utilize our accumulated knowledge to enhance our preparedness for future events — and there is epidemiological certainty that a future occurrence is inevitable. As that moment materializes, we must maintain robust public health infrastructures and, ideally, available vaccines.
Reprinted from Fair Doses: An Insider’s Story of the Pandemic and the Global Fight for Vaccine Equity by Seth Berkley, MD, courtesy of University of California Press. Copyright 2025.
$29.95 at Amazon
Fair Doses: An Insider’s Story of the Pandemic and the Global Fight for Vaccine Equity
“Fair Doses” presents the narrative of vaccines: their genesis, significance, and implementation on a global scale — albeit our pursuit of vaccine equity remains in progress. Through this captivating exploration of vaccines, Dr. Seth Berkley, a globally esteemed infectious-disease epidemiologist and public health figure, furnishes an internal view of the difficulties associated with crafting and disseminating vaccines for a wide spectrum of illnesses, spanning Ebola to AIDS to malaria and beyond.
TOPICSbooksvaccinesPandemic
Dr. Seth BerkleyEpidemiologist, public health leader and author
Dr. Seth Berkley, an epidemiologist focusing on infectious diseases, currently advises vaccine, biotech, and tech enterprises. He is also an adjunct professor and senior advisor at Brown University’s Pandemic Center. Previously, he was CEO of Gavi, the Vaccine Alliance, from 2011 to 2023, co-founded COVAX, and created and led the International AIDS Vaccine Initiative as CEO.
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