An invisible divide formed early last year as COVID-19 vaccines spread through rich countries, while the rest of the world waited. In one part of the globe, newly vaccinated doctors and nurses breathed sighs of relief and grandparents hugged their grandchildren for the first time in months. In the other part, hospitals overflowed with an unmitigated surge of COVID-19.

“We saw our fellow nurses dying with COVID,” says Milly Kumwenda, a nurse at Queen Elizabeth Central Hospital in the city of Blantyre in southern Malawi, as she recalls a deadly surge of the disease in January 2021. After two cabinet ministers died of COVID-19, Malawi’s president declared a state of national disaster. The aid agency Médecins sans Frontières (MSF, also known as Doctors without Borders) rushed to help and issued an appeal to the rest of the world: “Malawi urgently needs access to the vaccine.”

Vanishingly few doses arrived — in unpredictable spurts and often close to expiry. By the time the next surge hit in July 2021, just 1% of Malawians had been vaccinated. Many people had stopped seeking care by then because they had lost faith in the health system, says Loveness Gona, another nurse at the hospital. There are few ventilators in Malawi, no antiviral infusions or monoclonal antibody treatments, and chronic shortages of drugs to manage deadly symptoms such as blood clots and inflammation. These are some of the reasons that death rates among people hospitalized for COVID-19 in low-income countries have been more than twice as high as in wealthy nations1. Gona remembers coming into work to find corpses propped up in chairs in the hospital waiting room, their loved ones demanding a test. “Somewhere else, they’d be alive,” she says.

Vast, ongoing delays in the global distribution of COVID-19 vaccines have resulted in death on a massive scale and arguably allowed the evolution of the Omicron variant, which was first reported in South Africa late last year. Such inequities are jarring, but hardly new. Many years passed before life-saving vaccines and drugs for pneumonia and HIV were widely available in Africa, and important treatments for cancer and cystic fibrosis that are common in rich countries remain almost unobtainable in poorer ones.

At the root of the problem lies a dependence on the limited goodwill of countries — mainly in the global north — where the majority of large pharmaceutical companies are based. That’s why more than a dozen countries in the global south are banding together with the World Health Organization (WHO) and other groups in a long-term initiative to build vaccine- and drug-making capacity throughout Africa, South America, Asia and Eastern Europe. “The COVID-19 pandemic has shown that reliance on a few companies to supply global public goods is limiting and dangerous,” said WHO director-general Tedros Adhanom Ghebreyesus as he announced the initiative last year.

Called the mRNA vaccine technology transfer hub, the initiative is built around the shiny new promise of messenger RNA as a tool for vaccines and drugs. At the hub’s core is a small biotechnology firm in Cape Town, South Africa, called Afrigen Biologics and Vaccines. It is linked to South African universities and pharmaceutical companies based in 15 countries, including Senegal, Argentina and Indonesia (see ‘Changing the equation’). Together, these groups aim to make their own effective mRNA vaccine against COVID-19, before expanding into other diseases that are relevant to their regions, be it HIV, Zika or measles.