The Pakistan Tehreek-i-Insaf government‘s recent step to allow the private sector to import the Covid-19 vaccine Sputnik-V from Russia has raised several ethical, epidemiological and economic questions. The issue of vaccine imports through the private sector caught the media attention only after Transparency International-Pakistan (TIP) called on the prime minister of Pakistan to review its policy because it was an aberration.

The TIP chairperson, Justice Nasira Iqbal (retired) highlighted that governments were procuring vaccines and administering them to the citizens for free throughout the world because vaccination was a prime responsibility of the state. One of the factors that dismayed the TIP chairperson was the federal government’s setting the maximum sale price at Rs 8,449 for two doses of Sputnik-V.

By any standards, it was an exorbitant price as it was estimated to be 160 percent higher than the international price of the dose. TIP‘s letter also reminded the government that allowing the private sector to import vaccines would provide a window of corruption and the government vaccines may be sold to private hospitals.

TIP‘s letter was a timely reminder to the government about the responsibility of the state and the risks of corruption in involving the private sector in procuring vaccines. However, the problems related to Covid-19 vaccination are infinitely more intractable and need to be looked at in a broader context.

The situation as it stands now: Pakistan has had over 0.6 million cases of Covid-19 and close to 14,000 deaths. So far, Pakistan has received 1 million doses of Sinopharm vaccines donated by China. Pakistan expects another 17 million doses of the AstraZeneca-Oxford vaccine through Gavi-WHO vaccine initiative Covax. The Covax programme is the global scheme to vaccinate people in poor and middle-income countries against the coronavirus. It plans to deliver at least 2 billion vaccine doses by the end of 2021 to cover 20 percent of the most vulnerable people in 91 countries, mainly in Africa, Asia and Latin America.

The catch lies in the fact that vaccine delivery through the Covax programme may be inordinately delayed and actual deliveries may well be significantly less than the commitment. The internal documents leaked to Reuters suggest that the Covax programme is struggling because of a lack of funds, supply risks and complex contractual arrangements, making it impossible to achieve its goals.

The quality of the vaccine that may be delivered through Covax also has clear question marks. Covax plans to rely on cheaper vaccines, many of which have yet to receive approval, rather than vaccines from front-runners like Pfizer/BioNTech and Moderna, which use more expensive mRNA technology. Covax has made non-binding supply agreements with AstraZeneca, Novavax and Sanofi. Novavax vaccine is currently being assessed by the UK regulator MHRA and the government officials are reluctant to put any date on when the vaccines will be approved. Sanofi suffered a significant setback in its work to produce the Covid-19 vaccine in December last year. Even if everything goes as planned, Sanofi will not deploy its vaccine before the second half of 2021.

Delays in Covax for Pakistan imply that it will not be able to vaccinate its population anytime soon.The question is why a nuclear Pakistan cannot vaccinate its entire population out of its own resources. The most straightforward answer is that Pakistan has limited means and an even more limited will to vaccinate its entire population of 223 million people. At the risk of some oversimplification, the cost of injecting two shots each to the entire population at the international price of Rs 1,500 per shot adds up to a massive sum of Rs 669 billion.

To put these costs into context, this represents 52 percent of the defence expenditure, 23 percent of markup payments, and 11 percent of the total current expenditure of the FY 2020-21 budget. To add a little more context, almost 68 percent of the current expenditure is accounted for by three major heads: markup payment (36 percent), foreign loan repayment (16 percent), and defence expenditure (16 percent) (the figures are for FY2019-20). The sobering truth is that the amount required to vaccinate the whole population is approximately 26 times higher than the expenditure on health in the FY2020-21 budget. How likely is Pakistan then to roll out its vaccination plan from its resources should not be difficult to fathom.

The TIP‘s letter, discussed earlier, may have only tangentially underscored the risk of precipitating further social inequality by allowing one segment of the population to be vaccinated while leaving the large majority high and dry. However, the issue of inequality in access to the vaccine is not unique to Pakistan.

In New Delhi, it is primarily the wealthy Indians who are being inoculated; the reason being that vaccine appointments require online registration and less than half of the Indian population has access to the Internet, even fewer have smartphones. It is not only the developing countries in the Global South that been have been struggling for vaccination; even the developed countries have a hard job of vaccinating their whole population.

In the United States, Hispanic and black Americans, are twice as likely to die from Covid-19 as the white Americans and are being vaccinated at a significantly slower rate than their white compatriots.

Canada ordered enough doses to vaccinate the population five times over, the UK 3.6 times over, the European Union 2.7 times over, Australia 2.5 times over, the US twice over.

Even if there are stark inequalities in vaccination access within countries, cross-country vaccination inequalities are even starker. Dr Tedros Ghebreyesus, the WHO director-general, recently lamented that the inequitable distribution of Covid-19 vaccines is becoming “more grotesque every day.“ So far, 448 million doses of Covid-19 vaccines have been administered worldwide.

The high-income countries, 16 percent of the world‘s population, have accounted for more than half of the doses injected, whereas only 0.1 percent of the doses have been administrated in the low-income countries. The WHO chief says that “Countries that are now vaccinating younger, healthy people at low risk of disease are doing so at the cost of the lives of health workers, older people and other at-risk groups in other countries.“

Some countries have ordered enough vaccines to inoculate their population many times over, let alone taking into account two mandatory doses. Canada, for instance, has ordered enough doses to vaccinate the population five times over, the UK 3.6 times over, the European Union 2.7 times over, Australia 2.5 times over, the US twice over. Pakistan, on the other hand, is among 85 countries dependent on Covax, and therefore will not have Covid-19 vaccines widely available until 2023.

There can be little doubt that science and technology have been benefiting only those with sufficient purchasing power. The Covid-19 vaccination apartheid brings back the haunting memories of the Bengal Famine of 1943 when three million people starved to death. While the people were starving, food grains were hoarded and sold in the black market because the Bengalis, pauperised by colonial war policies, did not have the purchasing power.

India and South Africa tabled a proposal in a recent WTO meeting, sponsored by 57 countries and the WTO, to temporarily waive any intellectual property rights for vaccines and treatments. The proposal was opposed by the United States and other Western countries. Since WTO works via consensus, the rest of the world cannot expect the Covid-19 vaccine shots anytime soon.

What would be the likely consequences for public health if only a tiny minority within countries and across the world is vaccinated, and the large majorityare left unprotected? Dr Tedros Ghebreyesus has stressed that the inequitable distribution of vaccines is not only morally outrageous but is also economically and epidemiologically self-defeating. When some countries vaccinate their entire populations while other countries have nothing, the vaccinating countries only buy short-term security. The reason is that when there is more transmission of the disease, there will be more mutations and more virus variants with a higher risk of defeating vaccines. As long as the virus continues to circulate anywhere,people will continue to die, trade and travel will continue to be disrupted, and economic recovery will be further delayed.

Vaccination is an issue that can be legitimately seen in binary terms. The Covid-19 vaccination, just like polio vaccination, only helps if everyone is vaccinated. According to one estimate, the global cost of not vaccinating everyone will be $ 4 trillion. Suppose the advanced economies, such as the US and Canada vaccinate everyone in 2021. In that case, these economies will still bear nearly 50 percent of the cost, even if they manage to vaccinate their whole populations.

For good or bad, this is the stark externality of a globalising world. All countries are connected through trade and production networks. If the production networks do not work to their total capacity, the economic costs can be catastrophic.

The Covid-19 crisis may well be the moment of truth for the human race in more ways than one. The moral order that seeks to create and perpetuate inequality is bound to collapse.

The writer is an Assistant Professor in the Department of Economics at COMSATS University Islamabad, Lahore Campus