We are all waiting for the vaccine. Waiting to be protected against Covid-19. The positive news over the last couple of weeks gives us hope that things can return to normal again. Three vaccines can be available at the beginning of the year.

But to whom? While the most vulnerable people are likely to be vaccinated against Covid-19 first in more affluent countries, the opposite is the case globally. The poorest and most vulnerable will have to wait. In fact, they will be at the very end of a long queue of billions of people - if at all.

The reality is that the rich countries already have bought most of the vaccines that are in the pipeline. The US will get the first 20 million doses, followed by the EU and other rich countries. Middle-income countries have a much smaller share, while not a single vaccine dose has been reserved by low-income countries for their citizens.

They will have to wait for a very long time. To try to compensate for this somehow, several international initiatives to provide vaccines to developing countries have been launched, including the Covax Facility-alliance (which aims to equitably distribute 2bn vaccine doses by the end of 2021) and the Access to Covid-19 Tools (ACT) Accelerator, an even broader alliance to provide similar assistance. But they have not taken off. The resources are lacking. While Covax has not reached more than a third of its target, ACT-A lacks 30 bn USD to reach its goal. A lot of money, yes. Yet, compared to what has been used by the world's largest economies and global financial institutions to cater to the impact of Covid-19 in countries worldwide, it is not much.

In addition, there are other constraints that need to be overcome in poor countries around the world. They need vaccines that can be safely stored and distributed in tropical climates, preferably in normal cold-chain systems. One of the early candidates seems to be more robust in this way than the other two. It is also critical that investments in health systems are scaled up, so we don’t see funding for health programmes be shifted to vaccine initiatives. There is not much help in providing vaccines to countries if they lack qualified health personnel and delivery systems to get the population vaccinated.

Unless priorities shift dramatically, therefore, billions of poor people are not likely to have access to a Covid-19 vaccine before 2024. It is against this backdrop that South Africa and India, supported by China and many low-income countries have taken an important initiative in the World Trade Organization (WTO).

Intellectual property rights allow companies to patent their inventions and monopolize production and sales of their product, recovering cost and generating profit. These TRIPS rules are anchored in the WTO regulations. South Africa and India have proposed a waiver from the rules, allowing for copying of the technologies and cheaper production closer to home.

I was development minister at the time when the pharmaceutical industry produced the first ground-breaking drugs against HIV and AIDS more than 20 years ago. The prices were so crazy that almost no patients in Africa, the hardest hit continent, had access. 10 000 USD a year per person. It was about profit, not production costs. An estimated 11 million people died in Sub-Saharan Africa because they were without access to these antiretroviral drugs (ARVs). Through negotiations in WTO in 2001, an exception to the patenting rules was negotiated. Not only were the prices dramatically reduced, the subsequent significant increase in production capacity in India helped lower the prices further, providing access to these drugs for poor people. More could afford a drug that costs around 130 USD per year. Thanks to this exception, combined with scaled up assistance to deliver the ARVs from donors, millions of lives have been saved worldwide and not least in Sub-Saharan Africa.

The TRIPS rules now create barriers on access to affordable Covid-19 medicines and vaccines. South Africa and India therefore want these restrictions to be eased, as during the AIDS epidemic. Despite a global pandemic, killing more people than HIV and AIDS, their proposal is met with opposition. On Friday 20 November, wealthy nations, UK, US, Canada, Australia and the EU went against the waiver for Covid-19 drugs in WTO. That the Norwegian government also was among them is very disappointing.

But this defeat does not mean the fight is over. The global supply of Covid-19 vaccines is likely to be far short of what is required until at least 2024. A study by Duke University in the US shows this is caused by limited manufacturing capacity and countries hoarding doses. There will be a need for more production capacity. India has that.

Responding to this challenge cannot be done by markets alone. Nor can it be done by aid mechanisms alone. This is also a structural issue. It is about trade rules. That is probably why the World Health Organization says it supports tackling the barriers to access to Covid-19 medicines. So does Nigeria’s Ngozi Okonjo-Iweala, slated to take over as WTO’s next Director General. She is now the chair of the vaccine alliance, GAVI and an envoy on the Act accelerator. I know Ngozi. She is a fighter. And she knows what had to be done when we were dealing with HIV and AIDS as ministers 20 years ago. It is the same now. Preparing for tough negotiations with the drug companies on the trade rules, Ngozi says:

I’m seeing it from the front lines, and we want to make sure that we don’t have a situation where access to vaccines for other countries where they are not made is blocked… The world is so interconnected now that no one is safe until everyone is safe, and no country is safe until all countries are safe.

Indeed, if we are to follow the principle of the poorest and most vulnerable being given priority, we need to protect lives over profit also globally. Only then can the poorest avoid ending up at the very end of the longest queue in the world.