As I write this, I am days away from becoming a father. My primary concern? Naturally, the health of my son-to-be, and that of his mother. Making sure he gets all the routine vaccinations is the single most consequential intervention that will protect him against some of the most horrendous and preventable diseases.

Of the many different public health and policy interventions required to overcome COVID-19, a pandemic that has cost the world economy trillions of dollars, vaccination is by far the most consequential. More than 225 million doses have been administered in the year since the virus’s genome was published, and COVAX – the primary mechanism through which most low- and middle-income countries will likely access COVID-19 vaccines – has begun distributing the first of the 1.3 billion doses it aims to send to 92 such countries by the end of 2021.

We often hear that ‘no one is safe until everybody is safe’. And that, strictly speaking, is true. It means that everyone must eventually have access to safe and effective COVID-19 vaccines, including people in the hardest-to-reach areas of countries affected by armed conflict and violence – countries where, according to one estimate, over 70% of epidemics in the three decades leading up to 2009 originated. Ensuring equitable access for people in these areas too makes moral, epidemiological, and economic sense. And time is of the essence, as new variants may render existing vaccines less effective.

To date, most debate has focused on equitable distribution of a limited global supply of COVID-19 vaccines between countries, with the cost of a nationalist, ‘me first’ distribution estimated to be as high as $9 trillion. But now, as COVID-19 vaccines start arriving in countries at war, what can responsible authorities do to ensure equitable access within countries?

Plan for success

First, they can plan for success. States must include everyone in national vaccination plans, whomever they are, according to WHO equitable access guidance.[1] As unanimously affirmed in UN Security Council Resolution 2565 on COVID-19 vaccinations in conflict settings, this extends to people in the so-called ‘last mile’. This oft-heard expression does not have a universal definition, but can be interpreted as referring to people living in areas where national health authorities have limited reach or where they are unable, and sometimes unwilling, to reach at all – for example, the 60-80 million people the ICRC estimates who are living in areas controlled by non-State armed groups.

In countries without reliable population data, however, even identifying populations corresponding to WHO guidance may not be straightforward. For example, confirming age without documentation, assessing co-morbidities, or crossing contested areas to access remote communities all pose formidable logistical challenges – and this in countries whose infrastructure and supply chains may be crippled by years of conflict.

Such factors and past experience suggest that despite States’ best efforts to reach all populations, some will slip through the cracks. The ‘humanitarian buffer’ mechanism currently under development within COVAX is for them. The buffer is neither an excuse for bad national vaccination plans, nor a way to deal with politically sensitive or geographically remote populations. It is a genuinely last resort mechanism to reach high-risk populations in humanitarian settings.

States concerned about equitable access in last mile areas can also work with other States, donors, and humanitarian organizations without resorting to the humanitarian buffer (which will comprise a mere 100 million doses). As part of the Red Cross Red Crescent Movement, the ICRC stands ready to act as a neutral intermediary to facilitate access for specific populations in places of detention and hard-to-reach areas in countries affected by armed conflict and violence. Concretely, this could, for example, involve actually bringing together government health staff and health staff associated with armed groups to improve vaccination coverage and referral pathways – as the ICRC has done in Myanmar and Afghanistan, which required seeking dialogue with all sides to earn their trust.

International humanitarian law (IHL) envisages these kinds of scenarios by providing for access by impartial humanitarian organizations. It contains obligations by parties to armed conflicts on ensuring non-discriminatory access to vaccines, on protecting vaccinations as medical activities, and on protecting health workers and others administering vaccines. This is therefore not a question of creating parallel health systems; rather, of planning effective public health interventions and ensuring compliance with IHL, since infection can cross frontlines at least as easily as it has crossed national borders.

Seize the day

Second, States can use the momentum and massive resource mobilization around COVID-19 vaccines to strengthen vaccination plans against all preventable diseases. Gavi, for example, estimates that 10.6 million children have not yet been reached with even a single dose of basic vaccinations, a situation that could worsen due to the focus on COVID-19 vaccines. Measles alone remains a leading cause of vaccine-preventable infant mortality and, before measles vaccines were introduced in 1963, measles killed about as many people per year as COVID-19 has killed to date (2.6 million). Over 117 million children may now miss out on these vaccines – which helped save 21.1 million lives from 2000-2017 – with measles cases hitting a 23 year high in 2020. Moreover, measles is one of the world’s most contagious diseases, risking major outbreaks if vaccination rates continue falling.

While it is true that COVID-19 vaccinations and routine vaccinations may initially target different populations, making both part of a broader public health strategy rather than standalone activities will pay dividends by strengthening the national and international public health architecture. This, in turn, will help prepare for the next pandemic/epidemic and for a longer-term scenario where COVID-19 becomes endemic. The Ebola vaccine being added to the International Coordinating Group stockpile is a positive development in epidemic preparedness, and polio networks (e.g. Global Polio Eradication Initiative) provide good examples of how global vaccination goals can be translated into door-to-door campaigns, even in conflict settings.

For its part, the ICRC includes vaccinations as primary healthcare activities within a broader public health approach, through which it helped to vaccinate 4.3 million people in 28 countries affected by armed conflict and other situations of violence in 2019 (much less in 2020 due to COVID-19). Its healthcare in detention activities in 55 countries assist around a million detainees. Building on these capacities, and in coordination with the IFRC, the ICRC can support national vaccination activities through Ministries of Health and/or National Red Cross and Red Crescent Societies.

Walk the talk

Third, national authorities can be mindful of the manner in which vaccines are distributed. Beyond the rhetoric, genuine community engagement must be part-and-parcel of vaccination activities. This is because, even with physical access to last mile areas, we cannot assume that communities will accept vaccinations if they do not trust those administering them or if the vaccines don’t respond to their most pressing and long-neglected health-related needs.

Community engagement takes time, effort, and money, but it is as important to successful vaccination activities as cold-chain management and qualified health workers – particularly where military and security forces are involved, which can heighten suspicion. These are among the painful lessons of Ebola responses in West Africa.

Done well, effective community engagement will be a force multiplier of vaccination efforts and other public health measures. It will enhance the safety of frontline health workers and the reach of humanitarian action. Done poorly, it will cripple public trust in vaccinations and government more broadly, with long-term ramifications beyond pandemic response.

For the Red Cross and Red Crescent Movement, it is less about combatting vaccine hesitancy and more about promoting vaccine acceptance: building trust through presence and communicating clearly with evidence, so communities can make informed choices for themselves. And it is not rocket science; it’s investing time and showing empathy – drink more tea, sit with people and listen to them to understand their concerns, cultures, and creeds before coming at them with a needle.

In the end

Among the many differences faced by a child born in a country at peace or one at war is their access to routine, and eventually, COVID-19 vaccines.  But a parent’s concern for their health and happiness is the same. The present momentum around vaccines presents an opportunity to eliminate this difference by eliminating preventable disease.

As vaccines arrive in countries affected by armed conflict and violence, this means preparing for the last mile by:

• Ensuring national vaccination plans include everyone – on paper and in practice – and working with impartial humanitarian organizations in vaccination activities when required;
• Making routine as well as COVID-19 vaccinations parts of a broader strategy that strengthens health systems and responds to communities’ main causes of morbidity and mortality; and
• Engaging communities in planning and implementation to ensure ownership and sustainability.

To do these things well would be to learn the lessons of past epidemic responses in conflict settings, and to strengthen our collective readiness for future pandemics. And if we expect our children to learn life lessons and grow stronger and wiser, we should expect at least as much of ourselves.

[1] See the Fair Allocation Framework, Values Framework, Prioritisation Roadmap.

See also

• Paola Forgione, ‘Please, don’t tell anyone!’: healthcare stigma in the COVID-19 era, November 12, 2020
• Alexander Breitegger, COVID-19 vaccines and IHL: ensuring equal access in conflict-affected countries, November 5, 2020
• Cordula Droege, COVID-19 response in conflict zones hinges on respect for international humanitarian law, April 16, 2020