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 in low- and middle-income countries, and outlines a vision for doing better next time.
The idea for COVAX was born over drinks at the Hard Rock Hotel in Davos on January 23, 2020, when reports of a new virus in China were beginning to worry some attendees. Berkley and colleagues at the World Economic Forum, including Richard Hatchett of CEPI, discussed how to ensure that if scientists produced a vaccine, every country would have access regardless of wealth. They had no money, staff, or mandate, but they began planning a mechanism to pre-purchase vaccine candidates and distribute doses equitably by population — a concept that became COVAX.
COVAX’s approach required countries to commit funds up front to buy vaccines that might never work. That risk was necessary in a pandemic, Berkley says, and was supported by earlier investments in coronavirus vaccine work and the emerging mRNA technology that enabled extremely rapid development. The first COVID vaccine was authorized in the U.K. on Dec. 8, 2020; COVAX delivered its first doses to a low- and middle-income country 39 days later in India and to Africa 43 days later in Ghana and Côte d’Ivoire.
Between 2021 and 2023, COVAX distributed about 2 billion doses to 146 countries. In the 92 poorest countries, primary-dose coverage reached roughly 57%, compared with about 67% global coverage — a significant improvement for many people but falling short of true equity. Berkley characterizes COVAX as the fastest and most equitable vaccine rollout in history, but he acknowledges major failures and obstacles.
Key problems included vaccine nationalism (wealthy countries buying multiple vaccine candidates and hoarding supply), export bans, and supply chain issues. A critical blow came in spring 2021 when the Delta surge in India led the Serum Institute of India, the world’s largest vaccine manufacturer and a major COVAX supplier, to stop exports to prioritize domestic needs. That decision and other supply disruptions left COVAX about 600 million doses short. Berkley notes that although critics said COVAX put all its eggs in one basket, the initiative had negotiated with many manufacturers and ended up with a broader portfolio than others; the shortage resulted largely from wealthier countries buying most supplies and from export and production constraints.
From those experiences, Berkley draws several lessons for future pandemic preparedness. Most important is having funds available on day one to enter procurement queues and make deals with manufacturers. Gavi now maintains about $500 million in capital for that purpose. He also stresses the importance of networks — coordinating UNICEF, WHO, the World Bank, civil society and others — rather than expecting a single institution to do everything. Expanding and geographically diversifying manufacturing capacity is vital; Africa, with a large share of the global population, produced less than 0.1% of vaccines during COVID-19, so building local facilities can help, though it doesn’t automatically guarantee equitable access across many countries.
Berkley warns that global preparedness has slipped since the pandemic. Public conversation cooled, and political and institutional changes weakened readiness. He highlights challenges from misinformation and disinformation — not only foreign state actors but influential domestic figures and even elements within U.S. institutions spreading doubts about vaccines. Countering that requires engaging trusted local voices — doctors, nurses, community and religious leaders — but it becomes much harder when national leaders undermine public health messaging.
He also criticizes policy moves that dismantled pandemic-focused teams and cut foreign aid and health funding. Berkley points to reductions in U.S. support for institutions like Gavi and cuts to pandemic-focused staff at the National Security Council and CDC, warning these decisions have real consequences: estimates suggest halted funding could leave millions of children unimmunized and lead to additional deaths.
On communication, Berkley emphasizes science and humility. When a new disease emerges, experts must provide guidance based on available evidence while acknowledging uncertainty and updating advice as knowledge evolves. Clear messaging about changing information and its reasons is crucial for public trust.
Berkley’s account in Fair Doses is both a record of what COVAX achieved and a critique of global responses that limited its impact. The book argues for sustained political will, pre-positioned financing, coordinated international networks, expanded manufacturing capacity, and improved public communication to make vaccine access truly equitable in the next pandemic.
