As the world enters its third year fighting the COVID-19 pandemic, health care professionals have administered 10 billion-plus vaccine doses worldwide, protecting large majorities of people in rich countries. Yet few doses have reached those living in war zones or places affected by conflict or violence, who remain largely unvaccinated and vulnerable to the disease. Preventing those countries from falling further behind will require increasing the supply of vaccines, improving delivery and overcoming barriers to vaccine acceptance. It will also necessitate doing more to navigate the politics of vaccine administration, including through peacebuilding strategies that promote dialogue and trust with marginalized communities.

Health workers in Sierra Leone give COVID vaccinations in the village of Kathantha Yimbo, handing blue record cards to vaccinated residents. Mistrust of vaccines is one obstacle to protecting people in fragile states. (Finbarr O'Reilly/The New York Times)
Health workers in Sierra Leone give COVID vaccinations in the village of Kathantha Yimbo, handing blue record cards to vaccinated residents. Mistrust of vaccines is one obstacle to protecting people in fragile states. (Finbarr O'Reilly/The New York Times)

The Deep Vaccine Inequity

For wealthy nations with well protected populations, this massive inequity is not only a moral failing. COVID-19 will remain a threat to everyone so long as it continues to affect large numbers of people anywhere in the world, with new and potentially more deadly or transmissible variants — like Omicron — arising from areas with low vaccination rates. At the same time, the pandemic will continue to worsen living conditions and conflicts in fragile states. It diverts already frail health systems from routine services to emergency responses. It forces lockdowns and quarantines that have devastated economies and livelihoods. It spikes prices for food and other essentials, pushing countries deeper into cycles of poverty and violence.

While the forecast for vaccine supplies for 2022 has improved considerably over the past few months, just 14 percent of people in low-income countries had received at least one dose as of March 16. It is now clear that the rate of COVID-19 vaccinations in low-income countries has been slow.

The numbers are particularly low in countries afflicted by violent conflict and humanitarian crisis. Of 283 million people in the world’s 10 “most fragile” states (as measured by the Fragile States Index), just 7.5 percent are considered fully vaccinated against COVID-19. In many of these countries, violent conflict complicates efforts to administer vaccines. The countries’ success rates in administering the doses they have received have varied — for example, from 12.2 percent in the Democratic Republic of Congo to 60.4 percent in Sudan. But only about 4 percent of the vaccine doses administered globally were to people in the 30 countries where complex crises have prompted the United Nations to issue formal “humanitarian response plans.”

Roots of the Problem — and of Solutions

Improving vaccination rates in fragile states is partly a problem of supply — of vaccine doses and funds to produce and distribute them. Limited global supplies of vaccines disproportionately went to high-income countries, especially in 2021. Since then, international efforts have accelerated development and broadened access to some vaccines, notably through the U.N.-backed COVAX Advance Market Commitment mechanism, which is targeted at the 92 lowest-income countries. But COVAX was initially slowed by the failure of donor countries to provide sufficient resources and by its reliance on the Serum Institute of India to make vaccines. India halted exports during the Delta variant surge in early 2021.

Thankfully COVAX has increased shipments of vaccines since late 2021. COVAX established a “humanitarian buffer” — an initiative to reserve vaccine doses and distribution funds for people caught in conflict zones or humanitarian crises who otherwise have no access to vaccinations. But like the broader COVAX effort, the buffer began operation slowly, in part because humanitarian agencies have hesitated to apply for the funding out of concern that they could be vulnerable to lawsuits over adverse outcomes from any shots not fully approved by the World Health Organization or national regulatory agencies. The result is even fewer vaccines for fragile states. To overcome some of these hurdles, regional efforts, for example by the Africa Centers for Disease Control and Prevention, are improving supplies by striking deals directly with pharmaceutical companies, waiving patents to encourage technology transfer, and building manufacturing capacity in underserved regions.

Even if they can now acquire vaccines more easily, many fragile states lack the funds, skilled personnel and health systems to administer them effectively — including, for example, the ultra-cold freezers and reliable electricity required to store the doses. For countries that have worked over several decades to increase rates of immunization for children, shifting the focus to providing vaccines for adults requires different outreach tools and communications that are not always readily available. These obstacles are multiplied in places like Syria, Gaza or Yemen, where warfare has destroyed hospitals, roads or other vital infrastructure. Where violent conflict is continuing, vaccination campaigns put health workers and civilians at risk. Even where cease-fires can be arranged, such campaigns need more than safe spaces. In conflict zones, or other places where state services are limited, people may lack formal identification or records of vaccines they already may have received.

The Biden administration’s Global Vax initiative will surge $250 million to help 11 countries in sub-Saharan Africa boost general healthcare infrastructure and vaccine delivery mechanisms. Still, the welcome efforts to improve supplies and delivery systems will not be enough; such funding must also address the deficit in public trust of governments that fuels vaccine hesitancy in fragile states.

Mind the Trust Gap

At the core of instability in fragile states is public mistrust in the institutions of governance, often bred by authoritarian rule, long-standing corruption and abuses of power. This culture of mistrust has often obstructed national and international responses to health crises, as in the 2014-2016 Ebola epidemic in Guinea, Sierra Leone and Liberia. In Nigeria, delays in containing the poliovirus — including a 2003-2004 boycott against vaccinations — were rooted in the widespread distrust in government institutions, notably in the country’s north.

Where fragile states are highly polarized — or suffering from active violent conflict — vaccine distribution risks being manipulated by rival factions. State and nonstate armed groups have weaponized vaccines by deliberately excluding targeted populations from vaccination campaigns in places like Venezuela and Somalia, particularly when vaccines are scarce. Thankfully, most countries now include refugees in their national COVID-19 vaccination plans, and the World Health Organization urges countries with ongoing conflicts to commit some of their vaccine stockpile for marginalized people. Still, more diplomatic engagement and prioritization is needed.

In states where communities mistrust their governments, and especially amid violent conflict, those countries and international donors will need to support contextualized vaccination campaigns that incorporate approaches peacebuilders use to prevent conflict and stabilize communities. This requires promoting more meaningful engagement between the service providers — public health officials and humanitarian groups — and the communities in which they operate. Vaccination advocates should involve religious leaders, elders, youth and women’s groups and other community representatives from the beginning in planning vaccine programs, and should rely on them to provide accurate information about the vaccine in their communities. Health service providers should continuously monitor the situation and integrate “social listening” and community feedback mechanisms into their operations.

More work needs to be done to understand these demand-side issues. Donors should fund research on vaccine acceptance to help inform future strategies with better understandings of whether communities are willing to be vaccinated, the reasons why or why not, and the most trusted sources of information.

Ultimately, as the former soccer player David Beckham warned, “the COVID-19 pandemic won’t end anywhere until it’s over everywhere.” Ensuring broader vaccine coverage for the world’s most vulnerable populations must become a higher priority as the world enters the third year of this pandemic.

Katherine Bliss is senior fellow and director of immunizations and health systems resilience at the Global Health Policy Center at the Center for Strategic and International Studies (CSIS). Erol Yayboke is senior fellow and director of the CSIS Project on Fragility and Mobility.

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