Upcoming pandemics: inevitable. Vaccine equality needs improvement - Dr. Seth Berkley's view.

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“Fair Doses,” a fresh volume authored by Dr. Seth Berkley, reflects on the initiation of the COVID-19 immunizations to examine how we might be more equipped for the subsequent global health crisis.(Image credit: Bloomberg via Getty Images)

In the time leading up to the official declaration of COVID-19 as a worldwide pandemic, prominent figures in public health were intensely studying the preliminary information emanating from China and readying themselves for the worst-case scenario.

Dr. Seth Berkley — a well-known expert in infectious-disease epidemiology and the prior Chief Executive Officer of Gavi, a global entity focused on enhancing vaccine availability for children — stood among those leaders. Back in January of 2020, Berkley alongside his associates devoted themselves to establishing a structure with the aim that, if scientists managed to produce vaccines targeting this new virus, the doses would not be monopolized by affluent nations while being withheld from less prosperous ones.

Now, Berkley has brought out a recent 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 evolution of that effort and the insights gleaned throughout, all while emphasizing that the broader battle for equal vaccine distribution remains a cause far from won.

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On the 23rd of January, 2020, I was situated high in the Swiss Alps in Davos, participating in the World Economic Forum (WEF). My presence in Davos was in my capacity as the CEO of Gavi, the Vaccine Alliance, regarded as the foremost purchaser of vaccines globally, which worked diligently to supply new and underused immunizations to children within developing countries — territories that are home to roughly half of the world’s pediatric population. As per usual, my primary concern revolved around identifying approaches to more effectively safeguard the world through vaccines targeting both emerging and established ailments. At the time, there were whispers regarding a potential new epidemic of respiratory sickness triggered by a novel coronavirus originating in China.

In the Hard Rock Hotel’s bar area, my spouse, Cynthia [an academic physician and consultant], and I engaged in a conversation with Richard Hatchett, the CEO of the Coalition for Epidemic Preparedness Innovations (CEPI). While sharing nachos and beverages, we commenced a discussion regarding the anticipated trajectory of the novel coronavirus, which subsequently came to be known as COVID-19. Dialogue concerning this illness was not yet prominent at the higher echelons of politics, nor was it an official item on the Davos agenda; nevertheless, unease was intensifying, leading numerous individuals throughout that week to solicit our perspectives.

Our initial point of deliberation revolved around whether this scenario would simply amount to a concerning localized outbreak or potentially evolve into the widely anticipated “Big One” that epidemiologists had repeatedly cautioned about. Up to that point, we only possessed substantiated confirmation of a point-source epidemic, stemming from animals housed at the Wuhan live animal market and spreading to humans. However, within the specialized online communities centered on infectious diseases and epidemics, considerable discourse was already underway regarding the possibility of person-to-person transmission of the virus, which in our sector, represents a severe cautionary indicator. Our consensus was that the new virus possessed the latent capacity for extensive transmission. Regardless of whether or not this event signified the Big One, we needed to brace ourselves.

Such a situation presents difficulties for every nation, including those with accessibility to vaccinations. But for me, a much more significant apprehension was the inequity inherent in affluent countries’ pursuit of their own interests. In the past, individuals residing in developing countries, lacking access to immunizations, have typically faced the greatest susceptibility to illness and the heightened likelihood of experiencing complications if afflicted. Their access to even the most fundamental medical care has consistently been restricted.

Enhancing the provision of existing vaccines and establishing more robust delivery frameworks stands as the foremost approach to identify outbreaks during their initial stages, ready communities to contend with outbreaks of disease, and guarantee that health systems are not stretched beyond capacity during times of crisis — in addition to fortifying our reserve stockpiles of crucial resources for confronting epidemics.

If it proved feasible to develop vaccines targeting the ailment — something that, at that moment, we could not definitively assert — we anticipated that the most economically privileged nations would promptly secure supplies. The logical inference was that a substantial portion of the global population, predominantly those residing in lower-income developing nations, would find themselves excluded from the resultant arrangements, thus preventing them from obtaining timely access to the vaccine resources that might become accessible.

This represented the area where we believed we could offer assistance. Consequently, Richard, Cynthia, and I engaged in a thorough dialogue, devising a preliminary outline of the measures needed to ensure equitable access to any COVID-19 vaccines that came to fruition, as well as defining the roles that diverse organizations — including CEPI, Gavi, UNICEF, and WHO — in conjunction with pharmaceutical companies, could undertake to make that objective a reality.

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Assuming the perspectives of governmental decision-makers, we anticipated that they would be motivated to partake in an arrangement that effectively collectivized risk through the issuance of advance purchase commitments encompassing a diverse array of prospective vaccines. Their involvement had the potential to enable us to centralize demand, generating the requisite scale to incentivize heightened production levels and secure the most favorable pricing terms on behalf of every participant. We aspired to foster unity, to champion and satisfy the requirements of countries with modest economic means, and to galvanize a prompt and impactful worldwide movement dedicated to promoting equitable access.

Richard journeyed from Davos to his base in London, where he consulted with the CEPI staff, while I returned to Geneva to confer with the Gavi personnel as well as our Alliance associates WHO and UNICEF, after which we embarked on our collaboration. This unified endeavor ultimately materialized as COVAX [COVID-19 Vaccines Global Access, an initiative designed to guarantee equal access to COVID-19 vaccines].

The modest group of individuals engaged in the COVAX effort undertook what I consider to be the most ambitious project in the realm of public health thus far in the 21st century. The initial COVAX shipment was conveyed to a nation receiving support from COVAX a mere 39 days subsequent to the initial vaccination administered in the United Kingdom. Following the time necessary for WHO to grant prequalification to the vaccine, 43 days later the first doses were administered in Africa, specifically in Ghana and Côte d’Ivoire. After a further 42 days, COVAX vaccines had been disseminated to 100 nations. Numerous impediments arose as a result of export restrictions, vaccine nationalism, and manufacturing setbacks. Nonetheless, by the close of 2021, roughly 1 billion doses had been distributed; and by the end of 2022, COVAX had furnished in excess of 1.6 billion doses to individuals residing in the globe’s most economically disadvantaged nations, an achievement estimated to have averted 2.7 million fatalities within those countries. This represents the swiftest introduction of vaccines to developing nations ever witnessed.

The WHO estimates that approximately 16 million individuals perished during the initial two years of the pandemic; we remain in the process of enumeration, and this figure will undoubtedly continue to increase. Furthermore, COVID-19 does not constitute the sole source of infectious hazard: Currently, around one in every seven deaths, encompassing in excess of 7 million individuals per year, are attributable to infectious diseases. Countless individuals succumb to ailments for which we already possess vaccines.

It proves challenging to quantify the precise number of deaths averted through vaccination efforts; however, certain estimates indicate that vaccines have contributed to saving upwards of half a billion lives across the past 70 years, coinciding with the period during which they have been routinely available. Moreover, this figure exclusively pertains to the approximate 30 vaccines that we have developed to combat the more than 300 infectious diseases recognized to afflict humankind.

There exists a need for the formulation of an increased number of improved vaccines, specifically targeting prominent causes of mortality such as tuberculosis, malaria, and HIV, along with potential vaccinations against certain cancers. Concurrently, the hazards associated with infectious diseases are undergoing shifts.

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Even those among us who had devoted years to working within this field were taken aback by the degree to which the world was ill-prepared to confront a crisis of this magnitude. What’s more, we had to grapple with the risks arising from vaccine nationalism, vaccine diplomacy, and, at times, the self-serving conduct exhibited by manufacturers and world leaders. It became evident from the outset that the execution of this work would not be flawless. Nevertheless, we committed ourselves to doing our utmost, and I have endeavored to chronicle both the measures we implemented and the modifications I wish we could have made in order to glean valuable lessons from our collective history.

As the global community proceeds in its recovery from the most severe phases of the pandemic era, we may not derive gratification from considering the prospect of another pandemic on the horizon. We are confronted by complacency, weariness, and a growing skepticism towards both science and established institutions, intensified by intentional disinformation that spreads swiftly online. However, we also possess an opportunity to leverage the knowledge we have acquired to achieve superior outcomes moving forward — and there exists epidemiological certitude that a future recurrence is inevitable. When that time arrives, we must have resilient public health systems operational and, ideally, readily available vaccines.

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Fair Doses: An Insider’s Story of the Pandemic and the Global Fight for Vaccine Equity

“Fair Doses” is a narrative concerning vaccines: detailing their genesis, highlighting their relevance, and illuminating their worldwide allocation — in spite of our continuous endeavors to attain vaccine equality. Within this engrossing profound examination of vaccines, Dr. Seth Berkley, an internationally esteemed infectious-disease epidemiologist and figure of prominence in public health, provides an insider’s vantage point on the hurdles entailed in formulating and circulating vaccines to combat a vast selection of illnesses, ranging from Ebola to AIDS, malaria, and beyond.

TOPICSbooksvaccinesPandemic

Dr. Seth BerkleyEpidemiologist, public health leader and author

Dr. Seth Berkley, serves as an infectious-disease epidemiologist currently offering advice to vaccine, biotechnology, and technology enterprises; he also holds a position as an adjunct professor and principal advisor to the Pandemic Center at Brown University. He held the post of CEO at Gavi, the Vaccine Alliance from 2011 to 2023; he played a co-founding role in COVAX; and established and acted as CEO of the International AIDS Vaccine Initiative.

With contributions from