下一次，我们可以更快地弥合疫苗分配差距 | 盖茨笔记

Today, 46 percent of the world’s population has received at least one dose of a COVID-19 vaccine. It’s hard to overstate what a remarkable achievement this is. Humanity has never made and distributed a vaccine for a disease faster than it did for COVID-19. It accomplished in 18 months something that used to take a decade or more.

目前为止，全球有 46% 的人口至少接种了一剂新冠疫苗。毋庸置疑，这是一项了不起的成就。新冠疫苗是人类历史上研发交付速度最快的一支疫苗，仅用了18个月的时间。而在过去，这通常需要10年或更长时间才可能完成。

But within this amazing success there is a startling disparity: Just over 2 percent of people in low-income countries have received any COVID-19 vaccines. And the gap will be harder to close as rich-world governments buy up extra doses to serve as booster shots.

但在这一惊人的成就中，也存在着惊人的差距：低收入国家中仅有略高于 2%的人接种了新冠疫苗。随着发达国家购买额外剂量作为加强针，这一差距将更难弥合。

People are right to be upset about the inequity here. Vaccines make COVID-19 a largely preventable disease—and a survivable one in all but the rarest cases—and it is heartbreaking to know that people are dying of a disease not because it can’t be stopped but because they live in a low-income country. 

人们理应对这种不平等感到失望。疫苗的出现让新冠成为了一种基本可以预防的疾病——除了最罕见的病例外，几乎所有人都可以活下来——但令人心碎的是，导致人们死于一种疾病的原因并非疾病本身无法被遏制，而是因为他们生活在低收入国家。

Sadly, this inequity is not new. It is not even the worst gap in global health. There were shocking disparities in health long before any of us had heard of COVID-19. 

可悲的是，这种不平等并不罕见。这甚至不是全球健康领域最严重的差距。早在新冠疫情暴发之前，健康方面就已经存在令人震惊的差距。

Every year, more than 5 million children die before their fifth birthday, mostly from infectious diseases, and almost entirely in low- and middle-income countries. A child in northern Nigeria is 20 times more likely to die before the age of 5 than a child in a rich country. That is simply unjust, and reducing this inequity has been the Gates Foundation’s top priority for more than 20 years.

每年，都有超过 500 万儿童在5岁以前死亡，其中大部分死于传染病，而这几乎全部发生在中低收入国家。尼日利亚北部的儿童在5岁之前死亡的概率是发达国家儿童的 20倍。这完全是不公平的，而减少这样的不平等现象一直是盖茨基金会20多年来的首要任务。

If you step back and look at the trends, though, there is good news. Since 1960 the childhood death rate has been cut by more than 80 percent, thanks in large part to the invention and distribution of vaccines for children around the world.

不过，如果我们回顾一下，发展趋势还是比较乐观的。自1960年以来，儿童死亡率降低了80%以上，这很大程度上归功于世界各地儿童疫苗的研发和交付。

The fact that routine childhood vaccines are reaching so many people is reason to believe COVID-19 vaccines can too. Providing them to everyone who needs them is one of three crucial steps in controlling this pandemic, along with containing the virus so it doesn’t come roaring back and coordinating the global response. At the same time, we can learn from the inequities that were so clear during this pandemic so we can do a better job of closing the gap during the next one. (Assuming there is a next pandemic. I think it is possible to prevent them altogether. But that’s a subject for another time.)

如此多的孩子接种了常规儿童疫苗，这一事实让人们有理由相信，新冠疫苗的交付也可以做到这一点。让每个人都有机会接种疫苗，是遏制这一大流行病的三个关键步骤之一。除此之外，还需要遏制疫情蔓延并协调全球响应。与此同时，我们可以从这次新冠大流行凸显出的不平等现象中吸取经验教训，以便我们可以在下一次做的更好。 （假设还会有下一次大流行病。我认为完全有可能预防，但这是另一个话题了。）

How could we achieve vaccine equity in a future pandemic? I see two ways.

如何才能在未来的大流行病中实现疫苗公平？ 我认为有两种方式。

01

  Change how the world allocates doses.

改变世界分配疫苗的方式

What would the optimal allocation look like? It’s not simply a matter of proportional representation, where if your county has X percent of the world’s population, you get X percent of the vaccines. There are two different benefits to consider, and both are important.

怎样才算最佳的分配方式？这不仅仅是一个按比例分配的问题，并不是根据你所在的地区拥有世界人口的 X%，就获得X% 的疫苗这么简单。这里，有两个因素需要重点考虑。

One benefit is to the individual who’s immunized; they get protection from the virus. The more likely you are to get infected—and the more likely you are to become seriously ill or die if you do get infected—the more benefit you get from a vaccine. A COVID-19 patient in their seventies is 90 times more likely to die of the disease than a patient in their twenties. From a global perspective, it is neither fair nor wise to protect that young person before the old one.

一个是疫苗接种者所获得的益处，接种疫苗可以保护人们免受病毒侵害。而如果一个人感染传染病的可能性越大，或者因感染导致重病或死亡的可能性越大，相应的他从疫苗的获益就会越多。七十多岁的新冠患者死于这种疾病的可能性是二十多岁患者的90倍。从全球范围来讲，优先保护年轻人既不公平也不明智。

Second, when an individual is vaccinated, society gets the benefit of lowering the risk that the person will spread the disease to others. This is the core of the argument in favor of vaccinating health workers and people who work in elderly care facilities, since even when a lockdown is in place, they can transmit the virus to people at high risk.

其次，当一个人接种了疫苗，那么他将病毒传播给别人的风险也将随之降低，他所在的社区也将从中受益。这也是为什么有很多观点支持为卫生工作者和在老年护理机构的工作人员接种疫苗，因为即使封锁措施到位，他们也仍能将病毒传播给高危人群。

When a virus is spreading, we should maximize both benefits—saving lives and stopping transmission. This means that, when supplies are short, we should prioritize vaccinating people who both have a high risk of death and live in the places where the virus is spreading fastest. 

当病毒传播时，我们应该最大化疫苗在这两方面的作用——挽救生命和遏制病毒传播。这意味着当供应短缺时，我们应该为具有高死亡风险和居住在病毒传播最快的区域的人优先接种疫苗。

Those will not necessarily be low-income countries. When COVID-19 vaccines first became available, many of the most severe epidemics were in rich- and middle-income countries. 

这些国家不一定是低收入国家。当新冠疫苗问世时，疾病流行最严重的地区在高收入和中等收入国家。

The gravest inequity, even more than vaccinating rich people before poor ones, is vaccinating young people in rich countries before older people in middle-income countries with bad epidemics, such as South Africa and most of South America. 

相比于优先给富裕人群而非贫困人群接种疫苗这种不平等现象而言，更严重的不平等是优先给富裕国家的年轻人而非生活在病毒肆虐的中等收入国家的老年人接种疫苗，例如南非和大部分南美洲的国家。

To their credit, rich countries have pledged to share more than a billion doses with poorer countries during COVID-19. But they haven’t yet delivered fully on those pledges, and even if they had, the gap would still be enormous. 

值得称赞的是，发达国家已承诺在新冠疫情期间与贫困国家分享超10亿剂疫苗。但是他们还没有完全兑现这些承诺，而且即使他们兑现了这一承诺，差距仍将是巨大的。

Although sharing doses needs to be part of the solution, it will never be sufficient to solve the problem. For one thing, the number of doses won’t be high enough. 

虽然共享疫苗剂量需要成为解决方案的一部分，但这永远不足以解决根本问题。主要原因是疫苗的供应不够充足。

That’s why it’s so important to find ways to produce more doses in less time. The world should have the goal of being able to make and deliver enough vaccines for everyone on the planet within six months of detecting a potential pandemic. If we could do that, then the supply of doses would not be a limiting factor, and the way they were allocated would no longer be a matter of life and death.

这就是为什么找到在短时间内生产更多疫苗的方法如此重要。 全世界应该设定这样的目标：在监测到潜在大流行病的六个月内，为地球上的每个人生产和提供足够的疫苗。如果我们能做到，那么疫苗的供应就不会成为限制因素，如何分配也将不再是生死攸关的问题。

02

 Make more doses.

制造更多疫苗

As limited as the supply of COVID-19 vaccines has been, the situation could have been even worse. 

由于新冠疫苗的供应一直有限，情况可能会更糟。

We are fortunate that mRNA vaccines work so well, since this is the first disease for which the mRNA technology has been used. If they hadn’t, we would have been far worse off.

幸运的是，虽然这是mRNA技术第一次用于对抗一种疾病，但mRNA疫苗的效果非常好。反之，我们的情况会更糟。

It is also great that some vaccine companies entered into second-source deals, which allowed huge volumes of their vaccines to be manufactured by other firms. This was a crucial and remarkable step. (It’s as if Ford let Honda use its factories to build Accords.) Just one example: In less than two years, a single manufacturer, AstraZeneca, signed second source deals involving 25 factories in 15 countries. 

另一个值得高兴的事情是已有一些疫苗公司签署了合同生产商协议，这使得其他公司可以大量生产他们的疫苗。这是至关重要的一步。（就好像福特让本田用自己的工厂来制造雅阁一样。）举一个例子：在不到两年的时间里，仅阿斯利康一家疫苗制造商就签署了涉及 15个国家25家工厂的合同生产商协议。

You may have heard the argument that waiving intellectual property (or IP) restrictions would have made a difference. Unfortunately, that’s not true in this case. IP waivers and licensing are a complicated issue, so I want to take some time to untangle it.

你可能听说过这样的观点，即如果免除知识产权限制，情况就会大不一样。遗憾的是事实并非如此。知识产权免除和授权是一个复杂的问题，因此我想花时间解释一下

There are cases in which IP licensing is a great way to make something cheaper and better. For example, in 2017, the Gates Foundation and a number of partners were involved in an agreement to make a new, more effective version of an HIV drug cocktail that would be more affordable for the world’s poorest countries. 

在某些情况下，知识产权授权是生产更便宜、更优质产品的一个好方法。例如，2017年，盖茨基金会和一些合作伙伴达成了一项协议，制造一种新的、更有效的艾滋病(HIV)鸡尾酒疗法，以便世界上最贫困的国家也能负担得起。

In the deal, a pharmaceutical company gave the recipe for the key ingredient in this cocktail to firms that specialize in producing generic drugs. These firms were able to reduce the cost so much that today nearly 80 percent of people who get HIV treatment in low- or middle-income countries are receiving the improved cocktail.

根据协议，一家制药公司将这种鸡尾酒疗法中关键成分的配方提供给专门生产仿制药的一些公司，这些公司可以大幅度降低成本。因此，现在中低收入国家接受艾滋病治疗的人中，已有近80%的患者在接受改良鸡尾酒疗法。

Unfortunately, IP licensing doesn’t work as well with vaccines. Here’s why. 

然而，知识产权授权并不适用于疫苗。原因如下。

Many drugs are made using chemical processes that are well defined and measurable. If you mix the same ingredients in the right proportion and so on, you’ll get the same product every time, and you can check your work by looking at the chemical structure after the drug is made. Company A can give a recipe to company B, and company B will be able to make precisely the same drug consistently. 

许多药物的制作过程是经明确定义并且可测量的。如果将相同的成分按正确的比例混合，每次都会得到相同的产品，也可以通过查看药物制成后的化学结构来检查你的工作。A公司可以向B公司提供配方，B公司就能生产出完全相同的药物。

But many vaccines don’t work that way. Manufacturing them often involves living organisms—anything from bacteria to chicken eggs. Living things don’t necessarily act exactly the same way every time, which means that even if you follow the same process twice, you might not get the same product both times. Even an experienced vaccine maker might not be able to simply take another’s recipe and replicate it reliably. 

但许多疫苗并非如此。制造它们的过程通常涉及到活的生物体——例如细菌、鸡蛋等。活生物体不一定每次都能以完全相同的方式起作用，这意味着即使遵循相同的制造过程，也可能无法得到相同的产品。即使一个经验丰富的疫苗制造商也可能无法简单使用别人的配方并可靠地复制出来。

This is why broadly waiving IP proections would not meaningfully increase the supply of vaccines. (In the case of COVID-19, though, a narrow waiver that applied to specific easily transferred technologies during the pandemic made sense.) Supply has been limited not because of IP rules, but because there aren’t enough factories capable of handling the more complicated process of making vaccines.

这就是为什么只靠放弃知识产权保护无法提升疫苗供应的原因（不过，就新冠而言，在大流行病期间适用于容易转让的特定技术的部分豁免是有意义的。）供应受到限制不是因为知识产权，而是因为没有足够的工厂能够处理比较复杂的疫苗生产过程。

Licensing IP—or having the rights to it waived—only guarantees that company A can’t sue company B. Second-source deals are far superior because they involve sharing not only the recipe but also knowledge about how to use it, as well as personnel, data, and biological samples. It was a second-source deal with AstraZeneca—not an IP waiver—that allowed Serum Institute of India to produce 100 million doses at a very low cost and in record time. 

授权或放弃知识产权，只能保证A公司不能起诉B公司。合同生产商协议远比这要好得多，因为它不仅分享配方，还分享使用配方的方法，以及人员、数据和生物样本。与阿斯利康（AstraZeneca）的合同生产商协议就是采用这样的形式——而不是知识产权豁免——从而使得印度血清研究所能够以极低的成本在创纪录的短时间生产出1亿剂疫苗。

So how can the world make more doses faster next time? 

那么世界应该如何在下次疫情中更快地制造更多疫苗？

“

First, decision makers should get serious about expanding the world’s vaccine-making capacity.

首先，决策者应该认真考虑

扩大世界疫苗生产能力。

”

First, decision makers should get serious about expanding the world’s vaccine-making capacity. In particular, governments and industry should make sure there’s enough capacity to quickly make huge volumes of mRNA vaccines; now that we know the mRNA platform works, it will allow new vaccines to be developed faster than any other approach. And if companies that have second-source deals now maintain their relationships with each other, they won’t have to start from square one in the next outbreak.

首先，决策者应该认真考虑扩大全球疫苗生产能力。特别是政府和行业应确保有足够的能力快速生产大量mRNA疫苗；现在我们知道mRNA平台的作用，它比其他方法能更快地开发新疫苗。如果可以进行合同生产商协议的公司彼此间保持合作关系，大家就不必在下一次大流行病暴发时从头开始。

Another step is to develop prototype vaccines against the diseases that are most likely to cause future outbreaks, and to develop universal vaccines for flu and coronaviruses, which would protect people against any form of the two pathogens. The NIH and Coalition for Epidemic Preparedness Innovations are doing excellent work on both, but even more research is needed. 

另外一个关键步骤是，着手研发在未来有可能导致疫情暴发的疫苗原型，并研发针对流感和冠状病毒的通用疫苗，针对这两种病原体的任何型别产生保护效果。美国国立卫生研究院(NIH)和流行病防范创新联盟（CEPI）在这两个方面都做了很好的工作，但世界还需要在上述领域进行更多的投入和研究。

One longer-term step is for more countries to build the capacity to develop, manufacture, and approve vaccines themselves. 

从长远的角度考虑，我们还需要让更多国家建立自己研发、制造和审批疫苗的能力。

Historically, the companies that invent new vaccines have been based in higher-income countries. Because it costs so much to develop a new product, they try to recoup their costs as quickly as possible by selling doses at the higher prices that rich countries can afford. They have no financial incentive to try to lower their costs (by optimizing the production process, for example) so that the price can be cheap enough for lower-income countries. 

从过往看来，发明新疫苗的公司大多在高收入国家。这是因为开发一种新产品的成本很高，他们试图通过以发达国家能够承受的更高价格来出售疫苗以尽快收回成本。他们并没有经济动力试图降低成本（例如，通过优化生产过程），即便这样做对低收入国家来说，价格将更可负担。

The pentavalent vaccine—which protects against five diseases—is a great example. It was invented in the early 2000s, but there was only one manufacturer, and at more than $3.50 per dose, it was far too expensive for low- or middle-income countries. Our foundation and other partners worked with two vaccine companies in India—Biological E Limited and Serum Institute of India—to develop a pentavalent vaccine that would be affordable everywhere. Today that vaccine costs about $1, and it is given to 80 million children a year. That’s a 16-fold increase since 2005. 

可以预防五种疾病的五联疫苗就是一个很好的例子。它诞生于21世纪初，但只有一家制造商能够生产，而且每剂价格超过3.50美元，这对于中低收入国家来说过于昂贵。 我们基金会和其他合作伙伴一起与印度两家疫苗公司，即Biological E Limited公司和印度血清研究所，合作开发了一种任何地方都可以负担得起的五联疫苗。现在该疫苗的成本价仅为一美元，而且每年可以为八千万儿童进行接种。这比2005年时增长了16倍。

We need more examples like this. Pentavalent took years to pull off. If there were more high-volume vaccine manufacturers whose primary goal was to produce low-cost vaccines, then affordable doses would be available much faster. Middle-income countries are a natural home for these companies, and some have set ambitious goals for themselves. For example, a group of African leaders has set a target of manufacturing 60 percent of the continent’s vaccines by 2040. 

我们需要更多这样的范例。五联疫苗经过多年才取得这样的成绩。如果有更多以生产低成本疫苗为主要目标的大规模疫苗制造商参与，就可以更快地获得可负担的疫苗。这些公司通常来自于中等收入国家，而其中一些国家已经为自己设定了雄心勃勃的目标。例如，一些非洲国家领导人已制定了计划，希望到2040年前，能生产非洲大陆所需疫苗的60%。

Helping middle-income countries build their vaccine-making capacity is something the Gates Foundation has been working on for two decades. We’ve helped bring 17 vaccines to market, and we’re supporting the African efforts to build theirs out by 2040.

盖茨基金会二十年来一直致力于帮助中等收入国家加强疫苗生产能力。我们帮助了17种疫苗上市，正在帮助非洲国家在2040年以前生产他们自己的疫苗。

“

Creating an entire vaccine-making ecosystem is a tough challenge.

建立一个完整的疫苗生产生态系统是一项艰巨的挑战。

”

What we’ve learned is that creating an entire vaccine-making ecosystem is a tough challenge. But the obstacles can be overcome.

我们了解到，创建一个完整的疫苗生产生态系统是一项艰巨的挑战。但障碍是可以克服的。

One issue is the need for regulatory approvals. Almost all vaccines manufactured by developing countries have to be approved by their own government first, and then receive prequalification or emergency use listing by the WHO. It’s time-consuming. 

一个问题是需要获得监管部门的批准，几乎所有发展中国家生产的疫苗都必须先获得本国政府的批准，然后再申请获得世界卫生组织的资格预审/批准紧急使用，这很耗时。

Currently, regional agencies in Africa are working with the WHO and the European Union, governments are also collaborating on regional standards for vaccines. This way, manufacturers don’t have to meet different safety and efficacy requirements in each country. 

目前，非洲各区域机构正在与世卫组织和欧盟展开合作，同时各国政府也在疫苗的区域标准方面进行合作，这样制造商就不需要满足每个国家在安全性和有效性方面的不同要求。

Another challenge: If vaccine manufacturers don’t have other products to make between outbreaks, they’ll go out of business. Unfortunately, making existing vaccines isn’t a viable option, at least right now, because the market is already saturated with existing vaccines, and it would be hard for new entrants to compete on price with established low-cost / high-volume companies.

另一个挑战是如果疫苗制造商在两次疾病暴发期间没有其他产品可以生产，他们就会倒闭。不幸的是，制造现有疫苗并不是一个可行的选择，至少目前是这样，因为市场上现有疫苗已经饱和，新进入者可能很难在价格上与现有的低成本/大批量生产的公司形成竞争优势。

But new products are coming that would be ideal products for them. As vaccines become available for diseases like malaria, tuberculosis, and HIV, they’ll create opportunities for producers in middle-income countries. In the meantime, countries can take on the fill and finish process—putting vaccines made elsewhere into vials and distributing them. 

但是新产品对他们而言将会是理想的选择。随着疟疾、肺结核和艾滋病等疫苗相继问世，它们将为中等收入国家的疫苗制造商创造机会。与此同时，各国可以承担灌装和包装等一系列过程——将其它地方生产的疫苗装入小瓶进行交付。

To anyone who has lost a loved one to COVID-19, or had to choose between paying the rent or buying food, it is no comfort to suggest that anything has gone well in this pandemic. But as my friend the late Hans Rosling used to say, “The world can be both bad and better.” The situation today is bad, and also better than it would have been if COVID-19 had come along ten years ago. If the world makes the right investments and decisions now, we can make things better next time. And maybe even make sure there is no next time at all.

对于那些因新冠疫情失去亲人或不得不在支付房租或购买食物之间做出选择的人们，任何有关疫情期间一切都还顺利的说法都无法带来安慰 。但正如我的朋友、已故的汉斯·罗斯林 (Hans Rosling)曾经说得那样：“世界可以既是糟糕的，但同时也在变得更好。” 现在的情况虽然很糟糕，但如果新冠病毒出现在十年前，情况还要比现在糟得多。如果现在做出正确的投入和决策，我们就可以在下一次做得更好，甚至确保下一次大流行不再发生。

This post originally appeared on CNN.com.

本文原篇刊登在CNN.com