The COVID-19 pandemic continues to present unprecedented challenges to global health and the global economy. With some 230 million infections globally and some 4.7 million deaths reported globally to date and with likely actual numbers a multiple of what has been reported, governments around the world have taken strong measures to control the spread of COVID-19, and there have been efforts to improve the equitable access to vaccines and other medical treatments and personal protective equipment for all peoples. The economic costs flowing from the pandemic to countries have been considerable, with many poorer countries experiencing loss of progress made over recent decades in terms of poverty levels, income, educational opportunities, trade and more.
While the pharmaceutical industry has responded impressively and will likely produce more than twice the number of COVID-19 vaccine doses in 2021 compared to all vaccines produced in 2020, access to vaccines has not been as equitable as desired or needed to end the pandemic. The lack of equitable access flows from a number of factors including some production challenges, early acquisition of large quantities of vaccines by wealthier countries, export restraints imposed by some countries, failure of Indian producers (who had been identified as a major source of vaccines for distribution through COVAX to low- and middle-income countries) to honor export contracts during 2021 in light of COVID challenges within India and others.
Vaccine distribution does not match population distribution but also doesn’t correspond to level of infections or deaths in most countries. When inequitable access is flagged by organizations or the media, it is based on population. But where some countries or regions are suffering greater levels of infections or deaths from the pandemic than others, one could argue that equitable access could also be measured by comparing to level of infections or deaths.
Bloomberg in a recent COVID-19 Tracker reports that the least wealthy 52 countries have received 3.6% of the vaccinations while having 20.5% of the global population. Bloomberg, More than 6.1 Billion Shots Given; Covid-19 Tracker, https://www.bloomberg.com/graphics/covid-vaccine-tracker-global-distribution/ (September 25, 2021). Obviously such low levels of vaccination for poor countries present pressing challenges. Fortunately, to date, infections and deaths have been much higher in higher income countries than in many low- and middle-income countries, so there is less of a mismatch with access to vaccines if measured by reference to infections or deaths. Some of the lower numbers for low- and middle-income countries may be due to reporting challenges in some of these countries, but the picture needs to be looked at from multiple angles to understand whether and the extent of equitable distribution challenges facing the world and individual countries. Let’s look at a few countries to understand the complexity of the analysis.
China, which has a population of 1.439 billion people in 2020 (18.45% of global totals) had administered 2.194 billion doses of COVID-19 according to the Bloomberg September 25, 2021 Tracker (35.98% of global doses distributed) yet has reported only 107,981 cases of infections since December 2019 (just 0.04% of global cases) and just 4,849 deaths (just 0.1% of global deaths). See ECDC, COVID-19 situation update worldwide, as of week 37, updated 23 September 2021, https://www.ecdc.europa.eu/en/geographical-distribution-2019-ncov-cases. Thus, China, while being the first country to report cases, has been successful in limiting the case spread both before and after the development of vaccines. Which highlights the question, where there are global shortages of vaccines, is the correct analysis vaccine doses as a share of global population or the short-term need based on infections or deaths? If China distribution of doses reflected its share of population, it would have administered 1.125 billion does, meaning an extra 1.069 billion doses could have been redirected to other countries in need. If done on the basis of the number of infections, China would have administered 2.44 million doses, meaning 2.192 billion doses could have been redirected to other countries in need. If done on the basis of the number of deaths, it would have administered 6.1 million doses to date, meaning 2.188 billion doses could have been redirected to other countries. Under any analysis, China is a major cause of inequitable access to vaccines through late September and that is regardless of doses sold or given to trading partners by China.
India had a population in 2020 of 1.38 billion people (17.69% of the global population). According to the recent Bloomberg Tracker, India has administered 850.372 million doses (13.94% of global doses). India, which has had a serious outbreak of COVID-19 cases in the summer, has recorded 33,478,419 cases of infection (14.59% of global cases) and 445,133 deaths (9.47% of global deaths). Press accounts have indicated that the case and death counts in India are likely significantly understated. However, equitable access to vaccines if based on population or based on percent of global infections as reported by India would show India needing additional doses (an additional 228.718 million based on population; an additional 39.618 million based on percent of global infections). Based on percent of global deaths, India arguably has consumed 272.702 million more doses than death percentage would warrant (if deaths were substantially higher, obviously the answer would differ). Thus, India is almost certainly a country that has been in need of larger volumes of COVID-19 vaccines than it has obtained and explains the country’s decision to halt exports of COVID-19 vaccines for many months this year.
The United States had a population in 2020 of 331 million people (4.24% of global population. It has administered 388.567 million doses of vaccine (6.37% of global doses administered). As a major developed country, one would have expected the United States to have gotten control of the pandemic early or at least to have been able to get the pandemic under control within the United States after vaccines were approved for emergency use authoriztaion. However, the U.S. has recorded 42.288 million cases of infection (18.43% of global cases) (and has recorded 676,075 deaths (9.67% of global deaths) — the most of any nation. Moreover, while the early roll out of vaccines sharply reduced infections, hospitalizations and deaths a few months ago, the large percentage of adults who remain unvaccinated, the opposition of many to basic public health requirements (e.g., mask wearing in many situations) and failure to get vaccinated has resulted in the U.S. having a very large outbreak in the last month or so with the spread of the delta variant — a wave of infections, hospitalizations and deaths of the unvaccinated. If the number of doses administered matched the U.S. share of global population, the U.S. would have administered 129.93 million fewer doses. However, if based on percent of infections or deaths, the U.S. should have administered far more doses — 735.66 million more based on infections and 201.3 million based on deaths — although such numbers would be capped by the number needed for full vaccination.
The above analysis is not to say vaccine equity of access and distribution isn’t important. Rather the analysis is meant to stress the complexity of the analysis, particularly for countries that have suffered large rates of infection and death.
Recent efforts to improve the equitable access to and distribution of COVID-19 vaccines and other medical materials
A great deal of effort has gone into establishing entities to facilitate equitable access to COVID-19 vaccines. For example, COVAX is described on the GAVI webpage as follows (https://www.gavi.org/covax-facility):
“COVAX is the vaccines pillar of the Access to COVID-19 Tools (ACT) Accelerator
“The ACT Accelerator is a ground-breaking global collaboration to accelerate the development, production, and equitable access to COVID-19 tests, treatments, and vaccines.
“COVAX is co-led by the Coalition for Epidemic Preparedness Innovations (CEPI), Gavi and the World Health Organization (WHO), alongside key delivery partner UNICEF. Its aim is to accelerate the development and manufacture of COVID-19 vaccines, and to guarantee fair and equitable access for every country in the world.”
COVAX had hoped to get at least 2 billion doses to countries participating (including 92 low- and middle income countries who would get vaccine doses at no- or low-cost) in 2021. As of September 22, 2021, COVAX had distributed over 301 million doses in 142 countries. https://www.gavi.org/covax-vaccine-roll-out. This is out of the 6.1 billion doses administered globally. Recent projections suggest COVAX will get at least 500 million fewer doses in 2021 than originally expected, though higher volumes could happen under certain circumstances. See World Health Organization, Joint COVAX Statement on Supply Forecast for 2021 and early 2022, 8 September 2021, https://www.who.int/news/item/08-09-2021-joint-covax-statement-on-supply-forecast-for-2021-and-early-2022 (“According to its latest Supply Forecast, COVAX expects to have access to 1.425 billion doses of vaccine in 2021, in the most likely scenario and in the absence of urgent action by producers and high-coverage countries to prioritize COVAX.”).
Amidst a constant drumbeat from the WHO that no one is safe until all are safe and that the 2021 distribution to date has left many countries behind, most countries have agreed for the need for greater equitable distribution going forward. Some countries (India, South Africa and others) have called for waiving intellectual property rights at the WTO on vaccines and other medical goods needed to address the pandemic. Some organizations and countries have argued for the need for development of local production capabilities in low income countries. The WTO has monitored export restrictions imposed and tracked the level and elimination of such restrictions as well as market liberalization efforts. Events have been held to gather information on production bottlenecks, efforts of pharmaceutical companies to expand production around the world and countries have been urged to release surplus doses and give up their place in line with pharmaceutical companies to permit larger volumes to be shipped earlier to low- and middle-income countries.
In recent months both the U.S. and the EU have been working to facilitate these efforts and recently announced joint actions. See A U.S.-EU Agenda for Beating the Global Pandemic Vaccinating the World, Saving Lives Now, and Building Back Better Health Security, September 22, 2021, https://www.whitehouse.gov/briefing-room/statements-releases/2021/09/22/a-u-s-eu-agenda-for-beating-the-global-pandemic-vaccinating-the-world-saving-lives-now-and-building-back-better-health-security/.
“Vaccination is the most effective response to the COVID pandemic. The United States and the EU are technological leaders in advanced vaccine platforms, given decades of investments in research and development.
“It is vital that we aggressively pursue an agenda to vaccinate the world. Coordinated U.S. and EU leadership will help expand supply, deliver in a more coordinated and efficient manner, and manage constraints to supply chains. This will showcase the force of a Transatlantic partnership in facilitating global vaccination while enabling more progress by multilateral and regional initiatives.
“Building on the outcome of the May 2021 G20 Global Health Summit, the G7 and U.S.-EU Summits in June, and on the upcoming G20 Summit, U.S. and the EU will expand cooperation for global action toward vaccinating the world, saving lives now, and building better health security.
“Pillar I: A Joint EU/US Vaccine Sharing Commitment: the United States and the EU will share doses globally to enhance vaccination rates, with a priority on sharing through COVAX and improving vaccination rates urgently in low and lower-middle income countries. The United States is donating over 1.1 billion doses, and the EU will donate over 500 million doses. This is in addition to the doses we have financed through COVAX.
“We call for nations that are able to vaccinate their populations to double their dose-sharing commitments or to make meaningful contributions to vaccine readiness. They will place a premium on predictable and effective dose-sharing to maximize sustainability and minimize waste.
“Pillar II: A Joint EU/US Commitment to Vaccine Readiness: the United States and the EU will both support and coordinate with relevant organizations for vaccine delivery, cold chain, logistics, and immunization programs to translate doses in vials into shots in arms. They will share lessons learned from dose sharing, including delivery via COVAX, and promote equitable distribution of vaccines.
“Pillar III: A Joint EU/US partnership on bolstering global vaccine supply and therapeutics: the EU and the United States will leverage their newly launched Joint COVID-19 Manufacturing and Supply Chain Taskforce to support vaccine and therapeutic manufacturing and distribution and overcome supply chain challenges. Collaborative efforts, outlined below, will include monitoring global supply chains, assessing global demand against the supply of ingredients and production materials, and identifying and addressing in real time bottlenecks and other disruptive factors for global vaccine and therapeutics production, as well as coordinating potential solutions and initiatives to boost global production of vaccines, critical inputs, and ancillary supplies.
“Pillar IV: A Joint EU/US Proposal to achieve Global Health Security. The United States and the EU will support the establishment of a Financial Intermediary Fund (FIF) by the end of 2021 and will support its sustainable capitalization. The EU and United States will also support global pandemic surveillance, including the concept of a global pandemic radar. The EU and the United States, through the European Health Emergency preparedness and Response Authority, and the Department of Health and Human Services Biomedical Advanced Research and Development Authority, respectively, will cooperate in line with our G7 commitment to expedite the development of new vaccines and make recommendations on enhancing the world’s capacity to deliver these vaccines in real time.
“We call on partners to join in establishing and financing the FIF to support to prepare countries for COVID-19 and future biological threats.
“Pillar V: A Joint EU/US/Partners Roadmap for regional vaccine production. The EU and the United States will coordinate investments in regional manufacturing capacity with low and lower-middle income countries, as well as targeted efforts to enhance capacity for medical countermeasures under the Build Back Better World infrastructure and the newly established Global Gateway partnership. The EU and the United States will align efforts to bolster local vaccine manufacturing capacity in Africa and forge ahead on discussions on expanding the production of COVID-19 vaccines and treatments and ensure their equitable access.
“We call on partners to join in supporting coordinated investments to expand global and regional manufacturing, including for mRNA, viral vector, and/or protein subunit COVID-19 vaccines.“
See also United States–European Commission Joint Statement: Launch of the joint COVID-19 Manufacturing and Supply Chain Taskforce, September 22, 2021, https://www.whitehouse.gov/briefing-room/statements-releases/2021/09/22/united-stateseuropean-commission-joint-statement/.
The announced joint efforts of the U.S. and the EU occurred at the same time as the U.S. hosted another event with governments, multilateral organizations and the private sector to find solutions to the COVID pandemic. The event was held on the margins of the UN General Assembly meeting in New York last week. See White House Briefing Room, Global COVID-19 Summit: Ending the Pandemic and Building Back Better, September 24, 2021, https://www.whitehouse.gov/briefing-room/statements-releases/2021/09/24/global-covid-19-summit-ending-the-pandemic-and-building-back-better/. The write-up is copied below.
“On September 22, 2021, President Biden convened a virtual Global COVID-19 Summit focused on ending the pandemic and building better health security to prevent and prepare for future biological threats.
“The President called on the world to collectively end the COVID-19 pandemic as soon as possible, with every country, partner, and organization doing its part, aligning around shared goals and targets, and holding each other to account. At the same time, all countries need the capacity to prevent, detect, and respond to biological threats, including future pandemics. The Summit introduced ambitious targets in three critical areas for ending this pandemic and preventing and preparing for the next: Vaccinate the World; Save Lives Now; and Build Back Better.
“President Biden hosted the virtual Global COVID Summit: Ending the Pandemic and Building Back Better, which included participation by representatives from more than 100 governments and other partners and more than 100 leaders from international organizations, the private sector, the philanthropic sector, civil society, academia, and other stakeholders. These are listed below.
“The COVID-19 pandemic has already claimed over 4.5 million lives and continues to ravage communities and economies around the world. President Biden called on Summit participants to not only do more, but to do enough to end the pandemic and build back better.
“President Biden was also joined at the Summit by Vice President Kamala Harris, Secretary of State Antony Blinken, U.S. Ambassador to the United Nations Linda Thomas-Greenfield, U.S. Agency for International Development Administrator Samantha Power, Department of Health and Human Services Director of the Office of Global Affairs Loyce Pace, and State Department Coordinator for the Global COVID-19 Response and Health Security Gayle Smith. The full list of participants is available below.
“Throughout the Summit, leaders of countries and organizations underscored the importance of coalescing around shared targets to align commitments with outcomes, as all parties worked together to: Vaccinate the World, Save Lives Now, and Build Back Better Global Health Security over the months ahead. Reaching these targets will require leadership, ambition, boldness, collaboration, transparency, and new commitments.
“In advance of and during the Summit, many countries and stakeholders announced their intention to donate vaccines and financial support to critical vaccine readiness activities to ensure shots get into arms around the world. Leaders broadly aligned around the World Health Organization (WHO) target of vaccinating at least 70 percent of the global population in every country by UNGA 2022 and expressed shared urgency to do more, to act now, to enhance accountability, and to monitor progress. To advance this effort, President Biden called for another Heads of State-level Summit in the first quarter of 2022, and Secretary Blinken committed to convene Foreign Ministers in 2021. Countries made new commitments to share doses and/or double or triple previous pledges for vaccines, delivery, oxygen and testing support, and health security.
“Participants from around the world and across sectors, listed below, brought commitments to the Summit – further details will be available over the coming days. While the event was not a pledging conference, participants’ combined commitments exceeded 850 million additional COVID-19 vaccine doses and major new commitments for vaccine readiness, oxygen, testing, health systems, and health security financing.
“A list of new commitments announced by the United States at or around the Summit can be found in this Fact Sheet.
“A link to the common targets released by the United States during the Summit for tracking and accountability can be found here.
“Session 1. Calling the World to Account and Vaccinating the World
“President Biden chaired the opening session of the Summit, which was focused on the need for all countries, organizations, and stakeholders to do more to make COVID-19 vaccines available to all people, everywhere. He was joined by U.S. Ambassador to the United Nations Linda Thomas-Greenfield. Participants echoed President Biden’s call to align around common targets, more urgently track progress, and support one another in fulfilling commitments. World leaders embraced the World Health Organization goal of fully vaccinating at least 70 percent of the population in every country and income category with quality, safe, and effective vaccines by UNGA 2022, and leaders called for more urgent and equitable distribution of vaccine doses.
“President Biden announced bold new commitments from the United States to supply an additional 500 million doses of Pfizer vaccine that will all be shipped by this time next year, bringing the U.S. total commitment of donated vaccines to over 1.1 billion.
“He also announced that the United States is stepping up efforts to get shots into arms and boost global manufacturing. He encouraged countries to join the United States in upholding a set of principles to ensure we can fulfill our collective global commitments for equitable global distribution of safe and effective WHO Emergency Use Listed-authorized COVID-19 vaccines. Those principles include committing to donate, rather than sell, doses to low- and lower-middle income countries with no political strings attached; to support COVAX as the main mechanism for sharing WHO-authorized vaccines; to fight vaccine disinformation; to exercise transparency; to build public trust; and to work toward common goals and targets to measure progress and to hold ourselves and each accountable. The President acknowledged efforts through the Quad partnership to help produce at least 1 billion vaccine doses in India to boost the global vaccine supply by the end of 2022, as well as U.S. financing to help strengthen manufacturing in South Africa and produce more than 500 million J&J doses in Africa for Africa by next year.
“President Biden also emphasized the vital logistical challenge of getting those vaccines into the arms of people, and he called on all participants to significantly step up investments in this area. He announced a commitment of an additional $370 million to support global vaccine readiness and delivery, and he committed more than $380 million in assistance for Gavi, The Vaccine Alliance, to provide political risk insurance to facilitate shipment of vaccines to nine countries across three continents. In addition, he called on countries, vaccine manufacturers, and other partners to expand global and regional vaccine manufacturing capacity and enhance transparency to make vaccine production and distribution more predictable and coordinated. He emphasized the United States is working with partner nations and manufacturer to increase their capability to produce and make safe and highly effective vaccines in their own countries.
“The President also underscored the importance of saving lives now, and noted the United States is providing nearly $1.4 billion to reduce COVID-19 deaths and mitigate transmission through bulk oxygen support, expanded testing, strengthening healthcare systems and more.
“Finally, President Biden emphasized U.S. support for the establishment of a global health security financing mechanism to prepare for the next pandemic, which Vice President Harris detailed later in the Summit. He closed the meeting by calling on leaders to set targets that require us to aim high, follow through on our commitments, and hold each other accountable to end the pandemic and advance health security for all.
“Finally, President Biden called for a whole of society response, with an ask for the private sector, country governments, philanthropies, and civil society to take up the U.S. call to action to solve core challenges toward ending the pandemic and building back better – including making vaccinations available to everyone, everywhere; solving the oxygen crisis; financing health security, and more. Representatives from businesses, foundations, and civil society joined global leaders at the Summit. Some of those leaders announced coalitions to combine funds, expertise, and capacity to help realize specific challenges within each of the goals, for example addressing the global oxygen crisis, closing the testing gap, and ensuring vaccines are delivered and administered.
“United Nations Secretary-General António Guterres called for a global vaccination plan to at least double vaccine production and ensure 2.3 billion doses are equitably distributed through COVAX to reach 40 percent of people in all countries by the end of this year, and 70 percent in the first half of 2022 as WHO recommends. He framed global vaccination not as philanthropy but as self-interest for all parties, emphasizing the need for low and lower-middle income countries (LMICs) to have the resources and technology to manufacture their own vaccines. He also called for better resourced and stronger global health security architecture. The United Nations will continue to support vaccine rollout in countries and communities that are hardest to reach.
“World Health Organization Director-General Dr. Tedros Adhanom-Ghebreyesus emphasized the importance of multilateralism in addressing the disparity in vaccine access between high- and low-income countries. He praised the new U.S. vaccine commitment and called on countries to work with companies to swap places with other countries in vaccine queues, for countries to fulfill dose share pledges immediately, and for sharing the intellectual property necessary to facilitate manufacturing around the world. He observed that we owe it to those who lost their lives to build better governance, financing, systems, and tools to ensure global health security. He called on leaders to support the vaccination of at least 40 percent of the population of every country by the end of this year and 70 percent by mid-2022. He also called on those who control existing vaccine supplies to ensure that 2 billion doses are provided rapidly to LMICs in order to begin meeting these targets, as the Secretary General highlighted.
“Republic of South Africa’s President Matamela Cyril Ramaphosa highlighted the risks of not reaching the vaccination targets set out in the Summit, and discussed how the pandemic exacerbates the global vaccine gap and the ways it undermines global health security. He also affirmed the importance of enabling countries to do their own vaccine manufacturing and procurement, and called on WTO member states to approve the TRIPS waiver proposal from South Africa, India, and other co-sponsors. He shared the African Union’s impactful work in hosting the first mRNA tech transfer on the African continent, then called for a sustainable plan to support LMICs through technology and finance to meet vaccine targets. He also supported the establishment of a global health security financial intermediary fund for pandemic preparedness, a Global Health Threats Council, and Secretary-General Guterres’ proposal for a global vaccination plan.
“European Commission President Ursula von der Leyen described the pandemic as one of the most pressing societal challenges we have ever faced. To help address this challenge, she announced a new European Union partnership with the United States to help vaccinate the world with a joint objective of a 70 percent global vaccination rate by UNGA 2022. The EU-U.S. global vaccination partnership seeks to expand supply and improve delivery while managing constraints to supply chains. This partnership will seek to boost vaccine production in LMICs and coordinate investments to build regional manufacturing. The EU is investing more than €1 billion with partners in Africa and the pharmaceutical sector to bring mRNA technology to the continent beginning with hubs in South Africa, and Senegal, and Rwanda. She reaffirmed the EU’s commitment to share more than 500 million doses by the middle of next year, and the EU commitment that every second dose of vaccine produced in Europe is shipped abroad (to date, 800 million doses). President von der Leyen also committed that the EU will work with the United States and within the G20 to establish a global health security FIF to help build a healthy and secure future.
“Republic of Indonesia President Joko Widodo called for the strengthening of theglobal health architecture and for a new mechanism to mobilize resources. He articulated the need for LMICs to be part of the solution, by enhancing capacity to manufacture of vaccines, medicines, and supplies. He appealed for an end to vaccine nationalism, and said Indonesia as G20 chair next year will focus on strengthening the global health security architecture and preparing for future challenges.
“World Trade Organization Director-General Dr. Ngozi Okonjo-Iweala noted the urgency of preventing more people from dying in poor countries due to lack of access to lifesaving vaccines and other medical countermeasures. She emphasized the risk of the pandemic to economic recovery, if slow vaccination progress allows the emergence of even more dangerous variants, saying, “Either we converge downwards by allowing the virus to drag all of us back down, or we converge upwards by vaccinating the world.” She noted the centrality of trade in this effort, and she provided the example of the Pfizer- BioNTech and Moderna vaccines requiring inputs from nineteen countries. She reiterated the importance of the WTO’s work to reduce export restrictions, address supply bottlenecks, and smooth regulatory obstacles. She called on industry to donate doses and swap contracts so that COVAX and less advantaged countries can move up in the queue and receive supplies for distribution. She urged leaders to find pragmatic compromises on intellectual property rules for COVID-19 vaccines, therapeutics, and diagnostics, and she underscored the need for cooperative action to ensure a stable, predictable and fair multilateral trading system.
“Canada’s Prime Minister Justin Trudeau reiterated Canada’s commitment to being a trusted partner, and emphasized the target of equitably vaccinating 70 percent of the world by next September and both to protect the world’s population and ensure economic recovery. He called for a focus on vaccine readiness and delivery, and to increase the production and supply of shots. He outlined Canada’s contributions of more than $2.5 billion, including investing to share tens of millions of doses with the rest of the world and support the ACT Accelerator and COVAX. He referenced Canada’s interest in developing domestic vaccine production capacity, which would help Canada to help the world. He expressed support for working through the WTO to resolve intellectual property issues and also called for strengthened global health security infrastructure over the long term by investing in shared health institutions and strengthening global cooperation.
“Gavi, the Vaccine Alliance Chief Executive Officer Dr. Seth Berkley outlined COVAX’s leadership of the most complex, global vaccine deployment in history, which has – to date — shipped more than 300 million doses to 142 economies. He also said by the end of the year, COVAX seeks to deliver enough doses to protect about 40 percent of the adult population in the 92 lower income countries. 800 million doses have already been committed through COVAX, with 119 million received and delivered. He called leaders’ attention to serious obstacles and unacceptable inequalities in the global distribution of COVID-19 vaccines, and he thanked President Biden for the new U.S. commitment to donate of 500 million additional doses of Pfizer vaccine, as well as embraced the ambitious summit goal of vaccinating the world and accelerating vaccination in lower income countries. He urged leaders to provide more doses, remove export restrictions, leverage innovative financing and contingency funding to support surge manufacturing capacity, give up their place in production queues to COVAX where possible, and for vaccine manufacturers to commit to greater transparency on orders and delivery timelines, and asked them to waive requirements for indemnification for the humanitarian buffer.
“President Biden and U.S. Ambassador to the United Nations Linda Thomas-Greenfield closed the session by thanking participants and reiterating the goal of ending the pandemic, which will require ambitious, coordinated global action. President Biden noted we should set targets that require us to aim high, follow through on our commitments, and hold each other accountable in order to end this pandemic for everyone, everywhere. He concluded by noting this won’t be our last meeting.
“Session I. Video Interventions
- King Abdullah II bin Al-Hussein, Hashemite Kingdom of Jordan (video)
- Prime Minister Narendra Modi, Republic of India (video)
- Chancellor Angela Merkel, Federal Republic of Germany (video)
- Bill Gates, Bill & Melinda Gates Foundation (video)
“Session 2. Saving Lives Now
“USAID Administrator Samantha Power chaired the session, which was focused on ensuring equal access to the testing, therapeutics, and personal protective equipment that help prevent, diagnose, and treat COVID-19. She pointed out that even as the world focuses on the goal of achieving 70 percent vaccination, we must – at the same time – come together to ensure countries have the PPE to keep health workers safe, supply oxygen to treat people with COVID, and close the testing gap. She announced an intention to commit $50 million to increase access to oxygen in countries around the world, and that USAID would work to build a multi-sectoral coalition to coordinate global investment in oxygen access.
“Rockefeller Foundation President Dr. Rajiv Shah moderated the session. In his framing remarks, he reinforced the importance of the Save Lives Now agenda to helping communities and economies reopen safely amidst the pandemic. He highlighted the Rockefeller Foundation’s investment of $1 billion for pandemic response, recovery, and prevention, and announced a group of 18 diagnostic companies that are convening with the help of the Foundation to commit to expanding COVID-19 testing around the world.
“Vietnam’s President Nguyễn Xuân Phúc noted the toll the pandemic has taken on ASEAN members and expressed support for the goals set out by President Biden, including the creation of a global health security fund and increased vaccine production in developing countries. He emphasized the importance of early detection and public health measures, as well as treatment and large-scale vaccination, in responding to and ending the pandemic. President Phúc noted the need to improve global cooperation and take a systemic approach, including transforming health systems and industries that produce pharmaceuticals and supplies, particularly in developing countries. He noted that Vietnam donated $500,000 to COVAX and will continue to contribute, and that Vietnam and fellow ASEAN countries have used $10.5 million from a joint COVID-19 Response Fund to purchase vaccines.
“Director of the Pan American Health Organization (PAHO) Dr. Carissa Etienne emphasized that COVID-19 has particularly highlighted inequities in the Americas, and explained the path to recovery will only be through an equitable approach, with a focus on resilient, high-quality health systems for all. She discussed the challenges faced by people living in poverty in following public health measures, and the particular burdens on those in the informal economy, indigenous communities, Afro descendent populations and migrants. Dr. Etienne spoke about PAHO’s delivery of 33 million COVID tests and more than $14 million worth of PPE to countries, and announced that, along with WHO, PAHO had identified two countries to initiate a mRNA vaccine manufacturing hub in the Americas.
“Global Fund to Fight AIDS, TB, and Malaria Executive Director Peter Sands endorsed the Save Lives Now targets, noting that while vaccines are the most potent weapon against COVID-19, ending the pandemic will require stepped-up support to LMICS for testing, treatment, and PPE, as well as critical infection prevention and control. He noted that the Global Fund, which is the largest provider of grants to LMICS for non-vaccine COVID response, has already approved more than $3.6 billion to over 100 countries, including $478 million for oxygen equipment and supplies, $815 million for diagnostics, and $745 million for PPE. However, at a time when we must scale up these responses, Sands said that current funding will be exhausted by the end of the month, and urged increased investment in this critical response mechanism.
“Skoll Foundation CEO Don Gips discussed the role of philanthropy in taking risks, supporting civil society, testing out solutions that government can adopt, and connecting civil society and government– all important components of an all-society response to COVID-19. He announced that Skoll Foundation founder Jeff Skoll has prioritized ending the pandemic and will build on the Foundation’s previous $100 million commitment with an additional $100 million to support Summit objectives, with a focus on saving lives now – particularly oxygen – and building strong health and preparedness systems for the future as a global public good. Part of their investment will support Build Health International, which will increase medical oxygen supplies in Africa. Mr. Gips emphasized the importance of alignment and coordination around a global plan to end the pandemic, saying that the success of global COVID-19 response will be an indication of our ability to tackle other complex, interconnected global problems.
“Mastercard Foundation President and CEO Reeta Roy emphasized that achieving global health security requires bold and simultaneous action on all fronts. She also highlighted that we are all interconnected, and that there is no global health security without regional health security. She noted that African leaders have mobilized a collective response to the pandemic, and that the next step is to manufacture vaccines on the continent. Ms. Roy focused on African public health institutions, and expressed support for the Africa CDC’s efforts to achieve sustainable public health, detailing the Foundation’s $1.3 billion partnership with Africa CDC to purchase vaccines for 50 million people; equipping health care workers, encouraging vaccine acceptance, and increasing genomic sequencing; developing the workforce to manufacture vaccines in Africa; and strengthening the Africa CDC. She appealed to funders to support existing public health institutions.
“Amref Health Africa CEO Dr. Githinji Gitahi reminded attendees of the way COVID-19 affects individual people, including those lacking oxygen treatment and health workers who lack PPE. He pointed out that the toll of COVID-19 is much larger than what has been officially counted, due to the number of people in underserved areas dying at home without treatment. He noted that saving lives now requires making connections between the global mechanisms with resources and people in affected communities and includes strengthening health systems to respond at the local level, with a focus on community ownership and accountability. He emphasized the importance of grant funding rather than loans and stressed the need to invest quickly in local systems and existing mechanisms.
“Moderator Dr. Shah asked each panelist to comment briefly on the single most important thing needed to ensure we save lives now, equitably. Dr. Etienne replied with an emphasis on adequate tools to predict, prevent, and protect against COVID, as well as expanding regional vaccine production. Mr. Sands advised to “act now; act big.” Mr. Gips advocated for a coordinated global plan with real political commitment. Ms. Roy advocated for including everyone at the table to ensure an equitable response, including those hardest hit: “We act in our self-interest when we act together.” Mr.D Gitahi advised that rich countries take a step back from the vaccine queue to allow COVAX to access more, and that we strengthen existing mechanisms before building new ones.
“Administrator Power closed the session by noting that we have the ability to ramp up testing, improve availability of PPE, and develop sufficient oxygen capacity to treat those in need. She advised that today’s Summit should be the start of a more coordinated effort to save lives that would be lost without our support.
“Session II. Video Interventions
- Prime Minister Suga Yoshihide Japan (video)
- Prime Minister Jacinda Ardern, New Zealand (video)
- Tom Hart, ONE Campaign (video)
- Prime Minister Stefan Löfven, Sweden (video)
- Prime Minister Sheikh Hasina, Bangladesh (video)
“Session 3. Building Back Better Global Health Security
“Vice President Kamala Harris chaired the session, which was focused on building back better global health security to mitigate future biological threats and pandemics. She pointed out that nations need greater capacity now, and the world as a whole must be ready before, not after, the next pandemic. Vice President Harris issued a clear call to action to establish a global health security financial intermediary fund (FIF) to bring together new resources for pandemic preparedness, with an initial goal of reaching $10 billion in seed funding for country and corporations. She announced that the United States is prepared to contribute at least $250 million to help seed the FIF. Those funds will combat this pandemic while helping prevent the next, with an additional $850 million requested from the U.S. Congress. She also called for greater political leadership and accountability, calling for the establishment of a Global Health Threats Council to monitor progress and sound the alarm to prevent future pandemics.
“Loyce Pace, U.S. Department of Health and Human Services Office of Global Affairs Director, moderated the panel with an emphasis on urgency and equity of the global response.
“Prime Minister Solberg of Norway reiterated Vice President Harris’ perspective that we were not sufficiently prepared, and that we must transform ad-hoc solutions for the future. She also called for predictable health security financing, a future health security fund, and burden-sharing as an approach to funding for it. She stressed the importance of assistance beyond official development assistance, emphasized health security as a global public good, and stressed the need to strengthen WHO financing in parallel. She also strongly supported achieving global early warning networks to detect and respond to outbreaks early, research and development on vaccines, tests and treatment, with accessible technologies to all and regional production capacity, with universal equitable access. She emphasized that Norway stands ready to do its part.
“Prime Minister Gaston Alphonso Browne, Antigua and Barbuda, Chair of the Conference of the Heads of Government of the Caribbean Community (CARICOM) stated that CARICOM governments are committed to the 70% global vaccination target by September 2022, including in their own governments. He discussed his resolve to strengthen the Caribbean Public Health Agency (CARPHA) and called for international partnership. In discussing the goal of building back better, Prime Minister Browne reiterated that recovering from economic effects will be protracted because economic progress has been reversed. He discussed the importance of global public goods and the need to build health infrastructure, and stressed that none of us are safe until all of us are safe.
“Senior Minister Tharman Shanmugaratnam, Republic of Singapore and Co-chair of the G20 High Level Independent Panel on Financing the Global Commons for Pandemic Preparedness and Response focused on the need for substantially more investments in pandemic preparedness. He spoke of collective investments in areas such as global networks of surveillance and early warning, health security and public health capacities at national and regional level, and vaccines and critical medical supplies. He called for urgent establishment of a new multilateral Fund of $10 billion per year, less than 0.02 percent of most national GDPs, which could catalyze public, private, and philanthropic sources, besides domestic investments within nations. He also stressed the importance of an inclusive G20-Plus Board for governance, comprising health and finance ministers, and the leaders of the WHO and the other key multilateral institutions. He ended by noting, “It will be both morally indefensible and financially myopic to defer these investments or wait for the next pandemic to overwhelm us.”
“Ellen Johnson Sirleaf, former President of Liberia, Nobel Peace Prize recipient, and Co-Chair of the Independent Panel for Pandemic Preparedness and Response (IPPPR) called on the UN General Assembly to hold a Special Session to approve a political declaration on the reforms required for pandemic preparedness and response, including to establish a Global Health Threats Council led by Heads of State and Government, representative of the world’s regions, and focused on both accountability and political leadership. She noted the IPPPR’s call for an International Pandemic Financing Facility to mobilize $10 billion per year and disbursements of up to $100 billion for biological crises, and commended the United States’ call for a FIF with seed contribution. She expressed concerns about the severe inequality in vaccine availability and access (50-80 per cent of wealthy populations, with only 5 per cent in poorer countries), commended efforts to redistribute surplus vaccines to the 92 low-and middle-income countries, as well as technology transfers and voluntary licensing agreements for vaccine manufacturers. Finally, she called for adequate financing to the WHO, support for community health workers as a hallmark of the COVID19 response, and the burden COVID-19 has placed on women and girls. “It is clear that the current international system failed to protect us all from this catastrophic pandemic—and it is not fit to prevent another.”
“Dr. John Nkengasong, Director of the Africa Centers for Disease Control and Prevention, called for a “reset” button” on architecture for global health security, recognizing that this starts at the national, then regional, then global levels. Reflecting on urgent needs, Dr. Nkengasong pointed to the need for scaling up the workforce and frontline health workers – in order to be better prepared for the next pandemic. He discussed the need for all countries to house their own Centers for Disease Control that can serve as an emergency operation center, strengthen laboratory systems, and train the workforce. With regards to lessons learned from this pandemic, Dr. Nkengasong raised regional manufacturing and the gap between African manufacturing and African consumption of vaccines. Finally he called for innovative financing at the global and regional level, and that funding needs predictability, sustainability, and rapid access.
“Chief Executive Officer Marcel Arsenault, PAX sapiens, One Earth Future Foundation, stated that COVID-19 was our “dress rehearsal” for a far more devastating pandemic. He reiterated that an effective plan and implementation will require the whole of global society to join together. In that regard, he spoke to the role of philanthropies can play since they operate by more flexible rules than government, including their capacity for long term commitments. He announced a new $200 million commitment to help future pandemics, to partner with other donors and global institutions to build a better global system. Mr. Arsenault also committed to convene other donors and experts to finance pandemic preparedness and explore creative financing mechanisms outside of transitional development assistance. He also applauded the call by Vice President Harris to establish a FIF.
“Director Pace closed the session by highlighting the importance of global action toward “predictable, sustainable financing” allocated equitably to the most urgent needs and rooted in regional or local community perspectives. She emphasized the opportunity to mobilize public and private sector funds through multisector collaboration, and stressed the value of high-level political engagement and oversight.
“Session III. Video Interventions
- President Moon Jae-in, Republic of Korea (video)
- Carolyn Reynolds, Pandemic Action Network (video)
- Prime Minister Scott Morrison, Australia (video)
- Dr. Roopa Dhatt, Women in Global Health (video)
- Prime Minister Pedro Sánchez, Spain (video)
- Prime Minister Sheikh Hasina of Bangladesh (video)
“Session 4. Closing of Summit
“Coordinator for Global COVID-19 Response and Health Security Gayle Smith moderated the panel and focused on creating momentum, checking our progress, and constantly doing more. She asked G20 President Prime Minister Draghi to share a preview of the G20 Summit and areas in need of additional support.
“Secretary Blinken announced called on leaders to end the pandemic rather than just “doing better,” and announced his intent to personally convene foreign ministers before the end of the year to follow up with commitments made at the Summit, as well as the G20. He reiterated President Biden’s call for heads of state to reconvene on this issue in the first quarter of 2022. He also called for a multilateral leaders task force made up of experts from inside and outside the government to transparently and rigorously evaluate progress in the run-up to the G20 and at regular intervals thereafter.
“He stressed the target of vaccinating at least 70% of the population of every country, in every major income category, by UNGA 2022 and called on leaders to set ambitious targets with timelines that are openly tracked for progress and with accountability. He reiterated the United States’ willingness to lead, President Biden’s commitment to supply an additional 500 million doses of the Pfizer vaccine, and his commitment to work with global vaccine manufacturers to expand global and regional manufacturing for mRNA, viral vector, and protein subunit COVID-19 vaccines, as well as pledged to enhance transparency for the data on production and projections for dose manufacturing.
“He also called on leaders to accelerate efforts to get more shots into arms, to reduce morbidity and mortality from the virus, to expand access to oxygen, testing, and more, building on historic support for Gavi and the Global Fund, aid to countries and communities through USAID and the CDC, Treasury Secretary Yellen’s call to action on Special Drawing Rights, and U.S. support for a waiver of intellectual property protections in the WTO TRIPS Agreement for COVID-19 vaccines in service of ending this pandemic. Finally, he recognized community and healthcare workers on the frontlines of the pandemic, noting that the people are what’s critical to winning the fight against COVID-19. ‘It comes down to us. What we do in this critical moment, in the weeks ahead, in the months ahead.’
“Prime Minister Mario Draghi of the Italian Republic addressed the Summit and announced a new commitment that will triple Italy’s existing dose donation pledge by providing 30 million additional doses by the end of the year. These are in addition to the 15 million doses pledged for donation, largely through COVAX, during the G20 Global Health Summit of which nearly half have been distributed to date. He called on leaders, as they work to end this pandemic, to also improve preparation for future pandemics, including by expanding the production capacity of vaccines and other medical tools worldwide – especially in the most vulnerable countries. He welcomed the U.S. proposal to establish a FIF for health security and stressed that it is fully complementary with the G20 proposal for a Global Health and Finance Board. He recalled the G20 Health Summit Rome Declaration and progress achieved since that time, including more than 2.5 million fully vaccinated worldwide. However, he stressed the grave inequalities in vaccine availability and emphasized the ACT-Accelerator and COVAX as the most effective ways to deliver and build capacity to administer. He asked countries to stand by existing pledges and make more generous ones and gave support to the EU plan to develop regional manufacturing hubs in Africa, and the U.S.-EU global vaccination partnership that launched this week. Finally, he committed that the G20 Summit will build on the outcomes from today’s summit.
“Ms. Zipporah Iregi of the National Nurses Association of Kenya called on leaders to support healthcare workers and include them in decision-making. She thanked leaders for committing to these targets to save lives, vaccinate people, and build back better. She also provided insight for leaders into the plight of healthcare workers serving on the front lines of the COVID-19 pandemic. She recounted staying home at the beginning of the pandemic, watching peers explore other careers. She urged leaders to support healthcare workers and help them to be prepared for the next crisis. She welcomed the U.S. announcement of additional vaccine sharing. She expressed concerns about impending shortages of healthcare workers and called on leaders to support and recruit more healthcare workers, including ensuring they are paid on time and provided with personal protective equipment that is necessary to provide care.
“Mr. Lwazi Mlaba a COVID-19 Survivor and Global Health and Global Fund Champion, provided final remarks for the Summit, sharing his personal journey with long COVID and advocating for urgency to strengthen community assistance and support investments to expand community healthcare workers. He noted that his survival depended on them. He called for Universal Health Coverage and for global solidarity and leadership to beat the COVID-19 pandemic. He ended by saying, powerfully, “We know what we need to do. We know how we need to do it. The time has come to actually do it. Invest now, invest big. Let’s go now and do it.”
“More than 100 governments and other partners participated in the President Biden’s Global COVID-19 Summit on September 22, 2021.
Principality of Andorra; Antigua and Barbuda; Argentine Republic; Republic of Armenia; Commonwealth of Australia; Republic of Austria; Commonwealth of The Bahamas; Kingdom of Bahrain; People’s Republic of Bangladesh; Barbados; Kingdom of Belgium; Belize; Kingdom of Bhutan; Bosnia and Herzegovina; Republic of Botswana; Brunei Darussalam; Kingdom of Cambodia; Republic of Cameroon; Canada; Republic of Chile; Republic of Colombia; Republic of Cote d’Ivoire; Republic of Croatia; Czech Republic; Kingdom of Denmark; Commonwealth of Dominica; Arab Republic of Egypt; Republic of Estonia; Kingdom of Eswatini; Federal Democratic Republic of Ethiopia; European Commission; Republic of Finland; Gabonese Republic; Georgia; Federal Republic of Germany; Republic of Ghana; Hellenic Republic (Greece); Grenada; Republic of Guatemala; Republic of Guinea-Bissau; Cooperative Republic of Guyana; Republic of Haiti; Republic of Iceland; Republic of India; Republic of Indonesia; Ireland; State of Israel; Italian Republic; Jamaica; Japan; Hashemite Kingdom of Jordan; Republic of Kazakhstan; Republic of Kenya; Republic of Kiribati; Republic of Korea; Republic of Kosovo; Kyrgyz Republic; Lao People’s Democratic Republic; Republic of Latvia; State of Libya; Republic of Lithuania; Grand Duchy of Luxembourg; Republic of Malawi; Malaysia; Republic of Malta; Republic of Mauritius; Federated States of Micronesia; Republic of Moldova; Mongolia; Montenegro; Kingdom of Morocco; Republic of Mozambique; Republic of Namibia; Nepal; Kingdom of the Netherlands; New Zealand; Federal Republic of Nigeria; Republic of North Macedonia; Kingdom of Norway; Sultanate of Oman; Islamic Republic of Pakistan; Republic of Palau; Palestinian Authority; Republic of Peru; Republic of the Philippines; Republic of Poland; Portugal; Romania; Russian Federation; Kingdom of Saudi Arabia; Republic of Serbia; Republic of Sierra Leone; Republic of Singapore; Federal Republic of Somalia; Republic of South Africa; Kingdom of Spain; Sri Lanka; Federation of Saint Kitts and Nevis; Democratic Socialist Republic of Sri Lanka; St Vincent and Grenadines; Republic of the Sudan; Republic of Suriname; Kingdom of Sweden; Swiss Confederation; Taiwan; Kingdom of Thailand; Togolese Republic; Republic of Trinidad and Tobago; Republic of Tunisia; Republic of Turkey; Ukraine; United Arab Emirates; United Kingdom of Great Britain and Northern Ireland; United Nations General Assembly (Republic of Maldives); Republic of Uzbekistan; Republic of Vanuatu; Socialist Republic of Vietnam; Republic of Yemen; Republic of Zambia; Zimbabwe
“International Organizations, Non-Governmental Organizations, Private Sector, and Philanthropies
“More than 100 International Organizations, non-governmental organizations, private sector, and philanthropies participated in the President Biden’s Global COVID-19 Summit on September 22, 2021.
“Abbott; Access Bio; AdvaMedDX; Africa Centres for Disease Control and Prevention; The World Health Organization Regional Office for Africa (AFRO); African Development Bank; African Union; Alphabet Inc.; American Chamber of Commerce of Mexico; American Chamber of Commerce in South Africa; American Clinical Laboratory Association; American Society of Tropical Medicine and Hygiene; Amref Health Africa; American Public Health Association; Asian Development Bank; Association of Public Health Laboratories; Association of Southeast Asian Nations; Becton, Dickinson and Company; Biotechnology Innovation Organization; Boston Consulting Group; CARE; Caribbean Public Health Agency; The Carter Center; CDC Foundation; Center for Supporting Community; Development Initiatives; Coalition for Epidemic Preparedness Innovations; The Clinton Foundation; Clinton Health Access Initiative; CORE Group; COVID Collaborative; Danaher Corporation; Deloitte; Emory University; European Bank for Reconstruction and Development; Friends of the Global Fight; The Bill & Melinda Gates Foundation; Gavi, The Vaccine Alliance; Ginkgo Bioworks; Global Citizen; Global Communities; The Global Fund; Global Poverty Project; Global Health Council; Global Health Technologies Coalition; Health GAP; Hologic, Inc.; International Federation of Pharmaceutical Manufacturers & Associations; International Monetary Fund; InterAction; International Air Transport Association; International Atomic Energy Agency; International Civil Aviation Organization; International Committee of the Red Cross; International Federation of Red Cross and Red Crescent Societies; International Maritime Organization ; International Organization for Migration; International Vaccine Institute; IntraHealth International; Johnson & Johnson; Jubilee; LEGO Foundation; JustActions; LumiraDx; Management Sciences for Health; Marked by COVID; Mastercard Foundation; Matahari Global Solutions; Mayo Clinic Laboratories; McKinsey & Company; Merck Group; MilliporeSigma; National Nurses Association of Kenya; NETWORK for Catholic Social Justice; Nuclear Threat Initiative; ONE Campaign; One Earth Future Foundation; Open Society Foundations; OraSure Technologies; Oxfam America; Pan American Health Organization; Pandefense Advisory; Pandemic Action Network; PATH; PerkinElmer; Pfizer Inc.; Pharmaceutical Research and Manufacturers of America; Public Citizen; Public Health Foundation of India; QIAGEN; Roche; The Rockefeller Foundation; Sabin Vaccine Institute; SalivaDirect at the Yale School of Public Health; Save the Children; Schmidt Futures; Seed Global Health; The Skoll Foundation; Sustainable Energy for All; Thermo Fisher Scientific; United States Chamber of Commerce; United Nations Foundation; Unitaid; United Nations Children’s Fund; United Nations Environment Programme; United Nations High Commissioner for Refugees; United Parcel Service; The United States Global Leadership Coalition ; World Health Organization; Women in Global Health; World Bank Group; World Food Programme; WOTE Kenya; World Trade Organization.”
The damage from the COVID-19 pandemic is much worse than should have occurred had the world had a robust monitoring system and the global infrastructure to address the problem early on and cooperation among nations in the effort. Developed countries demonstrated a slowness of response. China was not forthcoming early on on developments in their country and has limited the ability of the world to understand the origins of the virus. Leadership in a number of countries downplayed the seriousness of the virus causing untold human suffering from runaway infections. Misinformation and misguided notions of personal choice have slowed the ability to take responsible action where public health care measures would have reduced the human damage and even the willingness to take a life saving vaccine. The world has been set back years or decades in its fight against poverty and other Sustainable Development Goals. While many countries are bouncing back economically and trade wise, it has often been with massive government infusions which reduced the economic collapse of particular economies but which are, of course, not sustainable and which were not available to most countries.
Despite the structures in place to facilitate a rapid development and equitable distribution of vaccines and other medical goods during a pandemic, a host of problems have reduced the success in the acquisition and distribution of vaccines to low- and middle-income countries to date.
The efforts of the United States and the European Union and other countries in recent months are important and will help correct — albeit months late — the issue of equitable access to vaccines. The U.S. and EU push for donations of vaccine doses versus sales with strings attached, working through COVAX for distributions to low- and middle-income countries and the need to address a range of other issues going to reducing death rates around the world (oxygen, therapeutics, PPEs), helping expand vaccine production capacity in low- and middle-income countries, as well as preparing for the next pandemic so the world is better able to respond in a timely manner are all important aspects for ending this pandemic and ensuring a more capable global response in the future. How successful the efforts of the U.S. and EU are will depend on the depth of commitment from other countries, multilateral organizations and the private sector as well as their own ability to deliver and even expand on their own initiatives.
Last week was an important one for the global effort to terminate the pandemic. While the media didn’t pay a lot of attention, the efforts of the U.S. and the EU are critical to a successful conclusion to the health crisis.