The vast majority of COVID-19 vaccines have gone straight from drug companies to affluent countries such as the United States. Worldwide only about 1% have made it to low-income countries.
And here's what's happening all across the United States: Millions of vaccine doses at risk of spoiling are sitting on freezer shelves, with no easy way to get them to countries desperately waiting for shots.
In North Carolina, for example, more than half a million Pfizer shots are set to expire by the end of August. Alabama just threw away 65,000 doses. Last month, Arkansas tossed 80,000.
State health officials warn the current demand for the vaccine may not be enough to get much of the supply into arms before they reach their expiration dates.
It's a stark reminder of the chasm between the COVID-19 vaccine haves and have-nots.
How many shots are ultimately at risk of going to waste? The answer is hard to come by given how decentralized the systems are. Jenny Ottenhoff, senior policy director for global health and education at the ONE Campaign, says her best guess is that the total number of expired vaccines combined with those about to spoil in the coming weeks and months, is in the millions in the United States.
"We should be moving those as quickly as possible, especially as we know more doses will be coming into the U.S in the coming months," she says.
The Food and Drug Administration came up with a workaround recently when it extended the shelf life of the Johnson & Johnson vaccine by six weeks — buying states more time to make use of the shots. But in some places, the grace period won't change the fact that interest in vaccines has dwindled. And brands such as Pfizer have not yet received the OK to move back the expiration date.
So there are still a good chunk of vaccines that won't make it into arms before they spoil.
"I'm angry, upset, disappointed," says José R. Romero, the Arkansas secretary of health. "As a nation, we've worked so hard to get these vaccines out, and not to have them accepted by the public is very disappointing, very disappointing. If you look at it from a global point of view, millions of people are affected by this virus around the world and we're throwing it away.
"It is difficult to understand and difficult to accept."
Donating doses isn't as easy as it sounds
It also seems difficult to understand why the soon-to-expire doses can't be sent to nations that don't have enough vaccines. But at the moment, a combination of red tape and logistical challenges have left states with no clear pathway to send the extra doses to countries that need them.
States can't just bypass the federal government and send their leftover doses to countries that need them, but federal officials should be able to give states permission to take this route, says Govind Persad, a professor at the University of Denver Sturm College of Law.
Yet there are legitimate concerns about trying to retrieve doses and ensuring that all the conditions of storage and temperature are maintained, says Prashant Yadav, a senior fellow at the Center for Global Development and an expert on health care supply chains.
Aside from the logistics, moving these soon-to-expire doses is not only complex, Yadav says, but also runs up against some legal obstacles, including concerns among drugmakers about liability if their products cause harm in another country.
Persad says another barrier could be the contracts that the Trump administration signed with vaccine makers in which there appears to be some language restricting the use of vaccines abroad — although the contract language isn't fully public.
"Most of us have come to realize, once it's out in the states and particularly if it's been distributed to local communities, pulling it all back is kind of asking for some error or problem," says Dr. Marcus Plescia, chief medical officer for the Association of State and Territorial Health Officials. "The only option is to get people to take it here."
States have already stopped asking for new deliveries — a move that at least assures the pool of unused doses isn't growing any larger, he says.
Meanwhile, the White House is purchasing and giving away doses. Last week, the Biden administration announced it had donated and shipped 110 million doses of COVID-19 vaccines to more than 65 countries and plans to ship hundreds of millions more later this year and next. Those doses, however, have come from manufacturers and federal stockpiles, not from states that already have the doses in hand.
"Is there something different about the vaccine being in a state already, as opposed to coming directly from the stockpile?" Persad says. And it's also unclear why drug companies would want to sue if vaccines were used abroad, he says, "given that the basic sort of PR [public relations] of the suit would be we would rather these vaccines be thrown out in America than used to protect people overseas."
Putting pressure on the U.S.
International advocates are pressuring the United States to get its unused doses to other countries. Every dose available right now remains a precious resource in the face of the global surge of the delta variant, says Dr. Carissa Etienne, director of the Pan American Health Organization, an international public health agency affiliated with the World Health Organization.
"Please don't wait until you have surplus doses. You [countries that have enough doses] need to share out of what you have now," Etienne told reporters last month.
While it could be complex and costly to reclaim these orphaned doses, the University of Denver's Persad says the U.S. shouldn't lose sight of what those vials represent — human lives that could be saved: "If you get even 100 vaccines that would help people instead of being wasted, that's actually really important."