Vaccine rollouts lay bare the Middle East’s deep inequalities

The Middle East is a microcosm of that global problem.

The first Arab countries to begin vaccinating their citizens and residents were also the richest: Saudi Arabia, the United Arab Emirates, Qatar, Kuwait, Bahrain and Oman.

The UAE stands out. The country of almost 10 million, which has one of the highest GDPs per capita in the world, also has one of the highest vaccination rates globally. More than 2 million residents and citizens have already been vaccinated using the Pfizer/BioNTech shot and China’s Sinopharm vaccine.
The Gulf state has already vaccinated more people than middle-income Jordan plans to inoculate in the first phase of its roll out. Lebanon, currently in the throes of a financial meltdown, has not yet had any vaccines delivered.
The first Saudi citizen receiving the Pfizer-BioNTech coronavirus vaccine in Riyadh in December 2020.

Regional states battered by war do not have concrete plans for procuring and distributing the vaccines even as international organizations step in to help.

Arnaud Bernaert, the head of global health and healthcare industries at the World Economic Forum (WEF), said the world shouldn’t be “naive” about these inequities.

“High-income countries have political and legal reliability, which allows them to organize the fastest possible plans to protect their populations,” he said. “It will always be that way.”

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“[Gulf Arab] countries have smaller populations, larger amounts of funds and strong health systems, so they’re in a better position to start their rollout earlier, and that is a fact,” Dr. Yvan Hutin, director of communicable diseases at the World Health Organization’s (WHO) Eastern Mediterranean Regional Office, said.

“The Middle East is simply categorized by substantial inequity.”

For the non-Gulf Arab states, ridden with poverty, endemic corruption or conflict, the vaccination plans are complicated not just by poor administration, but by a deep distrust for the political leadership.

“You need to have a clear vision for the plan [to vaccinate a population], which requires strong governance as well as the capacity to pay,” Hutin told CNN. “Most countries in the region don’t have either.”

A medic walks around the coronavirus ward at the Italian field hospital at the Lebanese University campus in the town of Hadath in September 2020.

In Lebanon, a ruling elite widely accused of corruption has for decades bled the country’s resources dry, culminating in a financial downward spiral last year. The medical system has not been spared, and buckled under medicinal shortages and an exodus of health care workers. Last August’s Beirut port explosion, which damaged some major hospitals, exacerbated what the country’s president has called a full-fledged “health state of emergency.”

Despite having some of the lowest case numbers in the region in the early months of the pandemic, Lebanon now leads the Arab world in cases per million population.

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Two million doses of the Pfizer/BioNTech vaccine are expected to arrive in early February, but they are expected to only cover around 20% of the country’s population. On Lebanon’s streets, few people believe that the rollout is imminent, or that it will be conducted safely.

It’s a similar story in Iraq and Jordan, countries suffering from economic turmoil and where people have regularly protested to demand political reform.

Jordan’s free Pfizer/BioNTech vaccination program is already underway, but only a very small percentage of the population has signed up to receive it, citing an absence of trust, according to health officials. In Iraq, only 1.5 million doses of the Pfizer/BioNTech vaccine will be available for its 40 million-strong population, despite the country having grappled with repeated surges in Covid cases over the last year.

But where governments falter, the international community says it’s trying to fill in the gaps. WHO is organizing the distribution plans for middle to low-income countries through programs like the COVAX alliance, a global initiative with 190 participating nations aimed at working with manufacturers to provide countries worldwide with equitable access to vaccines.

People line up at a vaccination facility in Dubai's financial center district on January 24, 2021.

Bernaert says he expects a fast rollout despite the myriad challenges. “Although there will be a lag in vaccinating lower-income countries against Covid-19, it will be far shorter than what we’ve seen in the past,” he said.

Iran and Egypt are the two most populous countries in the region, with Iran at close to 85 million people and Egypt at over 100 million — complicating distribution for two states that have struggled economically in recent years.

Egypt started vaccinating its people, starting with medical workers, with the Sinopharm shot on January 24. GAVI, the vaccine alliance that co-leads COVAX, will also supply inoculations for 20% of the population, while the Egyptian government said it has signed a deal for 20 million doses of the AstraZeneca vaccine, covering an additional 10% of the North African state’s inhabitants.

Buckling under sanctions imposed by former US President Donald Trump, Iran is the hardest-hit country by the virus in the region. It has had over 1 million cases and more than 50,000 deaths.

But Iran is the only regional state that says it plans to produce its own vaccine. Officials say the country also intends to import almost 2 million doses from India, Russia and China by the end of the first quarter of 2021. The imported vaccines will barely cover 2% of the population.

An elderly man receives a dose of the Sinopharm vaccine in Amman, Jordan, in January.

Conflict zones with a vague prospect of vaccines

In the region’s conflict zones, governments are incapable of buying their own vaccines, or even distributing them in territories crisscrossed with armed factions and competing spheres of political control. They must almost completely rely on international organizations to do so.

COVAX has secured nearly 2 billion doses of Covid-19 vaccines to be distributed across all its participating 190 countries. But Hutin says that’s not enough.

“We really wish we had more to give,” he said. “We’re working on securing more doses, but it’s just not going to happen tomorrow.”

Syria, already on its knees after almost a decade of civil war, is facing an economic crisis. The country’s president, Bashar al-Assad, does not control all of its territory — much of it was wrested from his regime by opposition groups during the conflict. The government in Damascus — repeatedly accused of war crimes and human rights abuses — will rely on GAVI, the vaccine alliance that co-leads COVAX. Opposition groups in Syria’s largely Kurdish northeast, and rebel-controlled northwest will do the same.

In war-torn Yemen, suffering a devastating humanitarian crisis, rival governments in the country’s south and north appear to have only a vague notion of what the vaccine rollout will look like.

Aden has seen its cemeteries rapidly expand as Yemen's Covid-19 death toll surged.
In Aden, the seat of the Saudi-backed government, Deputy Health Minister Dr. Ishraq Al-Subei said that Yemen may receive its first batch of the vaccine in March, but that shipment will cover only 20% of the country. It is unclear if this will include territories controlled by Houthi rebels, recently designated terrorists by the former Trump administration.

In Israel and the Palestinian territories, region-wide vaccine disparities also come into sharp focus. Israel’s world-leading vaccination campaign, which is on course to meet the government’s target of inoculating the entire country by the end of March, leaves at least 4.5 million Palestinians living in the West Bank and Gaza behind.

So far none have had the injections, and most are unlikely to get them any time soon — because there is no Covid-19 vaccination campaign in the Palestinian territories.

According to United Nations experts, a policy of immunization that differentiates between those with Israeli IDs, and those without, is “unacceptable.”

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A UN expert report, published by the UN’s Office High Commissioner for Human Rights in January, says that Israel is the occupying power in and over Gaza and the West Bank, and has been since 1967, and is thereby ultimately responsible for the health care of those living under occupation.

Israel disagrees, pointing to the Oslo accords, signed in the mid-1990s with the Palestine Liberation Organization, which led to the creation of the Palestinian Authority (PA). Included in the first of those agreements is a clause that hands responsibility to the PA for the health of all Palestinians under its civil administration.

Israeli Health Minister Yuli Edelstein told CNN: “If we’ll get to the situation where everyone in the country who wants to be vaccinated is vaccinated, we will be more than ready to share the vaccines with our neighbors.”

The Palestinian Authority health minister, Dr. Mai Al-Kaileh, says they expect to get hold of the Covid-19 vaccine by the end of March, but that there is no specific date set yet for their arrival. The ministry says it has contracts with four companies producing the vaccine. These vaccines will cover 70% of the Palestinian population and the WHO will provide doses for a further 20%, the PA said in a January 9 statement.

A health care worker administers a vaccine in Jerusalem, on January 6.

‘The beginning of a new era’

According to Hutin, the WHO has approached rich countries, including the Gulf nations, to share their doses, and that they have complied but that it’s still a work in progress.

Abu Dhabi’s Department of Health launched a local collaboration called the Hope Consortium, which is set to deliver 18 billion vaccine doses globally by the end of 2021.

The undersecretary at the department, Jamal Mohamed Al Kabbi told CNN’s Becky Anderson that the plan represents a complete supply chain solution to address and facilitate vaccine availability across the world.

Bernaert told CNN despite the delay in vaccinations in lower-income countries, he is more optimistic than he was a few months ago.

“Are we going to be able to vaccinate everyone in 2021? No, I don’t think so. Is the vaccination tale going to continue in 2022, or even 2023? Yes, I think so. But what we’ve managed to do so far is a sign that we may be at the beginning of a new era.”

CNN’s Mostafa Salem in Abu Dhabi, Aqeel Najm in Baghdad, Eyad Kourdi in Gaziantep, Gul Tuysuz in Istanbul, and Andrew Carey, Sam Kiley and Abeer Salman in Jerusalem contributed to this report.


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