Is Covid Sparing Africans? The Mystery Matters.Stephanie Nolen 🇸🇱 Reporting from Sierra LeoneThen I learned that Sierra Leone — and other countries in the region — have had plenty of Covid exposure. A study of blood samples found 78 percent of people have Covid antibodies (although few are vaccinated). The World Health Organization says it’s at least 65 percent across Africa.But in many places (like here) there’s no testing, so no cases are counted. Maybe people are dying, but not counted?

The coronavirus was expected to devastate the continent, but higher-income and better-prepared countries appear to have fared far worse.KAMAKWIE, Sierra Leone — There are no Covid fears here.The district’s Covid-19 response center has registered just 11 cases since the start of the pandemic, and no deaths. At the regional hospital, the wards are packed — with malaria patients. The door to the Covid isolation ward is bolted shut and overgrown with weeds. People cram together for weddings, soccer matches, concerts, with no masks in sight.Sierra Leone, a nation of eight million on the coast of Western Africa, feels like a land inexplicably spared as a plague passed overhead. What has happened — or hasn’t happened — here and in much of sub-Saharan Africa is a great mystery of the pandemic.The low rate of coronavirus infections, hospitalizations and deaths in West and Central Africa is the focus of a debate that has divided scientists on the continent and beyond. Have the sick or dead simply not been counted? If Covid has in fact done less damage here, why is that? If it has been just as vicious, how have we missed it?The answers “are relevant not just to us, but have implications for the greater public good,” said Austin Demby, Sierra Leone’s health minister, in an interview in Freetown, the capital.The assertion that Covid isn’t as big a threat in Africa has sparked debate about whether the African Union’s push to vaccinate 70 percent of Africans against the virus this year is the best use of health care resources, given that the devastation from other pathogens, such as malaria, appears to be much higher.In the first months of the pandemic, there was fear that Covid might eviscerate Africa, tearing through countries with health systems as weak as Sierra Leone’s, where there are just three doctors for every 100,000 people, according to the World Health Organization. The high prevalence of malaria, H.I.V., tuberculosis and malnutrition was seen as kindling for disaster.That has not happened. The first iteration of the virus that raced around the world had comparatively minimal impact here. The Beta variant ravaged South Africa, as did Delta and Omicron, yet much of the rest of the continent did not record similar death tolls.Into Year Three of the pandemic, new research shows there is no longer any question of whether Covid has spread widely in Africa. It has.Studies that tested blood samples for antibodies to SARS-CoV-2, the official name for the virus that causes Covid, show that about two-thirds of the population in most sub-Saharan countries do indeed have those antibodies. Since only 14 percent of the population has received any kind of Covid vaccination, the antibodies are overwhelmingly from infection.A busy morning at the fish market at Man of War Bay in Freetown, Sierra Leone’s capital.Finbarr O’Reilly for The New York TimesFudia Kamara, 25, sat with her son Kabba Kargbo, 3, in the hospital in Kamakwie, Sierra Leone. Like nearly all the children in the pediatric ward, he had malaria.Finbarr O’Reilly for The New York TimesA new W.H.O.-led analysis, not yet peer-reviewed, synthesized surveys from across the continent and found that 65 percent of Africans had been infected by the third quarter of 2021, higher than the rate in many parts of the world. Just 4 percent of Africans had been vaccinated when these data were gathered.So the virus is in Africa. Is it killing fewer people?Some speculation has focused on the relative youth of Africans. Their median age is 19 years, compared with 43 in Europe and 38 in the United States. Nearly two-thirds of the population in sub-Saharan Africa is under 25, and only 3 percent is 65 or older. That means far fewer people, comparatively, have lived long enough to develop the health issues (cardiovascular disease, diabetes, chronic respiratory disease and cancer) that can sharply increase the risk of severe disease and death from Covid. Young people infected by the coronavirus are often asymptomatic, which could account for the low number of reported cases.Plenty of other hypotheses have been floated. High temperatures and the fact that much of life is spent outdoors could be preventing spread. Or the low population density in many areas, or limited public transportation infrastructure. Perhaps exposure to other pathogens, including coronaviruses and deadly infections such as Lassa fever and Ebola, has somehow offered protection.Since Covid tore through South and Southeast Asia last year, it has become harder to accept these theories. After all, the population of India is young, too (with a median age of 28), and temperatures in the country are also relatively high. But researchers have found that the Delta variant caused millions of deaths in India, far more than the 400,000 officially reported. And rates of infection with malaria and other coronaviruses are high in places, including India, that have also seen high Covid fatality rates. So are Covid deaths in Africa simply not counted?Most global Covid trackers register no cases in Sierra Leone because testing for the virus here is effectively nonexistent. With no testing, there are no cases to report. A research project at Njala University in Sierra Leone has found that 78 percent of people have antibodies for this coronavirus. Yet Sierra Leone has reported only 125 Covid deaths since the start of the pandemic.Most people die in their homes, not in hospitals, either because they can’t reach a medical facility or because their families take them home to die. Many deaths are never registered with civil authorities.This pattern is common across sub-Saharan Africa. A recent survey by the United Nations Economic Commission for Africa found that official registration systems captured only one in three deaths.Nurses at a hospital in Neave, South Africa, moved a patient who died of Covid to a temporary morgue in November 2020. South Africa is the only country in sub-Saharan Africa to record high Covid infection and death rates.Samantha Reinders for The New York TimesPreparing a Covid vaccine in the town of Kathantha Yimbo in Sierra Leone. The lack of reported Covid cases in the country is raising questions about whether resources should be directed at more urgent problems.Finbarr O’Reilly for The New York TimesThe one sub-Saharan country where almost every death is counted is South Africa. And it’s clear from the data that Covid has killed a great many people in that country, far more than the reported virus deaths. Excess mortality data show that between May 2020 and September 2021, some 250,000 more people died from natural causes than was predicted for that time period, based on the pattern in previous years. Surges in death rates match those in Covid cases, suggesting the virus was the culprit.Dr. Lawrence Mwananyanda, a Boston University epidemiologist and special adviser to the president of Zambia, said he had no doubt that the impact in Zambia had been just as severe as in South Africa, but that Zambian deaths simply had not been captured by a much weaker registration system. Zambia, a country of more than 18 million people, has reported 4,000 Covid-19 deaths.“If that is happening in South Africa, why should it be different here?” he said. In fact, he added, South Africa has a much stronger health system, which ought to mean a lower death rate, rather than a higher one.A research team he led found that during Zambia’s Delta wave, 87 percent of bodies in hospital morgues were infected with Covid. “The morgue was full. Nothing else is different — what is different is that we just have very poor data.”The Economist, which has been tracking excess deaths throughout the pandemic, shows similar rates of death across Africa. Sondre Solstad, who runs the Africa model, said that there had been between one million and 2.9 million excess deaths on the continent during the pandemic.“It would be beautiful if Africans were spared, but they aren’t,” he said.But many scientists tracking the pandemic on the ground disagree. It’s not possible that hundreds of thousands or even millions of Covid deaths could have gone unnoticed, they say.“We have not seen massive burials in Africa. If that had happened, we’d have seen it,” said Dr. Thierno Baldé, who runs the W.H.O.’s Covid emergency response in Africa.“A death in Africa never goes unrecorded, as much as we are poor at record-keeping,” said Dr. Abdhalah Ziraba, an epidemiologist at the African Population and Health Research Center in Nairobi, Kenya. “There is a funeral, an announcement: A burial is never done within a week because it is a big event. For someone sitting in New York hypothesizing that they were unrecorded — well, we may not have the accurate numbers, but the perception is palpable. In the media, in your social circle, you know if there are deaths.”Dr. Demby, the Sierra Leone health minister, who is an epidemiologist by training, agreed. “We haven’t had overflowing hospitals. We haven’t,” he said. “There is no evidence that excess deaths are occurring.”Which could be keeping the death rate lower?Abu Kamara tended to his mother, Ramatu Sesay, in the hospital at Kamakwie, Sierra Leone. The hospital wards contain cancer and malaria patients, but none with Covid.Finbarr O’Reilly for The New York TimesA path leading to the community graveyard in Mabin. Many Sierra Leoneans who die are laid to rest in small village burial grounds and not included in official records.Finbarr O’Reilly for The New York TimesWhile health surveillance is weak, he acknowledged, Sierra Leoneans have the recent, terrible experience of Ebola, which killed 4,000 people here in 2014-16. Since then, he said, citizens have been on alert for an infectious agent that could be killing people in their communities. They would not continue to pack into events if that were the case, he said.Dr. Salim Abdool Karim, who is on the African Centers for Disease Control and Prevention Covid task force and who was part of the research team tracking excess deaths in South Africa, believes the death toll continentwide is probably consistent with that of his country. There is simply no reason that Gambians or Ethiopians would be less vulnerable to Covid than South Africans, he said.But he also said it was clear that large numbers of people were not turning up in the hospital with respiratory distress. The young population is clearly a key factor, he said, while some older people who die of strokes and other Covid-induced causes are not being identified as coronavirus deaths. Many are not making it to the hospital at all, and their deaths are not registered. But others are not falling ill at rates seen elsewhere, and that’s a mystery that needs unraveling.“It’s hugely relevant to things as basic as vaccine development and treatment,” said Dr. Prabhat Jha, who heads the Centre for Global Health Research in Toronto and is leading work to analyze causes of death in Sierra Leone.Researchers working with Dr. Jha are using novel methods — such as looking for any increase in revenue from obituaries at radio stations in Sierra Leonean towns over the past two years — to try to see if deaths could have risen unnoticed, but he said it was clear there had been no tide of desperately sick people.Some organizations working on the Covid vaccination effort say the lower rates of illness and death should be driving a rethinking of policy. John Johnson, vaccination adviser for Doctors Without Borders, said that vaccinating 70 percent of Africans made sense a year ago when it seemed like vaccines might provide long-term immunity and make it possible to end Covid-19 transmission. But now that it’s clear that protection wanes, collective immunity no longer looks achievable. And so an immunization strategy that focuses on protecting just the most vulnerable would arguably be a better use of resources in a place such as Sierra Leone.“Is this the most important thing to try to carry out in countries where there are much bigger problems with malaria, with polio, with measles, with cholera, with meningitis, with malnutrition? Is this what we want to spend our resources on in those countries?” he asked. “Because at this point, it’s not for those people: It’s to try to prevent new variants.”And new variants of Covid pose the greatest risk in places with older populations and high levels of comorbidities such as obesity, he said.Other experts cautioned that the virus remained an unpredictable foe and that scaling back efforts to vaccinate sub-Saharan Africans could yet lead to tragedy.“We can’t get complacent and assume Africa can’t go the way of India,” Dr. Jha said.A new variant as infectious as Omicron but more lethal than Delta could yet emerge, he warned, leaving Africans vulnerable unless vaccination rates increased significantly.“We should really avoid the hubris that all Africa is safe,” he said.

Huge pay incentives and immigration fast-tracks are leading many to leave countries whose health systems urgently need their expertise.LUSAKA, Zambia — There are few nurses in the Zambian capital with the skills and experience of Alex Mulumba, who works in the operating room at a critical care hospital. But he has recently learned, through a barrage of social media posts and LinkedIn solicitations, that many faraway places are eager for his expertise, too — and will pay him far more than the $415 per month (including an $8 health risk bonus) he earns now.Mr. Mulumba, 31, is considering those options, particularly Canada, where friends of his have immigrated and quickly found work. “You have to build something with your life,” he said.Canada is among numerous wealthy nations, including the United States and United Kingdom, that are aggressively recruiting medical workers from the developing world to replenish a health care work force drastically depleted by the Covid-19 pandemic. The urgency and strong pull from high-income nations — including countries like Germany and Finland, which had not previously recruited health workers from abroad — has upended migration patterns and raised new questions about the ethics of recruitment from countries with weak health systems during a pandemic.“We have absolutely seen an increase in international migration,” said Howard Catton, the chief executive of the International Council of Nurses. But, he added, “The high, high risk is that you are recruiting nurses from countries that can least afford to lose their nurses.”About 1,000 nurses are arriving in the United States each month from African nations, the Philippines and the Caribbean, said Sinead Carbery, president of O’Grady Peyton International, an international recruiting firm. While the United States has long drawn nurses from abroad, she said demand from American health care facilities is the highest she’s seen in three decades. There are an estimated 10,000 foreign nurses with U.S. job offers on waiting lists for interviews at American embassies around the world for the required visas.Since the middle of 2020, the number of international nurses registering to practice in the United Kingdom has swelled, “pointing toward this year being the highest in the last 30 years in terms of numbers,” said James Buchan, a senior fellow with the Health Foundation, a British charity, who advises the World Health Organization and national governments on health worker mobility.“There are 15 nurses in my unit and half have an application in process to work abroad,” said Mike Noveda, a senior neonatal nurse in the Philippines who has been temporarily reassigned to run Covid wards in a major hospital in Manila. “In six months, they will have left.”As the pandemic enters its third year and infections from the Omicron variant surge around the world, the shortage of health workers is a growing concern just about everywhere. As many as 180,000 have died of Covid, according to the W.H.O. Others have burned out or quit in frustration over factors such as a lack of personal protective equipment. About 20 percent in the United States have left their jobs during the pandemic. The W.H.O. has recorded strikes and other labor action by health workers in more than 80 countries in the past year — the amount that would normally be seen in a decade. In both developing countries and wealthy ones, the depletion of the health work force has come at a cost to patient care.European and North American countries have created dedicated immigration fast-tracks for health care workers, and have expedited processes to recognize foreign qualifications.A jumble of wheelchairs and hospital beds in an empty room in a clinic outside Lusaka. João Silva/The New York TimesThe British government introduced a “health and care visa” program in 2020, which targets and fast tracks foreign health care workers to fill staffing vacancies. The program includes benefits such as reduced visa costs and quicker processing.Canada has eased language requirements for residency and has expedited the process of recognizing the qualifications of foreign-trained nurses. Japan is offering a pathway to residency for temporary aged-care workers. Germany is allowing foreign-trained doctors to move directly into assistant physician positions.In 2010, the member states of the W.H.O. adopted a Global Code of Practice on the International Recruitment of Health Personnel, driven in part by an exodus of nurses and doctors from nations in sub-Saharan Africa ravaged by AIDS. African governments expressed frustration that their universities were producing doctors and nurses educated with public funds who were being lured away to the United States and Britain as soon as they were fully trained, for salaries their home countries could never hope to match.The code recognizes the right of individuals to migrate but calls for wealthy nations to recruit through bilateral agreements, with the involvement of the health ministry in the country of origin.In exchange for an organized recruitment of health workers, the destination country should supply support for health care initiatives designated by the source country. Destination countries are also supposed to offer “learn and return” in which health workers with new skills return home after a period of time.Lillian Mwape, left, the chief nursing officer for the National Heart Hospital in Lusaka. “We are always overstretched for critical care,” she said. “You cannot just put any nurse into the operating theatre.”João Silva/The New York TimesBut Mr. Catton, of the international nurses organization, said that was not the current pattern. “For nurses who are recruited, there is no intention for them to go back, often quite the opposite: They want to establish themselves in another country and bring their families to join them,” he said.Zambia has an excess of nurses, on paper — thousands of graduates of nursing schools are unemployed, although a new government has pledged to hire 11,200 health workers this year. But it is veteran nurses such as Lillian Mwape, the director of nursing at the hospital where Mr. Mulumba works, who are most sought by recruiters.“People are leaving constantly,” said Ms. Mwape, whose inbox is flooded with emails from recruiters letting her know how quickly she can get a visa to the United States.The net effect, she said, “is that we are handicapped.”“It is the most-skilled nurses that we lose and you can’t replace them,” Ms. Mwape said. “Now in the I.C.U. we might have four or five trained critical-care nurses, where we should have 20. The rest are general nurses, and they can’t handle the burden of Covid.”Dr. Brian Sampa, a general practitioner in Lusaka, recently began the language testing that is the first step to emigrate to the United Kingdom. He is the head of a doctor’s union and vividly aware of how valuable physicians are in Zambia. There are fewer than 2,000 doctors working in the public sector — on which the vast majority of people are reliant — and 5,000 doctors in the entire country, he said. That works out to one doctor per 12,000 people; the W.H.O. recommends a minimum of one per 1,000.Twenty Zambian doctors have died of Covid. In Dr. Sampa’s last job, he was the sole doctor in a district with 80,000 people, and he often spent close to 24 hours at a time in the operating theater doing emergency surgeries, he said.The pandemic has left him dispirited about Zambia’s health system. He described days treating critically ill Covid patients when he searched a whole hospital to find only a single C-clamp needed to run oxygenation equipment. He earns slightly less than $1000 a month.Dr. Brian Sampa with his daughter, Yasa, outside his home in Lusaka. He is taking steps to emigrate to the U.K. In his last job, he was the only doctor in the district and often spent nearly 24 hours at a time in the operating room doing emergency surgeries.João Silva/The New York Times“Obviously, there are more pros to leaving than staying,” Dr. Sampa said. “So for those of us who are staying, it is just because there are things holding us, but not because we are comfortable where we are.”The migration of health care workers — often from low-income nations to high-income ones — was growing well before the pandemic; it had increased 60 percent in the decade to 2016, said Dr. Giorgio Cometto, an expert on health work force issues who works with the W.H.O.The Philippines and India have deliberately overproduced nurses for years with the intention of sending them abroad to earn and send remittances; nurses from these two countries make up almost the entire work force of some Persian Gulf States. But now the Philippines is reporting shortages domestically. Mr. Noveda, the nurse in Manila, said his colleagues, exhausted by pandemic demands that have required frequent 24-hour shifts, were applying to leave in record numbers.Yet movement across borders has been more complicated during the pandemic, and immigration processes have slowed significantly, leaving many workers, and prospective employers, in limbo.While some countries are sincere about bilateral agreements, that isn’t the only level at which recruitment happens. “What we hear time and time again is that recruitment agencies pitch up in-country and talk directly to the nurses offering very attractive packages,” Mr. Catton said.The United Kingdom has a “red list” of countries with fragile health systems from which it won’t recruit for its National Health Service. But some health workers get around that by entering Britain first with a placement through an agency that staffs private nursing homes, for example. Then, once they are established in Britain, they move over to the N.H.S., which pays better.An ultrasound technician used her cellphone to illuminate a broken machine gathering dust in a clinic in Ngwerere, Zambia.João Silva/The New York TimesMichael Clemens, an expert on international migration from developing countries at the Center for Global Development in Washington, said the growing alarm about outflows of health workers from developing countries risks ignoring the rights of individuals.“Offering someone a life-changing career opportunity for themselves, something that can make a huge difference to their kids, is not an ethical crime,” he said. “It is an action with complex consequences.”The United Kingdom went into the pandemic with one in 10 nurse jobs vacant. Mr. Catton said it some countries are making overseas recruitment a core part of their staffing strategies, and not just using it as a pandemic stopgap. If that’s the plan, he said, then recruiting countries must more assiduously monitor the impact on the source country and calculate the cost being borne by the country that trains those nurses.Alex Mulumba, the Zambian operating room nurse, says that if he goes to Canada, he won’t stay permanently, just five or six years to save up some money. He won’t bring his family with him, because he wants to keep his ties to home.“This is my country, and I have to try to do something about it,” he said.Miriam Jordan

A former Africa correspondent, who covered the height of the AIDS epidemic there 15 years ago, finds lessons in the remarkable progress against that virus for our current fight.CHONGWE, Zambia — On a visit to a public hospital in a farming community in late November, I saw something that astonished me.Empty beds. Rows of them, their black plastic-covered mattresses stripped of sheets. Blue privacy curtains folded up over rails, out of the way.I had never seen a Zambian hospital like this. When I last toured one, nearly 15 years ago, patients lay two or three to a bed, head-to-feet-to-head. And more on the floor. More on thatch mats in the hallways. The patients were gaunt, their eyes huge above sunken cheeks. Hopelessness and suffering hung in the air.Now, the wards were silent, and not just because a Covid-19 wave had recently ended. There was only the bounce of my voice off the walls as I asked Morton Zuze, the doctor giving me a tour, where everyone was. When I told him that I had last spent time here in the mid-2000s, he knew what I was asking.“Well,” he said matter-of-factly, “there are 200,000 people in this district and 20,000 of them are on ART.” That was a staggering figure: 20,000 people on antiretroviral treatment for H.I.V.The only sign of H.I.V. that I saw in Zambia was glossy billboards dotted around the capital, Lusaka, showing stylish, smiling people, with the slogan “I’m ending AIDS with …” and some helpful strategy: testing regularly or taking treatment or using drugs to prevent infection.I was a correspondent based in Johannesburg at the height of the African H.I.V. epidemic, the last pandemic to batter this region. In the early 2000s, there were 28 million people living with the virus in sub-Saharan Africa, and about a third of young adults in Zambia were infected. More than two million Africans were dying of AIDS each year.H.I.V. had long since become a treatable illness in wealthy nations, but here the price of antiretrovirals was still more than $10,000 per person per year. Entirely, impossibly, unaffordable.The H.I.V. ward of the Hlabisa Hospital in Nongoma, South Africa, in 2001.João Silva for The New York TimesZackie Achmat, an AIDS activist, and Nelson Mandela in 2002.Mike Hutchings/ReutersBack then, I reported from villages in Eswatini, then known as Swaziland, where I couldn’t find more than a handful of people my age — just children and elderly people. I wrote from Johannesburg about the day that Nelson Mandela broke a powerful taboo and told South Africans his son had died of AIDS. I told the story of a grandmother named Regine Mamba in Zambia raising 12 orphaned grandchildren. And I interviewed the brave, and often desperately ill, activists, such as Zackie Achmat, a co-founder of South Africa’s Treatment Action Campaign, who were fighting with their lives to get access to treatment.Almost two decades later, the fruits of what they fought for were vividly on display, and a reminder — useful at this moment as another Covid wave makes this pandemic seem unending — of how much is possible.Science, in the form of drugs that quelled if not vanquished a deadly virus; a network of fierce, courageous activists; coordinated international efforts, including a massive investment by the U.S. government — they all combined to deliver the miracle of that empty, echoing Zambian hospital ward.We know how to do this.In a clinic outside Cape Town, Linda-Gail Bekker, a renowned H.I.V. researcher, mentioned to me almost in passing that “our longevity is back.” When I asked what she meant, she showed me the data: The life expectancy of South Africans, which H.I.V. drove down from 63 in 1990 to a low point of 53 in 2004, has risen steadily since treatment began to be delivered by the public health system, and will pass 66 this year.This was just one of a dozen interactions I had that I could not have imagined 25 years ago, when I began covering H.I.V. in Africa.In a public clinic in Soweto on my recent trip, I spent time with a community health care worker named Nelly Zulu, who told me that when people test positive for H.I.V. at the clinic where she works, they are given their first pills to suppress the virus that day: no more of the grim wait I used to watch, as people tracked the decline of their immune systems until they qualified for the scarce drugs.Nelly also told me the number of positive cases was falling. She and her co-workers said they attributed this in part to pre-exposure prophylaxis, better known as PrEP. It’s an antiretroviral taken every day that helps keep people from being infected if they are exposed to H.I.V. Gay men in the U.S. have been using it for years, but it’s only recently come to Africa. Nelly and her colleagues said that young women come to her clinic asking for it: “the ones who have older boyfriends who they can’t trust.”Nelly Zulu, a community health care worker, in November in Soweto, South Africa.João Silva/The New York TimesAntiretroviral drugs and hand sanitizer being distributed in 2020 at a clinic in Ngodwana, South Africa.Bram Janssen/Associated PressResearch shows that PrEP use isn’t high in Africa yet, but it was fascinating to me to hear Nelly talk about it casually. For so many years, the only thing that counselors like her had in their AIDS prevention arsenal was condoms, or trying to convince people not to have sex at all. In Durban, I happened to visit a clinic as nurses were screening young women volunteering for the first clinical trial of a South African broadly-neutralizing antibody to fight H.I.V., which researchers hope could be the key to new drugs to prevent infection, new treatments that would be easier to take, and perhaps even a cure.That same day, I visited the Africa Health Research Institute, where an infectious disease expert named Thumbi Ndung’u talked about that trial and other upcoming ones that represent real, strategic steps to a cure. I teared up when I began to understand the implications of the work he was describing.“You believe this is going to work, don’t you?” I asked Professor Ndung’u after he explained the hypothesis he would soon begin to test for inducing H.I.V. remission. His normal demeanor is somber to the point of sternness, but he broke into a wide grin. “If it works it will be very exciting,” he said.In Zambia, I stopped by the white bungalow in Lusaka that houses the H.I.V. treatment campaign. I wanted to interview Felix Mwanza and Carol Nyirenda, veteran activists I first met two decades ago, about lessons for the Covid response from the H.I.V. epidemic — including the idea that government must take vaccines to people where they are, the way they learned to take H.I.V. tests to bars and markets.But when I asked Carol and Felix how they were, they had more immediate concerns. They talked about the challenges of late middle age — a loss of bone density, the miseries of menopause — and how it troubled them that there was little research into long-term use of antiretroviral drugs in African settings. When they ask their doctors if something is “normal,” or perhaps a treatment side effect about which they should be concerned, they’re most often met with a shrug.Thumbi Ndung’u, an infectious disease expert leading research towards an AIDS cure at the Africa Health Research Institute in Durban, South Africa.João Silva/The New York TimesVeteran activists Carol Nyirenda, left, and Felix Mwanza, right, at the offices of the Treatment Advocacy and Literacy Campaign in Lusaka.João Silva/The New York TimesIt was a valid point: a source of frustration and real concern. And it also left me a little bit delighted, because when I met Felix, now 51, and Carol, now 58, no one imagined them having the luxury of aging.Back then, Carol, was getting A.R.V.s from friends abroad. But when they ran out of money and couldn’t send the drugs, she “sat back and waited to die,” ravaged by a tuberculosis infection that her immune-suppressed body could not fight.Last month, she was wearing a pink face mask made for her daughter’s bridal shower. Research hasn’t kept up with the needs of people who have lived for decades with H.I.V. in places such as Zambia, and it must. It’s also the best kind of problem to have.That night I had dinner with my friend Ida Mukuka and her family. I hadn’t seen Ida in 13 years. When we first met in 2003, she was a counselor at an H.I.V. clinic known for her ability to handle the tough cases — the men who threw their pregnant wives out of the house, or worse, when they were tested at the prenatal clinic and learned they were H.I.V.-positive.In 2006, Ida found out that her own husband had infected her. Treatment was still a rare commodity in Zambia then, and there was no guarantee she would survive until she had reliable access to it. I met her two daughters when they were small, wide-eyed girls, and Ida confided to me back then that all she wanted was to keep them in school so that they might one day go to university and never feel they had to stay married to a violent, untrustworthy man, the way she did.A mobile H.I.V. testing laboratory in 2003 in Sikwaazwa, Zambia.Ida Mukuka, an H.I.V. counselor, right, and her daughter, Teba, a lawyer, on the day Teba was called to the bar.via Ida MukukaOn this trip, those daughters joined us for dinner, coming straight from work. Mwamba is a brisk, funny woman of 25. She has a degree in development and is saving to go abroad for graduate school. Then Teba, 27, a lawyer, arrived, fresh from arguing her first case in front of the High Court.I was mesmerized by the young women and the way their lives have turned out so differently than the future their mother feared for them in 2006.So much of what I saw on this trip was unfathomable 25 years ago, or even 15. It was a shamefully long fight. The solutions came decades later than they should have. Each time I saw activists-turned-friends such as Carol and Ida, we talked about the colleagues and friends who didn’t survive, who were ghostly presences as we sipped tea.AIDS is far from over. Covid has caused a critical disruption in testing, interrupted drug delivery and undermined livelihoods in ways that make people more vulnerable to that other virus, too. An estimated 700,000 Africans were newly infected this year.But H.I.V. has been significantly beaten back. It’s a credit to former President George W. Bush’s PEPFAR program and the money it poured into treatment. To brilliant scientists such as those in Durban and Cape Town. And to activists like Ida, Felix and Carol.I’m taking heart in what I saw in Chongwe: proof of human resilience and ingenuity, a reminder that the timeline in a battle with a virus is not short — not nearly as short as we would like it to be. But it is possible to come out the other side, into a future we can barely envision right now.

They do seem to offer significant protection against severe illness, but the consequences of rapidly spreading infection worry many public health experts.A growing body of preliminary research suggests the Covid vaccines used in most of the world offer almost no defense against becoming infected by the highly contagious Omicron variant.All vaccines still seem to provide a significant degree of protection against serious illness from Omicron, which is the most crucial goal. But only the Pfizer and Moderna shots, when reinforced by a booster, appear to have success at stopping infections, and these vaccines are unavailable in most of the world.The other shots — including those from AstraZeneca, Johnson & Johnson and vaccines manufactured in China and Russia — do little to nothing to stop the spread of Omicron, early research shows. And because most countries have built their inoculation programs around these vaccines, the gap could have a profound impact on the course of the pandemic.A global surge of infections in a world where billions of people remain unvaccinated not only threatens the health of vulnerable individuals but also increases the opportunity for the emergence of yet more variants. The disparity in the ability of countries to weather the pandemic will almost certainly deepen. And the news about limited vaccine efficacy against Omicron infection could depress demand for vaccination throughout the developing world, where many people are already hesitant or preoccupied with other health problems.Most evidence so far is based on laboratory experiments, which do not capture the full range of the body’s immune response, and not from tracking the effect on real-world populations. The results are striking, however.The Pfizer and Moderna shots use the new mRNA technology, which has consistently offered the best protection against infection with every variant. All of the other vaccines are based on older methods of triggering an immune response.The Chinese vaccines Sinopharm and Sinovac — which make up almost half of all shots delivered globally — offer almost zero protection from Omicron infection. The great majority of people in China have received these shots, which are also widely used in low-and middle-income countries such as Mexico and Brazil.A preliminary effectiveness study in Britain found that the Oxford-AstraZeneca vaccine showed no ability to stop Omicron infection six months after vaccination. Ninety percent of vaccinated people in India received this shot, under the brand name Covishield; it has also been widely used across much of sub-Saharan Africa, where Covax, the global Covid vaccine program, has distributed 67 million doses of it to 44 countries.Workers unloaded a shipment of China’s Sinopharm vaccine in Bujumbura, Burundi. China’s Sinopharm and Sinovac vaccines together make up almost half of all the shots delivered globally.Tchandrou Nitanga/Agence France-Presse — Getty ImagesAdministering the AstraZeneca shot in Milan.Alessandro Grassani for The New York TimesResearchers predict that Russia’s Sputnik vaccine, which is also being used in Africa and Latin America, will show similarly dismal rates of protection against Omicron.Demand for the Johnson & Johnson vaccine had been surging in Africa, because its single-shot delivery regimen makes it easy to deliver in low-resource settings. But it too has shown a negligible ability to block Omicron infection.Antibodies are the first line of defense induced by vaccines. But the shots also stimulate the growth of T cells, and preliminary studies suggest that these T cells still recognize the Omicron variant, which is important in preventing severe disease.“What you lose first is protection against asymptomatic mild infection, what you retain much better is protection against severe disease and death,” said John Moore, a virologist at Weill Cornell Medicine in New York. He called it “a silver lining” that Omicron so far appears less lethal than the Delta variant.But this protection will not be enough to prevent Omicron from causing global disruption, said J. Stephen Morrison, director of the Global Health Policy Center at the Center for International and Strategic Studies.“The sheer scale of infection will overwhelm health systems, simply because the denominator will be potentially so big,” he said. “If you have a burst of infection worldwide, a shock, what does the world look like on other side of it? Is it, ‘The war is over,’ or, ‘The war has just entered another phase’? We haven’t begun thinking about any of that.”People with breakthrough cases may experience only asymptomatic infection or mild illness, but they can pass the virus to unvaccinated people, who could fall more severely ill, and become a source of new variants.A Sinovac vaccination in Cachoeira do Piria, Brazil, in January. Experts fear news of limited vaccine efficacy against Omicron will depress demand for vaccination in places where people are already hesitant.Tarso Sarraf/Agence France-Presse — Getty ImagesMonks signed up for AstraZeneca’s shot in Bangkok in April.Adam Dean for The New York TimesDr. Seth Berkley, the chief executive of Gavi, the global vaccine alliance, said that more data was needed before drawing conclusions about vaccines’ effectiveness against Omicron — and that accelerated vaccination should continue to be the focus of pandemic response.Preliminary data from South Africa suggest that with Omicron, there is a much higher chance of people who already had Covid getting reinfected than there was with the original virus and previous variants. But some public health experts say they believe that countries that have already been through brutal waves of Covid, such as Brazil and India, may have a buffer against Omicron, and vaccination after infection produces high antibody levels.“The combination of vaccination and exposure to the virus seems to be stronger than only having the vaccine,” said Ramanan Laxminarayan, an epidemiologist in New Delhi. India, he noted, has an adult vaccination rate of only about 40 percent but 90 percent exposure to the virus in some areas.“Without a doubt Omicron is going to flood through India,” he said. “But hopefully India is protected to some extent because of vaccination and exposure.”China does not have this layer of protection to back up its weak vaccines. Because of China’s aggressive efforts to stop spread of the virus within its borders, relatively few people have previous exposure. Only an estimated 7 percent of people in Wuhan, where the pandemic began, were infected.Much of Latin America has relied on the Chinese and Russian vaccines, and on AstraZeneca. Mario Rosemblatt, a professor of immunology at the University of Chile, said that more than 90 percent of Chileans had had two doses of one vaccine, but the great majority of these were Coronavac, the Sinovac shot. High vaccination coverage combined with early reports that Omicron does not cause serious illness is leading to a false sense of security in the country, he said.The Coronavirus Pandemic: Key Things to KnowCard 1 of 4A new U.S. surge.

Vaccinating Africa is critical to protecting the continent and the world against dangerous variants, but supply isn’t the only obstacle countries face.NGWERERE, Zambia — Four people turned up at a health clinic tucked in a sprawl of commercial maize farms on a recent morning, looking for Covid-19 vaccines. The staff had vials of the Johnson & Johnson vaccine stashed in the fridge. But the staff members apologetically declined to vaccinate the four and suggested they try another day.A vial of the Johnson & Johnson vaccine holds five doses, and the staff was under orders not to waste a single one.Ida Musonda, the nurse who supervises the vaccination effort, suspected that her team might have found more takers if they packed the vials in Styrofoam coolers and headed out to markets and churches. “But we have no fuel for the vehicle to take the vaccines there,” she said.They did vaccinate 100 people on their last trip to a farm; the records from that trip sat in a paper heap in the clinic because the data manager had no internet connection to access an electronic records system.For months, the biggest challenge to vaccinating Africans against Covid, and protecting both the continent and the world from the emergence of dangerous variants, has been supply: A continent of about 1.4 billion people has received just 404 million doses of vaccine, and only 7.8 percent of the population is fully vaccinated.But as supply has begun to sputter into something like a more reliable flow, other daunting obstacles are coming into focus. All of them are on view at and around Ngwerere.Weak health care systems with limited infrastructure and technology, and no experience vaccinating adults, are trying to get shots into the arms of people who have far more pressing priorities. At the same time, the global flow of information, and deliberate misinformation, on social media is generating the same skepticism that has stymied vaccination efforts in the United States and other countries.Some Zambians are hesitant, but others have an attitude that could better be described as vaccine indifference. This is a poor country where the economy has contracted sharply during the pandemic, and many unvaccinated people are more focused on putting food on the table.Simon Phiri, left, walked three kilometers on his day off to receive a Covid vaccine at a clinic in Chongwe, outside of Lusaka, Zambia.João Silva/The New York TimesBernadette Kawango was skeptical of the fearmongering around Covid vaccines, but said she had more urgent health worries than the coronavirus.João Silva/The New York Times“I’d like to get it but I work Monday to Saturday, and I don’t know if they vaccinate on Sunday,” said Bernadette Kawango, who supports a large extended family with her wages from an auto-parts store in a low-income neighborhood on the edge of Lusaka, the capital. She has heard many rumors: that people who receive the vaccine will die in two years; that the vaccine is part of a plot by Europeans to kill Africans and take their land; that Bill Gates is on a campaign to reduce the world population.Such stories make her roll her eyes. But Covid is not at the top of her list of health care worries. “It’s cholera season, and people have malaria, and there is H.I.V. and TB,” she said. She does not know anyone who has been diagnosed with Covid.All these challenges create two major problems. First, the pace of vaccination is far too slow to prevent unnecessary deaths in a fourth wave, which is already beginning in southern Africa, or to prevent the emergence of new variants such as Omicron, which was first identified in South Africa late last month. The vaccines now in stock — many of them donations close to their expiration dates when they arrive — may not be used before they must be destroyed.Second, the push to vaccinate against Covid is drawing resources from health systems that can hardly spare them, which could lead to disastrous consequences for the fight against other devastating health problems.At the Ngwerere health clinic, the usual bustle and screeching at the mother-and-child health area, where babies are monitored for signs of malnutrition and given childhood immunizations, was absent because everyone on that staff had been repurposed as Covid vaccinators.“Every time we have a wave here it really threatens the investments that have been made in H.I.V., maternal and child health, and TB and malaria, and it’s important that we protect those,” said Dr. Simon Agolory, who runs the large Zambia program of the U.S. Centers for Disease Control and Prevention.Women wait to see a nurse at a rural clinic in Chongwe DistrictJoão Silva/The New York TimesCharity Machika’s vaccination data was registered on a paper card because the technician at the clinic had no internet connection to make an electronic record.João Silva/The New York TimesDr. Andrew Silumesii, the director of public health for Zambia’s health ministry, said there was already clear evidence that infant growth monitoring and childhood immunization had declined over the course of the pandemic. He worries that malaria, TB and H.I.V. infections will also increase.So far, 7 percent of Zambians, some five million people, have been vaccinated against Covid. President Hakainde Hichilema has set a target of vaccinating another two million by Christmas, and 70 percent of the population by the third quarter of 2022, a goal that looks exceedingly ambitious.Zambia’s vaccines come mostly from Covax, the global vaccine-sharing initiative, with additional donations from China and the African Union. The fact that Zambia is dependent largely on donations means that it must adapt its program to whatever shipments arrive — a bit like making a meal with whatever arrives in a farm subscription box. The country is managing distribution of five different vaccines, each with different dosing regimens, storage requirements and vial volumes.That has created a huge additional administrative burden for skeleton staffs such as Ms. Musonda’s team. Her staff has no budget for cellphone calls to remind people about second shots, and the effect can be seen in the charts stapled on the vaccination room wall: Of the 840 people who received a first dose of AstraZeneca in April, only 179 came back for a follow-up shot in July.When Zambia experienced a severe third Covid wave earlier this year, the media coverage of people dying in the parking lots of hospitals that ran out of oxygen rattled a population that had been thinking of the virus as something that affected only white or rich people. There were pre-dawn lineups outside vaccination sites that couldn’t keep shots in stock.But when the wave abated, so did the demand.The Ngwerere health clinic has only basic infrastructure.João Silva/The New York TimesMany people here recall the time when Zambians were dying of AIDS in huge numbers and Western pharmaceutical companies refused to produce affordable lifesaving medications. There is skepticism now that those same companies have come offering free solutions.The Coronavirus Pandemic: Key Things to KnowCard 1 of 5The Omicron variant.

Scientists in a cutting-edge laboratory do part of the work. Local health workers on foot do the rest.NTUZUMA, South Africa — A few months ago, Sizakele Mathe, a community health worker in this sprawling hillside township on the edge of the city of Durban, was notified by a clinic that a neighbor had stopped picking up her medication. It was a warning sign that she had likely stopped taking the antiretroviral tablet that suppresses her H.I.V. infection.That was a threat to her own health — and, in the era of Covid-19, it might have posed a risk to everyone else’s. The clinic dispatched Ms. Mathe to climb a hill, wend her way down a narrow path and try to get the woman back on the pills.Ms. Mathe, as cheerful as she is relentless, is part of a national door-to-door nagging campaign. It’s half of a sophisticated South African effort to stanch the emergence of new variants of the coronavirus, like the Omicron strain that was identified here and shook the world this past week.The other half takes place at a state-of-the-art laboratory 25 miles down the road. At the KwaZulu-Natal Research Innovation and Sequencing Platform in Durban, scientists sequence the genomes of thousands of coronavirus samples each week. The KRISP lab, as it is known, is part of a national network of virus researchers that identified both the Beta and Omicron variants, drawing on expertise developed here during the region’s decades-long fight with H.I.V.This combination of high tech and grassroots represents one of the front lines in the world’s battle against the evolving coronavirus. On Friday, the research network in South Africa reported to a world waiting anxiously for new information that the new variant appeared to spread twice as quickly as Delta, which had been considered the most contagious version of the virus.The researchers at KRISP are global leaders in viral phylogenetics, the study of the evolutionary relationship between viruses. They track mutations in the coronavirus, identify hot spots of transmission and provide crucial data on who is infecting whom — which they deduce by tracking mutations in the virus across samples — to help tamp down the spread.Since the start of the pandemic, they have been closely scrutinizing how the virus changes in South Africa because they are worried about one thing in particular: the eight million people in the country (13 percent of the population) who live with H.I.V.Tulio de Oliveira outside the KwaZulu-Natal Research Innovation and Sequencing Platform lab in Durban, South AfricaJoão Silva/The New York TimesWhen people with H.I.V. are prescribed an effective antiretroviral and take it consistently, their bodies almost completely suppress the virus. But if people with H.I.V. aren’t diagnosed, haven’t been prescribed treatment, or don’t, or can’t, take their medicines consistently each day, H.I.V. weakens their immune systems. And then, if they catch the coronavirus, it can take weeks or months before the new virus is cleared from their bodies.When the coronavirus lives that long in their systems, it has the chance to mutate and mutate and mutate again. And, if they pass the mutated virus on, a new variant is in circulation.“We have reasons to believe that some of the variants that are emerging in South Africa could potentially be associated directly with H.I.V.,” said Tulio de Oliveira, the principal investigator of the national genetic monitoring network.In the first days of the pandemic, South Africa’s health authorities were braced for soaring death rates of people with H.I.V. “We were basically creating horror scenarios that Africa was going to be decimated,” said Salim Abdool Karim, an epidemiologist who heads the AIDS institute where KRISP is housed. “But none of that played out.” The main reason is that H.I.V. is most common among young people, while the coronavirus has hit older people hardest.An H.I.V. infection makes a person about 1.7 times more likely to die of Covid — an elevated risk, but one that pales in comparison with the risk for people with diabetes, who are 30 times more likely to die. “Once we realized that this was the situation, we then began to understand that our real problems with H.I.V. in the midst of Covid was the prospect that severely immunocompromised people would lead to new variants,” Dr. Abdool Karim said.The Covid-19 extraction room in the laboratory of the Centre for the AIDS Programme of Research in South Africa, where KRISP is housed.João Silva/The New York TimesResearchers at KRISP have shown that this has happened at least twice. Last year, they traced a virus sample to a 36-year-old woman with H.I.V. who was on an ineffective treatment regimen and who was not being helped to find drugs that she could tolerate. She took 216 days to clear the coronavirus from her system; in that time inside her body, the viruses acquired 32 different mutations.In November, Dr. de Oliveira and his team traced a coronavirus sample with dozens of mutations to a different part of the country, the Western Cape, where another patient was also poorly adhering to the H.I.V. drug regimen. The coronavirus lingered in her body for months and produced dozens of mutations. When these women were prescribed effective drugs and counseled on how to take them properly, they cleared the virus quickly.“We don’t have a lot of people like her,” Dr. Abdool Karim said of the woman who took 216 days to clear the coronavirus from her system. “But it doesn’t take a lot of people, it just takes one or two.” And a single variant can rattle the world, as Omicron has.The origin of this variant is still unknown. People with H.I.V. are not the only ones whose systems can inadvertently give the coronavirus the chance to mutate: It can happen in anyone who is immunosuppressed, such as transplant patients and those undergoing cancer treatments.By the time the KRISP team identified the second case of a person with H.I.V. producing coronavirus variants, there were more than a dozen reports of the same phenomenon in medical literature from other parts of the world.Viruses mutate in people with healthy immune systems, too. The difference for people with H.I.V., or another immunosuppressing condition, is that because the virus stays in their systems so much longer, the natural selection process has more time to favor mutations that evade immunity. The typical replication period in a healthy person would be just a couple of weeks, instead of many months; fewer replications mean less opportunities for new mutations.“Our real problems with H.I.V. in the midst of Covid was the prospect that severely immunocompromised people would lead to new variants,” said Salim Abdool Karim.João Silva/The New York TimesAnd because South Africa has so many people with H.I.V., and because this new pandemic has struck hard here, disrupting life in many ways, there is a particular urgency to the work of trying to block the variants.That is where the efforts of community health workers such as Ms. Mathe come in. On a typical workday, she walks dirt paths past leaking standpipes and front-step hair salons, armed with an ancient cellphone and a mental roster of who has turned up at the clinic lately, who is looking unwell and who needs a visit. Ms. Mathe, who herself has been on H.I.V. treatment for 13 years, is paid $150 a month.Silendile Mdunge, a thin 36-year-old mother of three, stopped taking her antiretrovirals during the brutal third wave of Covid that hit South Africa between May and July. Her drugs were no longer being delivered to a nearby community pickup point because many health care workers were redeployed. Instead she was supposed to collect the pills at a central clinic about nine miles away. But she feared contracting this new virus in a shared taxi or standing in the huge clinic lines that she heard about.She was off the medication for four months before Ms. Mathe turned up at the small home built of scrap wood that Ms. Mdunge shares with seven family members.The Coronavirus Pandemic: Key Things to KnowCard 1 of 5The Omicron variant.

Who Can Make mRNA Vaccines?Stephanie NolenReporting on Covid vaccine accessThe technology is new, but Pfizer-BioNTech and Moderna found ways to start production quickly. BioNTech went to a former cancer drug maker in Germany to make its shot. Moderna shipped its producers a modular kit, kind of like an Ikea kitchen.What’s essential is a company that does high-quality medicine production, plus a regulating body that can enforce top standards.From my years of reporting on global health, I knew of candidates in developing countries.

The company announced a licensing deal that will allow the drug, molnupiravir, to be made and sold cheaply in 105 developing nations.Merck has granted a royalty-free license for its promising Covid-19 pill to a United Nations-backed nonprofit in a deal that would allow the drug to be manufactured and sold cheaply in the poorest nations, where vaccines for the coronavirus are in devastatingly short supply.The agreement with the Medicines Patent Pool, an organization that works to make medical treatment and technologies globally accessible, will allow companies in 105 countries, mostly in Africa and Asia, to sublicense the formulation for the antiviral pill, called molnupiravir, and begin making it.Merck reported this month that the drug halved the rate of hospitalizations and deaths in high-risk Covid patients in a large clinical trial. Affluent nations, including the United States, have rushed to negotiate deals to buy the drug, tying up large portions of the supply even before it has been approved by regulators and raising concerns that poor countries would be shut out of access to the medicine, much as they have been for vaccines.Treatment-access advocates welcomed the new deal, which was announced Wednesday morning, calling it an unusual step for a major Western pharmaceutical company.“The Merck license is a very good and meaningful protection for peopling living in countries where more than half of the world’s population lives,” said James Love, who leads Knowledge Ecology International, a nonprofit research organization. “It will make a difference.”Charles Gore, director of the Medicines Patent Pool, said: “This is the first transparent public health license for a Covid medicine, and really importantly, it is for something that could be used outside of hospitals, and which is potentially going to be very cheap.”“This is hopefully going to make things a lot easier in terms of keeping people out of hospital and stopping people dying in low- and middle-income countries,” he said.Mr. Gore said that more than 50 companies, from all regions of the developing world, have already approached the organization about obtaining a sublicense.The agreement with Merck, Mr. Gore said, is also critically important as a precedent. “I hope this will start a landslide of people coming to the Medicines Patent Pool, wanting to do licensing, because there’s no question that access has been the problem,” he said. “From a scientific point of view, industry have done a really brilliant job — firstly, providing the vaccines, and now providing treatments. But the access side of it has let the whole thing down.”Pfizer also has a Covid antiviral pill in late-stage trials, and Mr. Gore said the company is also in talks with the patent pool.Molnupiravir was developed by Merck and Ridgeback Biotherapeutics of Miami, based on a molecule first studied at Emory University in Atlanta. All three organizations are party to this deal, which will not require a fee from any sublicensing company.Merck has submitted its clinical trial data to the Food and Drug Administration seeking emergency-use authorization; a decision could come in early December. Regulatory agencies in other nations that produce a version of molnupiravir will need to evaluate it. Some drug manufacturers will likely seek World Health Organization prequalification for their versions, so that they can bypass the country-by-country regulatory steps.Stephen Saad, chief executive of Aspen Pharmacare in South Africa, said his company expects to apply for a license to make molnupiravir and distribute it across Africa. He said that he believed that Aspen could make the drug for about $20 per course. The U.S. government has an agreement to buy 1.7 million courses of the drug, pending its authorization by the F.D.A., a deal that fixes the price at $712 per course.Mr. Gore said that he has been told by some in the field that a generic version of molnupiravir could be profitably produced for as little as $8 per course.Under the licensing deal, Merck would continue to produce and sell the drug in wealthy nations and many middle-income ones at significantly higher prices.Merck had already taken the step of licensing eight large Indian drug makers to produce generic versions of molnupiravir, pending authorization. But the company feared that production in just one region would not be enough to ensure rapid access to the drug across the developing world, said Jenelle Krishnamoorthy, Merck’s vice president for global policy.So the company also engaged in talks with the patent pool, which has deep experience in working with a network of global drug makers that can meet high-quality standards, including those required for W.H.O. prequalification, she said.“We knew we had to work faster, we had to do things we hadn’t done before, we had be more efficient,” Ms. Krishnamoorthy said.The licenses that Merck issued to the Indian generic makers restricts sales to developing countries and excludes most middle-income ones, including China and Russia — the site of a current raging Covid outbreak — raising the possibility that citizens in these nations, which often have weak health systems, will not get access to the drug.The patent pool agreement for molnupiravir also excludes middle-income countries and most nations in Latin America, Mr. Love said.“What are you going to do for countries like Chile or Colombia, Thailand or Mexico?” he asked. “They’re not in the license.”

Regulatory hurdles and supply chain issues could slow efforts to produce generic versions of Merck’s antiviral molnupiravir for developing nations, despite licensing agreements.The first easy-to-use Covid-19 treatment could be available in the United States by the end of this year, but it is unlikely to reach developing countries, where hundreds of millions of people remain without access to vaccines, until at least the middle of 2022, according to public health officials.The Bill and Melinda Gates Foundation announced on Wednesday that it would attempt to expedite the timetable for getting the drug, the antiviral molnupiravir, to low-income countries. It pledged an initial investment of up to $120 million to prompt eight generic drugmakers that have signed licensing agreements with the drug’s developer Merck to start producing the medicine now, a sort of insurance policy gambling that it will be approved by regulatory bodies.Molnupiravir was developed in record speed by Merck and Ridgeback Biotherapeutics, who have submitted an application to the Food and Drug Administration for emergency use authorization. Merck is already manufacturing the drug in anticipation of that approval, which could come in December.The U.S. government has a pre-purchase contract for 1.7 billion courses of the medication, a simple pill that in a large clinical trial halved the risk of hospitalizations and death from the coronavirus among high-risk people who took it in the first days of infection.In addition to licensing the eight Indian manufacturing companies to produce generic versions of molnupiravir, Merck is in discussions with the Medicines Patent Pool, a nonprofit backed by the United Nations, raising hopes the simple treatment could be widely accessible in nations where large numbers of unvaccinated people will continue to die of Covid infections.But drug production experts say there are critical challenges, such as the supply of raw materials, regulatory approval and financial investment, that will mean the drug will be available in Omaha long before it is in Zimbabwe.The drug approval and authorization process often takes about a year; the foundation and Unitaid, the global health agency based in Geneva, have been working for months — since conversations with Merck indicated early data on the drug’s effectiveness were strong — on steps to make this process as fast as possible.Mark Suzman, the Gates Foundation’s chief executive officer, said in an interview that it would be “an outrageous outcome” if the inequities in vaccine access were to carry over into access to therapeutics.“We can use resources that multilateral agencies would not be able to put forward at this stage, because they’re constrained waiting for regulatory approval, to incentivize those producers to start manufacturing now, so that we would have a stockpile ready to distribute if and when we get approval,” he said.The generic versions of molnupiravir will be evaluated by the World Health Organization and receive prequalification, the global body’s stamp of approval, which would allow countries to fast track purchases.Still, that process will take months, said Prashant Yadav, a supply chain expert with the Center for Global Development. There are only a few suppliers of the drug’s components (called the active pharmaceutical ingredient, or A.P.I.), and its manufacturers will have to be persuaded to ramp up their at-risk production, as well.The Gates Foundation’s efforts could make a meaningful difference, he said. “The foundation investing in a volume guarantee creates a more guaranteed supply of high quality A.P.I. for whosoever wants to make the finished formulation for the drug,” he said.The foundation has also been funding research into how the drug production process can be done more cheaply, and more quickly, Mr. Suzman said.Dr. Yadav said that individual companies would be unlikely to make such expenditures on their own, and that it would help to drive down the price of the medication.If a country such as Zimbabwe were to approve the drug and order it, the timeline to get it to patients would depend on how much was being made globally. “It could be months before the product is even shipped out,” he said. “To be pragmatic I think we are talking about six months before, I’m not even talking about somebody taking it, but even let’s say, before it’s in warehouses in a country.”Multilateral donors and national governments should consider a molnupiravir stockpile as a way to ensure continued flow of the drug’s ingredients, he said. Markets for therapeutics can be uncertain: If case counts fall, manufacturers may cut back their production, and the drug would not be available if there were a surge in infections.In addition to the deals Merck has negotiated with the Indian companies, the foundation hopes to spur drug manufacturers in other parts of the world to seek licenses, knowing the Gates pledge will underwrite their risk, Mr. Suzman said. “Ideally you wouldn’t want to have a single producer in a single country doing it because we’ve seen some of those risks,” he said.The Gates Foundation played a similar role trying to expedite Covid vaccine access, making a $300 million deal with the Serum Institute of India that facilitated accelerated production of the AstraZeneca and Novavax vaccines. However India banned vaccine exports for months during its second Covid waves.Financial and vaccine donations to Covax, the global body meant to ensure supply delivery to low-income nations, have been slow and erratic.“The world learned the hard way with Covid vaccines that unless we are willing to invest at-risk and at-scale as soon as promising technologies emerge — and ideally before — then there will be limited equitable access for far too long even when need and demand are extraordinarily clear,” said Herve Verhoosel, spokesman for Unitaid.