Recently, the White House unveiled its ambitious plan to develop a coronavirus vaccine before year’s end. While many immediately questioned the feasibility of this timeline, we worry that not enough attention has gone to a different but equally important concern:

Once we have a vaccine that works, who around the world will actually get to use it?

In our roles treating patients and researching global health issues, we’ve learned the hard way that life-saving discoveries don’t just “trickle-down.” That’s why more than 800,000 poor children globally die from pneumonia each year, even though effective immunizations for one common type have existed for over a decade. It’s why black Americans still have much less access to HIV pre-exposure prophylaxis (PrEP) than their white counterparts, despite facing higher rates of new HIV infections.

COVID-19 vaccines are unlikely to be an exception to this trend. The virus threatens to have its most devastating consequences among those traditionally placed at the back of the line for new interventions, like immigrants and refugees. We’re already seeing concerning inequities in the use of existing COVID-19 tools: just weeks ago, NBA superstars without symptoms were placed on a fast track for coronavirus diagnostics while entire countries did not have testing kits at all. During previous outbreaks, we’ve heard arguments that it’s too difficult or too expensive to reach the underserved with new technologies; accepting these assumptions will only exacerbate disparities of the current crisis

When we finally have a vaccine proven to protect us against COVID-19, how will we make sure that those who are most marginalized are not left behind?

It’s a challenge that we have a moral imperative to answer. Based on our experiences, we believe it’s not too late to ensure equity of life-saving tools – but only if there’s a plan to address several key issues before a vaccine arrives.

First, leaders of the COVID-19 response must guarantee that upcoming immunizations will be available for the communities that need them the most, not just those with the largest budgets. On Friday, President Trump and HHS Secretary Azar said there was “great spirit” around making a vaccine affordable, both within the US and abroad. But without specific details about how exactly low-resource communities will be able to obtain sufficient quantities of immunizations, good intentions will not be enough to prevent unjust distributions of essential supplies.

One group that could play a pivotal role in these discussions is the pharmaceutical industry, which has real opportunities to improve the reach of life-saving discoveries. In our work against neglected tropical diseases, we’ve watched the world’s largest pharmaceutical companies commit to donating billions of free treatments every year, enabling multiple countries to completely eliminate diseases like river blindness and trachoma. A similar joint commitment around COVID-19 vaccines would save lives, reign in transmission and demonstrate a clear dedication to people over profits.

Public health organizations will also have to answer tough challenges around immunization delivery. For example, many vaccines are only effective if someone gets multiple doses, which requires reaching all recipients more than once. Logistics will be further complicated by the current crisis: for instance, how will communities rapidly immunize huge numbers of people while simultaneously maintaining social distancing for safety?

To overcome these barriers, our colleagues will have to turn to the those with the smartest solutions to health challenges: those who are closest to the issues. In our work, we’ve consistently found that people on front lines of underserved settings have the best insights into delivery – like during the cholera outbreak in post-earthquake Haiti, where doctors, nurses and community health workers came up with brilliant strategies for vaccination campaigns, allowing us to reach 90 percent of participants with multiple immunization doses. When a COVID-19 vaccine becomes available, we must ensure these individuals have sufficient resources to translate their life-saving ideas into action.

We still have much to learn about COVID-19, and we don’t yet have all the details about what an effective coronavirus vaccine will look like. But if there’s one thing we know for certain, it’s that equity in new technologies is only achieved by choice, not by chance. As we grapple with this ongoing pandemic, which option will we choose?

Louise Ivers is an infectious diseases physician and can be reached on Twitter @drlouiseivers. Azfar Hossain is a medical student.

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