Seth Berkley, former CEO of Gavi, the Vaccine Alliance, has written a new book, Fair Doses, that tells the inside story of efforts to expand access to COVID-19 vaccines — especially to low- and middle-income countries — and outlines a vision for how the world might do better next time. Berkley stepped down from Gavi in 2023 and now works as a global health consultant. NPR spoke with him about what went right with COVAX, what went wrong, and why he believes the globe may be less prepared for the next pandemic than it was in January 2020. This interview has been edited for length and clarity.
The idea for COVAX was born at the Hard Rock Hotel in Davos on January 23, 2020. Reports of a new virus in China were just starting to surface; it hadn’t been named and human-to-human transmission hadn’t been confirmed, but Berkley and colleagues at the World Economic Forum treated it as if it could be the “big one.” Together with Richard Hatchett of CEPI and others, they discussed how to ensure that, if vaccines were developed, they would be available equitably — not only to wealthy countries. The concept was to pre-purchase bulk quantities from manufacturers developing vaccines and distribute them based on population size rather than ability to pay.
COVAX ultimately had mixed results. Between 2021 and 2023 it delivered roughly 2 billion doses to 146 countries, enabling some of the fastest vaccine rollouts to low- and middle-income countries in history. After the U.K.’s first jab on December 8, 2020, COVAX-supported vaccines reached India 39 days later and Ghana and Côte d’Ivoire 43 days later. Vaccination coverage of primary doses in the 92 poorest countries reached about 57%, compared with roughly 67% global coverage — not fully equitable, but significant progress.
At the same time, COVAX faced major setbacks. Berkley points to vaccine nationalism: wealthy countries, uncertain which vaccines would work, bought multiple candidates and quickly absorbed global supply. Export bans, supply chain disruptions, and manufacturing bottlenecks compounded the problem. In the early months, the lowest-income countries had far lower access; only about 1% of people in the poorest countries were covered in the first year.
A pivotal blow came in spring 2021 when the Delta variant devastated India. The Serum Institute of India (SII), the world’s largest vaccine manufacturer and a major COVAX supplier, paused exports to concentrate supplies domestically. India had previously donated doses abroad as part of vaccine diplomacy, which critics then highlighted when Delta struck. With SII exports halted, COVAX fell roughly 600 million doses behind its schedule. Berkley says they tried everything — diplomacy, engagement, even legal options — but could not get those doses released.
Berkley rejects the simplified accusation that COVAX put all its eggs in one basket. The initiative negotiated with many manufacturers and held the largest portfolio of vaccine candidates of any global effort. But because rich countries snapped up supplies, COVAX couldn’t secure deals with some companies and faced constraints beyond its control.
Reflecting on lessons for future pandemics, Berkley emphasizes several priorities:
– Day-zero financing: Having funds available immediately to enter manufacturer queues and secure supply is critical. Gavi now maintains about $500 million in capital for that purpose.
– A collaborative network: No single institution should be expected to do everything. Effective pandemic response requires clear roles for WHO, UNICEF, the World Bank, civil society, and others, with regular coordination and shared planning.
– Expanded, geographically dispersed manufacturing: Increasing global production capacity reduces vulnerability to national export restrictions and supply shocks. Africa, for example, has a substantial population but accounted for less than 0.1% of global vaccine production during COVID; building facilities there helps but doesn’t guarantee access across the continent.
Berkley is candid about current preparedness. He believes the world is less prepared now than it was before COVID because political will and attention have waned. He points to the corrosive effects of misinformation and disinformation — coming from foreign state actors, domestic political figures, and influential personalities — which make public health communication far harder. When high-level leaders publicly question vaccines or propose major changes to childhood immunization without scientific backing, reversing those narratives becomes much more difficult.
He also warns about the dismantling of critical preparedness infrastructure. Berkley cites cuts to U.S. foreign aid and health institutions, reductions in pandemic-focused staff at the National Security Council and CDC, and halted U.S. funding to Gavi. He estimates those funding cuts could leave 75 million children without immunizations and potentially contribute to an additional 1.2 million deaths.
On how to counter misinformation, Berkley returns to a longstanding public health strategy: engage local trusted voices — doctors, nurses, religious and community leaders — to communicate evidence and context. But he acknowledges that local outreach is harder when misleading messages come from national leaders.
Berkley’s final counsel is to rely on science, communicate uncertainty honestly, and exercise humility. In the earliest days of a new outbreak, experts know little; they must provide guidance based on current evidence while clearly signaling that recommendations may change as more data arrive. That honest communication, he argues, would build trust and help the public understand why policies evolve.
Fair Doses is Berkley’s inside account of the push to make vaccines global goods and a cautionary guide on how to strengthen international readiness for the next pandemic.
