In an unequal world, it is not surprising that COVID-19 vaccines are being rolled out in an unequal way. Rich countries are well into the process of inoculating their populaces, while poorer countries are still on the starting blocks. For example, Germany aims to have all its citizens vaccinated by the end of the summer, but countries such as Mali and Sudan will probably only achieve significant coverage in 2024.

Unsurprising as this may be, though, many say it is not inevitable—there are ways to fix the situation and, if they are not taken up, the effects will likely rebound on the richer countries that are gobbling up the lion's share of the vaccines.

The warning is clear: unless the "Global South" gets vaccinated soon, the pandemic will drag on for everyone. And this is a warning coming not just from human rights campaigners, but from business too.

"There needs to be an unprecedented global effort to fight COVID-19 and, in many respects, if the developed markets get vaccinated but the undeveleoped markets don’t, the problem hasn’t been solved," says Ralph Mupita, president and CEO of MTN Group, the Johannesburg, South Africa-based telecoms giant. "In an integrated world, people move around."

Private sector steps up

A week and a half ago, MTN announced it was donating $25 million to the African Union's vaccination program, which aims to inoculate 60% of the continent's population within the next two or three years. This proportion could allow for herd immunity; if it takes longer, the Africa Centres for Disease Control and Prevention (CDC) has warned, COVID-19 may become endemic.

MTN, Africa's largest mobile network operator, had already been working with the Africa CDC on getting out the message—literally, via bulk SMS—about masks and proper sanitation. It is also aiding the development of digital vaccine certificates. Mupita says his company may also be able to aid the development of digital vaccine certificates, and even floats the idea of using MTN's data center infrastructure for vaccine logistics.

"There may be capacity in data centers where there's cooling," he says. "Remember, electricity infrastructure is poorly developed [in parts of Africa]. We run a lot of our sites on generators and batteries. There may be an opportunity to participate in the cold chains of some countries."

But right now, MTN's $25 million is paying for the urgent delivery of 7 million AU-secured AstraZeneca vaccine doses, which will be distributed among African countries in the coming weeks. The AU has so far pre-secured around 670 million vaccine doses overall. (This initiative is separate from the United Nations-sponsored COVAX facility, through which Africa is supposed to get around 600 million doses this year—the United States was a COVAX holdout under the Trump administration, but is joining under President Joe Biden.)

"I would like to applaud MTN for this generous donation and I call upon private sector companies to follow the example of MTN," South African President Cyril Ramaphosa said Monday. On Thursday, the mining giant Anglo American pledged $30 million towards the vaccine rollout in countries where it operates, with $10 million of that cash going to South Africa's program.

However, donations can't fix the vaccine-production bottleneck that is hampering rollouts around the world—and effectively pushing poorer countries to the back of the queue.

Vaccine inequality

On Friday, the People's Vaccine Alliance—a coalition of organizations such as Oxfam, UNAIDS and Global Justice Now—accused the three biggest COVID-19 vaccine producers of strangling the global supply of safe and effective vaccines through their intellectual-property protections.

Pfizer/BioNTech, Moderna and AstraZeneca only have plans to produce enough vaccines to cover 1.5% of the global population this year, the alliance said, adding that Pfizer/BioNTech and Moderna's vaccines remained "prohibitively expensive for many poor nations."

The situation is different in richer countries, of course. The European Union, for example, has already secured enough doses to vaccinate its population twice, while Canada's orders could vaccinate its teenage and adult population five times over.

"We believe that this inequity is deeply morally unfair, but, more than that, it's not the way to combat a global pandemic," says Robbie Silverman, a private sector advocacy manager at Oxfam. He points out that the International Chamber of Commerce recently forecast $9.2 trillion of global economic losses due to vaccine nationalism in advanced economies—which could up to half of that hit—and noted that unvaccinated populations provide fertile ground for new COVID-19 mutations.

"Coronavirus anywhere is coronavirus everywhere," Silverman says.

The alliance's proposed solution? The suspension of intellectual-property rules that are stopping other producers from urgently manufacturing the vaccines that are known to work, and the sharing of the technology and recipes that make such production possible.

Intellectual property

The groundwork for both these proposals has been laid, but both remain stalled for now.

Last October, India and South Africa proposed to the World Trade Organization that it temporarily waive parts of the TRIPS Agreement—the global intellectual-property rulebook—in the case of COVID-19 vaccines and treatments, until most of the world's population has developed immunity.

Countries such as Kenya and Pakistan have since co-sponsored the proposal, but it faces opposition from the U.S., the U.K., the EU and other rich countries. As the WTO operates by consensus, a major international political shift would be needed if the idea is to get anywhere.

Meanwhile, the World Health Organization launched a technology and patent repository, called the COVID-19 Technology Access Pool (CTAP), last May. The idea is for companies that develop effective vaccines or treatments to contribute their knowhow, so other manufacturers can easily get to work.

More than a dozen generic pharmaceutical companies have jumped into the pool, but there's no sign of any of the big players whose contributions are needed.

The People's Vaccine Alliance is calling on the vaccine makers to change their tack and join CTAP. But, asked by Fortune for its response, Pfizer—which expects to make around $4 billion in profits from its COVID-19 vaccine this year—said only that it "stands by" the position set out last May by the International Federation of Pharmaceutical Manufacturers & Associations (IFPMA).

At the time, the IFPMA rejected the WHO's "Solidarity Call to Action", which urged "equitable global access to COVID-19 health technologies through pooling of knowledge, intellectual property and data." The trade group said the call "promotes a one-size-fits all model that disregards the specific circumstances of each situation, each product and each country."

AstraZeneca, meanwhile, responded to the CTAP question by saying it is "enabling access to the vaccine in up to 190 countries worldwide" through the COVAX initiative, which this week started allocating nearly 90 million doses to African countries, for delivery this month.

Oxfam's Silverman offers a degree of praise for AstraZeneca, which says it won't profit from its vaccine during the pandemic, and which has struck licensing deals with the likes of the Serum Institute of India to make low-cost vaccines for developing countries. "The other manufacturers really haven't followed suit," he says. "Governments could do much more to encourage those licensing deals."

But ultimately, Silverman argues, all the vaccines' development drew on public funding, and the results should be public goods. "Innovation should be rewarded, but this was created using public money and, given the unprecedented nature of this crisis, we need solutions that work for all people," he says.

That sentiment is shared by MTN's CEO. "We may need to make some amendments, because this is an unprecedented situation," says Mupita, who calls for any global securing of intellectual property to be "done responsibly".

"To that narrative of seeing vaccines as a public good and therefore creating special arrangements with intellectual property…we are certainly supportive from our perspective."

A form of this idea may be catching on in Europe, too. While the EU remains resolutely opposed to the idea of TRIPS waivers for COVID-19 drugs, European Council President Charles Michel and German Economy Minister Peter Altmaier have both recently indicated support for the compulsory licensing of vaccine-related intellectual property.

But what about all those doses that rich countries have ordered but that won't be needed, once their populations have been vaccinated?

Vaccine diplomacy

The U.S. isn't just joining the COVAX initiative and the WHO's ACT-Accelerator COVID-19 research partnership; it's also planning to offer poorer countries its unneeded doses.

"The United States will…develop a framework for providing surplus U.S. government vaccine doses to countries in need, once there is sufficient supply in the United States, including through the COVAX Facility as appropriate," the State Department said in an emailed statement.

However, Oxfam's Silverman warns against relying on such largesse. One problem, he notes, is that governments' deals with the pharma giants have been shrouded in secrecy—an issue that recently caused ructions in a delivery dispute between the European Commission and AstraZeneca. This means we know only vague terms around order volumes and delivery schedules.

"The lack of transparency really prevents us from having full knowledge of what these agreements are," he says. "It's especially galling as this is public money, but the public have no visibility. It's hard to rely on the beneficence of rich countries to get out of the crisis, in this deeply inequitable system."

Meanwhile, in the absence of supplies from the West, some low and middle-income countries have been turning to the vaccines being proffered by Russia and China.

In the case of Russia, that may not have been a bad bet. Its Sputnik V vaccine, which has already been ordered by countries such as Hungary, Egypt, Nepal and Mexico, was this week shown to be extremely effective in fending off the coronavirus. That creates a vaccines-but-at-what-cost headache for the neighboring EU, but at least the vaccine works.