Wealthier countries like the US and the UK have cleaned out global supplies of coronavirus vaccines, leaving many nations without access to any doses at all.
Rich countries have reserved more doses than their populations need, while lower-income countries are relying on a UN-backed acquisition program that may struggle to deliver.
Campaigners at large NGOs organizations told Insider that unequal vaccine access will deepen poverty and inequality, and ultimately harm rich nations too.
Rich countries' success in buying up most of the vaccine supply have left the rest of the world "scrambling for supplies" as they try to protect their populations, campaigners say.
The world's wealthiest countries have reserved enough vaccines to allow them to inject their populations multiple times over, and have started administering shots.
The oversupply is a consequence of countries buying up multiple types of vaccine before it was clear which ones would work.
If, as expected, most major candidates are approved then they will have many more than they need.
Meanwhile, poorer countries are firmly at the back of the line, and may have to wait years for mass vaccination.
Researchers and campaigners say the difference will be stark: One estimate from the Johns Hopkins Bloomberg School of Public Health says that 51% of vaccine doses have been reserved by countries representing less than 15% of the world's population.
Roz Scourse, a policy advisor for Médecins Sans Frontières/Doctors without Borders, told Insider: "I think the worst case scenario, to be blunt, is that we will continue to see people in low and middle-income countries dying of COVID for many years to come when there are effective vaccines and treatments available.
"There isn't a greater inequity, in my mind, than dying of something when you know that a treatment or a vaccine for that exists somewhere."
She said the current situation means much of the world is "scrambling for supplies."
Researchers for leading charities told Insider they fear that scenario will soon materialize.
Anna Marriott, Oxfam's health-policy manager, said countries have become "trapped in this deadly mix insufficient vaccine supply combined with inequality in ability to pay for the vaccine - with too little supply, and the supply that we have being primarily bought by rich countries."
"Now those countries have, I think, primarily through their purchasing power, have managed to jump to the front of the queue."
The warnings have been stark. Some experts warn low-income countries could have to wait years - perhaps to 2024 - before getting enough vaccines for most of their populations.
Steve Cockburn, the head of economic and social justice for Amnesty International, told Insider: "rich countries have acted quickly to buy up whatever vaccines had a chance of being produced, and their financial muscle has allowed them to preorder the majority of the world's vaccine supplies, leaving little left for other countries."
Charities including Amnesty and Oxfam have formed the People's Vaccine Alliance to campaign for more equal vaccine access.
It's warning that 67 countries will only be able to vaccinate one in 10 of their people next year, even taking into account existing efforts to spread out the vaccine supply.
And the campaigners warn these countries are already suffering.
Marriott, of Oxfam, said: "The impact of coronavirus on poorer nations has already been catastrophic. We know poverty's rising for the first time in over 20 years and hunger's rocketing.
"Unlike in developed nations, we're seeing vast numbers of people in developing countries receiving no government support or public funding to help cope with the effects of this pandemic."
The world's worst-off suffer most
Rich nations hedged their bets when buying vaccines: There was no clear indication of which vaccines would be approved or in what order.
This pushed officials to place orders with multiple vaccine makers - a situation that will leave them with an excess of doses if all the vaccines they've bought are approved.
How exactly countries like the US and UK managed to secure their supply is unclear, but wealth, as well as political factors like the vaccines being developed in those countries, played major roles.
But it is people already struggling under health and political crises that will likely find it hardest to get vaccines.
Campaigners pointed Insider to countries like Myanmar, where refugees are fleeing targeted violence in the country; and Nigeria, which is already dealing with a food crisis.
Vulnerable groups there are particularly likely to suffer, they said, including those in refugee camps or affected by armed violence.
Cockburn said that "unless urgent action is taken, the people who are most at risk could be the last to receive the vaccine."
"If rich countries continue hoarding vaccines, and pharmaceutical companies don't share their technology, these countries could be forced into even more debt and global poverty will be greatly deepened."
The system for equal access is failing
Some programs exist to equalize vaccine access. This includes Covax, the WHO-backed global effort to reach people in lower-income countries. Many countries, though not the US, have donated to it.
But it's struggling, with Reuters reporting that it is facing a lack of funds and structural issues. Internal documents say it's facing a high risk of failing in its quest to secure vaccines.
Scourse, of Doctors Without Borders, said wealthy countries are relying on Covax as a band-aid solution that lets them avoid offering further help, and to justify their own acts of self-preservation.
"That's the position we hear from the UK government all the time: Because Covax exists, there's no need to do anything else, basically."
She noted that, even if wealthy countries donate to Covax, "the money doesn't help if there's no doses to buy" because wealthy countries bought so much of what is available.
Canada has bought enough vaccines to inoculate its residents six times over, provided all those doses are approved and delivered, a New York Times analysis found.
The analysis found the US bought enough to inoculate residents four times, the EU bought enough to do it twice, and the UK bought enough to do it four times.
Canada has committed to, at some point, donating excess supply to other countries.
But Marriott said it was "abhorrent to suggest that the right to health of people in developing countries is dependent on distributing excess vaccines."
Campaigners see solutions
The campaigners say vaccine makers need to make their research public, and give up the exclusive ability to produce the vaccines.
This would allow other companies to start manufacturing the same vaccines and increasing the global supply.
They noted the vaccines were developed with public funding, and say the companies should commit to fair pricing, so more countries can afford them.
They said ensuring the rest of the world gets vaccinated is also in the direct interest of richer countries, as it would boosting global trade and manufacturing, and prevent the virus from spreading rapidly for years - which could allow it to mutate into something current vaccines do not protect against.
Marriott said: "No one is safe until everyone is safe. As long as the virus is allowed to continue in developing countries, the risk to public health in rich countries will also continue."
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