Seth Berkley on vaccines, COVID, and equity

Gavin is joined by Dr. Seth Berkley, former CEO of Gavi, the Vaccine Alliance, to discuss his new book, Fair Doses.

Dr. Berkley reflects on the global impact of vaccines, the ongoing challenges to vaccine equity, and the lessons learned from leading initiatives such as COVAX during the COVID-19 pandemic.

We also discuss the economics of vaccine distribution, the threat of misinformation, the promise of scientific innovation, and the future of global health preparedness, and a vision for strengthening international cooperation and ensuring that future advances in vaccine science benefit everyone, everywhere.

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Transcript

This transcript was automatically generated using speech recognition technology and may differ from the original audio. In citing or otherwise referring to the contents of this podcast, please ensure that you are quoting the recorded audio rather than this transcript.

Gavin:  Hello, welcome to The Lancet Voice. I'm Gavin kva. It's October, 2025, and today I'm joined by Dr. Seth Berkeley, the former CEO of Gavi, the Vaccine Alliance. Dr. Berkeley has played a pivotal role in global vaccine efforts from expanding access to lifesaving immunizations to co-founding covax in response to the COVID-19 pandemic.

In this episode, we discuss his new book, fair Doses, and we explore the critical issues of vaccine equity, scientific innovation, and global health security. We hope you enjoy the conversation.

All right, Dr. Seth Berkley, welcome to The Lancet Voice. Thank you so much for joining us. It's a real, uh, honor to have you on the podcast today. So you've spent your career at the Center of Global Vaccine Efforts, really, uh, for listeners who might not know. Perhaps you can just kind of set the scene by discussing why vaccines have been such a revolutionary force in public health. 

Seth: So if we go back in history to around 1975, less than 5% of the world received even a single dose of vaccine. And of course, what's happened since then has been an expansion in the number of vaccines. That, uh, uh, prevent a whole range of diseases. But also vaccines have become now the most widely distributed health intervention in the world with about 90% of families having access to at least one dose as part of the routine system.

And this has meant that we've seen vaccine preventable disease deaths go down by about. 70%. And of course that has led to an expansion in life expectancy and also a big shift in the type of diseases that people have because now they're living to much older ages. 

Gavin: Absolutely. So you've got your new book coming out.

In fact, by the time this podcast comes out, I believe your book, uh, will have come out. So congratulations on the publication of your new book Fair Doses. Now, in the book you talk about the the remarkable journey really of making vaccines available for diseases across the world. What would you say is the greatest challenge of getting vaccines to people that need them the most?

Seth: Well, the initial challenge related to having a delivery system to get them out there, and we'll come back to that again at the end. But then, um, at the time that I really got involved in this, the challenge was that new vaccines were being made for some of the most important diseases. And they were coming out in high income countries and were quite expensive.

And so one could arguably say that the greatest effect they could have would be in poor countries where people didn't have access to good healthcare. Um, but of course they couldn't afford it. And so this was about trying to make accessibility critical and, and in doing that, try to make it a win-win for manufacturers.

'cause one of the, the, the dirty secrets here is that, um, you know, the price points in the, in the West are such because, um, you know, companies can charge large amounts for these products. But once you've figured out how to manage the how to, how to manufacture the product and make it, the costs actually are not that high.

And so what we were able to is negotiate with, um, uh, vaccine companies to say. If you expand the coverage of your vaccine, you will drive down the cost of each vaccine and therefore you'll make more money in your primary markets, but you will also be able to provide vaccines for the rest of the world.

And that's what Gavi was able to do. 

Gavin: So would you say that's been the, kind of the economic side of things, is that, is that underappreciated when it comes to talking about global vaccine distribution, do you think? 

Seth: Yeah, it's important because what, what people often say is, oh, it's terrible that people in developing countries don't get access to access to these.

But at the end, these are private companies that are making the vaccines and are selling the vaccines. So what we need to do is figure out a way to make it a win-win so that they have an incentive to make those vaccines available to those living in the developing 

Gavin: world. And your career obviously has taken, um, an awful lot of those sort of discussions and trying to figure out how to make it win-win.

Seth: Yes. And, and, and you know, what's critical, and I said I would come back to the health system side. So what's critical is, um, initially there were no delivery systems in the developing world. Now there are delivery systems, but they're not reaching the final mile. And so I said about 90% of people get access to at least one dose out of the routine immunization system.

That last 10% is absolutely critical. Why two thirds of those families are living below the poverty line and 50% of the child deaths that are still are occurring are incurring in those families. When we think from a global health security point of view, those are the places where if you had an outbreak of infectious disease, there's really no health system there.

There's no health workers, and therefore it really could, you know, burn on for a while before it got identified. That's what happened in, um, 2014 in the West African Ebola outbreak. It occurred in an area between three countries and, and it took a long time to make the diagnosis of Ebola, and by then it spread to urban areas.

So what this is about is trying to get these powerful new vaccines that are active against, you know, the most severe diseases. For example, diarrhea and pneumonia, the two largest killers of children. But more and more we have now two vaccines against cancer. Hepatitis B against liver cancer and HPV against cervical cancer, the largest cancer killer of women.

We also now have, uh, for the first time a vaccine, again, a PA against a parasite, a malaria, which of course, again, is a, a really severe disease. So it's about making sure the vaccines are. Scaled up to the right, um, amount so that they're available, making sure the costs are appropriate so that people can get access to them, and then having that delivery system to get them out to the last mile.

Gavin: You mentioned the concept of the kind of, um, the reservoir of these diseases that can sit in that last 10% of hard to reach populations. I think that's a really key consideration, isn't it? When we talk about kind of. Global cooperation on vaccines, which obviously your, your career has taken a, uh, as, as largely focused on how receptive are high income countries to that message of this sort of reservoir of the last difficult to reach 10%.

Seth: Well, it's, it's a really important question because I think in the past, um, people had really two reasons to be thinking about that last mile. One is the humanitarian reason. These are people in other countries, they're poor. Um, uh, children are dying. You know, this is something that we should not have anywhere in the world.

So that's the humanitarian side, which is of course still valid. There's a second side as we begin to control infectious diseases around the world. And let me give you the example of measles. Measles was a disease. It's the most, um, uh, infectious disease that we know. It spreads the easiest. And this was a disease that caused deaths around the world since time immortal.

And, um, we've been able to, in many countries. Eliminate measles as an infectious disease through vaccines. But of course, as long as there is a reservoir of measles in other countries, then you know, people travel and when they travel they can be infected. And so you end up with. New outbreaks that occur.

And the same thing is said for polio, which has almost been eradicated, but still exists in its wild form in a couple of states. And so what we have to do is also think about this as a way to protect countries, not just the wealthy countries, but countries throughout the world. And the more one can dampen down these infections, the less risk there is of spread.

Lastly, um, we have another epidemic, some would say a pandemic going on right now, which is of antimicrobial resistance. And so one of the challenges are there are, there are many agents that can cause infections and if they are, uh, treated with antibiotics, they don't finish the antibiotics, the wrong antibiotics, you end up with resistance.

And of course then these can spread to other countries. The risk of that is that you end up in a situation where simple procedures that might have been lifesaving, you know, like a hernia operation or you know, basic things, uh, uh, a joint replacement, um, become infected with. Uh, agents that we don't have, uh, antimicrobials to treat and therefore change the whole dynamics of health.

So these are, these are factors that really make it important for, um, us to pay attention to the health issues anywhere in the world, not just in our own countries. 

Gavin: Yeah, really salient points. I wanted to talk about the story of Covax 'cause it's so extraordinary. You know, you found, you co-founded it during the pandemic.

It's 193 countries, and I think it was $12 billion you raised and something like 2 billion vaccine doses delivered during a global emergency. It's a staggering achievement, but I wanted to ask kind of what the most difficult moment out of all of that was. There must have been so many difficult moments, but, um, what were the biggest challenges you faced, uh, while, while operating Covax?

Seth: The, the reason we started it was right at the beginning. We knew that high income countries, if a vaccine was ever successful, would buy that vaccine up. That's what happened, uh, with, uh, avian flu previously. And so what we tried to do is put a system in place to make sure there would be equitable access.

And the challenge we had at the beginning is we had no money. No people, no authority to be able to do this. And so, um, you know, we, we dived in anyway and, uh, worked to build consensus of the importance of this at a time that everybody wasn't panic and raised the money. And ultimately, as you said, we're able to deliver 2 billion doses to 146.

But the real problem at the beginning was because we didn't have that money, we couldn't put orders in place. So unlike wealthy countries that could just open their treasuries and say, we'll take it. We don't care about the price, and by the way, we'll not only buy one vaccine, we'll buy 2, 3, 4, 5 vaccines because of course, traditionally vaccines have a very low success rate.

You know, something like 7% on average. And so, you know, people are like, well, we wanna make sure we have protection, so we're not gonna bet on one vaccine. We'll bet on many. And of course, this is a real challenge because once you start having wealthy countries buy many different vaccines, they, you know, use up all of the manufacturing capability that exists in the world.

So I think to me, that was perhaps the biggest lesson. And of course, um, we can talk in a second about what, what has been done since, to try to change that going forward. But other things were, we were surprised that there weren't systems in place. So when a new agent appears and new vaccines are being rolled out normally, um, the process goes very slowly and, and companies have insurance to deal with if there are any untold side effects.

In this case, because people were trying to move so quickly. Record time, 327 days. Um, people were therefore in a, in a position where they said, we, we really need some type of indemnification and liability. We need to make sure that there's some type of, uh, system in place if people do get sick, that they get taken care of.

And there wasn't any of that. So we had to build all of that from scratch and, and work through the issues that were associated with this. And so all of these ended up being quite, um, you know, difficult challenges. Now, I will say that at the end, um, we ended up with primary coverage in the 92 poorest countries in the world of 57%.

And that compared to about 67% in, in the, in, in the global average. So, not quite equitable, equitable, but best it's ever been. On the other hand, in the first year, um, in 2021 of vaccination, despite the fact that, um, uh, low income coun lowest income countries make up 11% of the world's population, and there were 11 billion doses made in 2021, only a little over 1% of people in those countries.

Ended up receiving a dose and, and you know, to me that's a real tragedy and shows the delay that was there in terms of access. We did have the first doses in 39 days after the first jab in the uk and that was again, something we were very proud of. And, you know, um, uh, another month and a half later we had reached a hundred countries.

But, um, we really were trying to do a better job at making sure we got the high risk groups covered in, in all countries in the world. 

Gavin: Yeah. I think what we're discussing here is something you discussed quite a lot in your book, right? Which is Vaccine nationalism. Perhaps for some of our listeners, you could sort of unpack the idea of what Vaccine nationalism is, and then we could talk about how it affected the global response to COVID-19.

'cause it seems quite crucial to this whole topic. 

Seth: Yeah, I mean, one of the challenges is we're not naive enough to think that, gee, we said if we had the money, we'll buy the vaccines at the beginning and then companies will say to, you know, let's say the UK or the us, oh, sorry, we already sold the vaccines.

We can't give any to you. So, so we understand that there will always be a priority for countries to have access to these products, and, and that in essence is what you expect your political leaders to do to try to protect your populations. The question we asked though was, should you vaccinate every single person in your country, including the lowest risk ones before you vaccinate some of the high risk populations in other countries?

And, and our goal was to try to get 20% of the world vaccinated. And that 20% included healthcare workers and people, um, with other comorbidities and the elderly, because those were the people at high risk of death and complications from COVID. So the idea would be that from a national point of view, you would prioritize your high risk populations, and then we would begin to cover high risk populations in other parts of the world.

But that's not what happens in many countries. Many countries said We wanna vaccinate every single person. Or even worse, we're gonna not only wanna vaccinate every single person, but we're gonna buy 3, 4, 5 doses. So maybe we have enough vaccines to vaccinate every person five times over, and then, you know, those aren't available for others.

So we had to then kind of change and adjust things because we did not believe, for example, that donations are the way you should deal with a pandemic when people are dying around the world. We felt that. We should be able to offer people whatever vaccines they wanted. But when we found out that many country had hoarded these vaccines.

And, um, they of course then wanted to get rid of them when they realized they might expire and, and be worthless and give them the, the demand that was there. So then they wanted to give them to us, often with a few weeks and wanted to get them into the developing countries, which didn't give countries time to plan.

So we had to build a whole dose donation system at the same time we were purchasing vaccines to try to use as many of those as we can. And also to try to get the, you know, countries, whatever their choice of, uh, was for vaccines. 

Gavin: It must have been frustrating for you to receive these. It's good to receive a donation of course, but, um, it must have been frustrating for you to be forced into that position to organize such, uh, quick response turnovers for these vaccines with very little time left on the clock.

Seth: I mean, at the beginning people were so panicked and, and so wanted to use them. And then when they couldn't choose them, they waited till the last minute and then they wanted to make them available. And, and initially countries were so desperate to receive them, they were willing to, you know, um, uh, go outta their way to try to organize emergency campaigns as the vaccines were arriving, et cetera.

But that, um, you know, what was interesting about the, the pandemic time was of course the people who gave vaccines. Were the heroes and they, the health workers, um, actually vaccinated during that period three times the number of people they normally would've. And, um, and, and that was also elderly and people with chronic conditions and health workers and others that they normally didn't deal with.

But of course, we needed them to continue. The routine and basic vaccines as well. And when there were outbreaks of other diseases, we needed them to engage there as well. So people were really stretched. And so every time you would have one of these emergency campaigns set up from a, a, a short shelf life vaccine coming in, it would disrupt routine activities as well, because it would be all hands on deck to try to get the vaccines out.

So these are, are really some of the lessons going forward. And eventually we. Put a request out to all countries saying we would not take doses unless there was adequate time for countries to plan and adequate time to transfer them to countries. 'cause also we had to deal with the liability if a country bought those vaccines.

They had the liability for those vaccines. Now they want to transfer them to Covax and we're gonna transfer them to another country. We had to make sure that that, um, liability was transmitted as well, which was paperwork and discussion. So many complications that were part of. 

Gavin: You've been working across your career with many different vaccines, you know, not just COVID. 

Are there any kind of key lessons that apply across all the different distribution efforts for different sorts of vaccines? Or does each of them require a kind of fundamentally different approach and con consideration of the disease? 

Seth: Well, well, the first thing to say about that is what we need are strong health systems.

And this is an important point everywhere in the world, because that's the backbone. You know, something like 70 to 80% of diseases, for example, in developing countries, can be treated through the primary healthcare system. So people, when they think about healthcare, they think of hospitals, and those are important places to fall back, but that's when the primary healthcare system fails.

So having those systems in place is absolutely critical. But those systems won't reach everybody. So for example, I mentioned already an HPV vaccine for cervical cancer. We use those because we, we still don't have enough vaccines for everybody in the developing world. They're given to adolescent girls because they're at the highest risk of obviously, cervical cancer, but that cancer is much more severe than the cancers that HPV causes in men.

So primarily it's important to get the, the women vaccinated first. Eventually, as in high income countries, it'd be good to get everybody vaccinated with this very powerful vaccine. So how do we reach those adolescent girls? Well, the best place to reach them is in school and, um, there are girls out out of school and you have to have other mechanisms, but the vast majority are in schools.

So then you need a way to reach into school. So that's. Campaign. You have people who then travel out to the schools, enroll the girls, and vaccinate them and do the follow up because it used to be two doses, now it's one dose, so it's a little easier. Um, but having those campaigns now, that's a different way of delivering than the routine system we talked about before.

But that then becomes relevant for when there are outbreaks of disease and you need to go out to communities and do a campaign like that. And then we also had the humanitarian, um, uh, setting where you had people in refugee camps or people who were displaced or people living in dense urban slums. And those need different types of delivery systems.

So, um, you know, we have a, a set of different systems we use for. Providing vaccines. And, and the challenge really is, is to understand which, um, type of approach needs to be done in which country at one time. And our job, of course, is not to do it. Our job is to help support the country in doing that work.

Gavin: Talking of community engagement, uh, disinformation is such a major problem, isn't it? When it comes to vaccine acceptance and uptake rates. Uh, how big a threat do you think misinformation is in global health? And also, I wanted to ask from working in the area of vaccines for so long, have you noticed the kind of nature of misinformation change over the years?

Seth: So the answer is, um, it is a massive problem and it has changed totally. If you go back in history, even to the original smallpox vaccine, right after that, there was misinformation and, um, there were, there were wood cuttings of people with having cows horns grow out of their heads because the original smallpox vaccine was, was, uh, from cowpox.

And, and so there's always been, you know, vaccine hesitancy, misinformation, but that could be dealt with. In a local setting with community leaders, whether it be village chiefs, whether it be religious leaders, whether it be doctors or nurses, you know, or family groups. You were able to get the correct information and, and, um, overcome that.

What's happened recently, of course, is we have now misinformation spread at the speed of light through the internet. You have, people have less and less respect for institutions and for experts, and they get their information on the internet. And there you have, uh, misinformation, people who, you know, don't know what they're talking about, but act as if they're experts and.

But you also have a lot of disinformation, intentional information spread by Russia or Chinese bots that are trying to, uh, discredit different settings. And even the US government during COVID, um, uh, went out and had disinformation, uh, suggesting that Chinese vaccines were made of pork products in Muslim countries to discredit those.

The challenge with all of this is it becomes much more difficult then, um, to, uh, control that misinformation and disinformation. And lastly. You know, for the first time we now have political leaders that are spreading, uh, disinformation. And, um, you know, in the US right now we have a Secretary of Health and Human Services, Robert F.

Kennedy Jr. Who himself is somebody who has a long history of spreading disinformation about vaccines and is doing it as part of. Official US policy. And this has an effect not just in the US of course, but it has an effect globally because people look up to the science community in the US and when they see this, they say, well, what do they know that we don't know?

And it becomes much harder to get that information. It's one of the reasons why. Uh, journals like The Lancet are so important where, you know, you have standards of scientific rigor, but you also have peer review processes and an ability for scientists to check and challenge what you do, but only if they can put the data behind it to show that there is.

Some other thing to do. And you know, without that, you know, in a sense all hope is lost. I mean, everybody is entitled to their own opinion, but they're not entitled to their own facts. Uh, um, as a famous senator in the US said at once, and, and that really was a challenge, particularly around COVID, where all this accelerated.

Gavin: Did Covax and Gabby have any particular approaches to misinformation? How did you deal with it through those bodies? 

Seth: Well, we've of course been dealing with mis and disinformation all the time through all of, uh, the campaigns. We do all the work, we do all the different vaccines, and there are ups and downs on that.

But in this particular case, it became more of a problem because the battleground became global. And um, I'll give you one more example of that. So the, um, Russian vaccine, Sputnik five, should have been a good vaccine. It was made of an adeno, uh, a based vector, a similar to the AstraZeneca. Vaccine that was, um, done by Oxford and, and, and launched in, you know, in the UK and in different parts of the world.

But we were never able to get the level of scientific rigor in the data that they put out. And at the end, WHO wasn't willing to pre-qualify it. Of course at the end, Russia spread disinformation about WHO, about covax, about others being prejudiced against it. When all we asked was that every country, um, when they, uh, present the data from their vaccines, it meets the scientific rigor that.

Others have have presented here and we were able to get, you know, the Chinese in the South Koreans and you know, all the other countries to do that. And we were never able to get Russia to do that. And you know, that's an example of one of the challenges we have in this times. 

Gavin: So rapid kind of advances in science, like for instance, mRNA of course during the start of the pandemic.

Um, they played a massive role in vaccine development over the years. How do you see scientific innovation kind of shaping the future of vaccine developments and delivery? 

Seth: Yeah. Well, first to say something about mRNA, um, you know, it, people think of it, oh, it just started at the, at the time of the, of the, uh, pandemic.

No, it's not true at all. People have been working on mRNA for decades before, and it was all that science that was built up that really allowed it to be ready to go at that time. Now, what of course happened during the COVID Pandemic is they were able to make a. A candidate vaccine. I think the number was 42 days after they originally had the genome published, and then 63 days later they had it in a vial ready to go.

And no other technology that we have today can be made that quickly. And this is an important thing because there will be more pandemics, it's evolutionary inevitable, and the next one might actually be significantly worse than this one. We don't know. And so we know when a pandemic occurs, every minute counts in terms of the speed at which you can make countermeasure.

mRNA vaccines are really the best. So the challenge right now is that's under attack in the US and funding has been withdrawn, and so I'm quite worried that we don't keep that research going on. If people have concerns, which. We've heard, you know, there are conspiracy theories about mRNA vaccines. What you need to do is do more research and, and make sure you, you know, you, you, you make sure that there's no problem with those rather than, um, just abandon them.

But technology will play a role. Another example of technology that's exciting right now is people are working on patches. That will allow you to be able to give a vaccine to have it stored at room temperature and be able to give it just by putting a patch on the skin. Now that opens up a whole nother world because you can have non-healthcare workers, trained health workers to give it.

It can also, you know, be used by parents. You can get it in the mail. And so, um, you know that, and people who are afraid of needles. We're also working on, uh, vaccines that will be inhalable or the nasal passages, and that will give local immunity in the places where viruses enter, which may give a much stronger.

More, um, you know, protected type of, uh, effort going forward. So I think there's lots of things to be able to, uh, hope for going forward. And the challenge really is keeping on this intense research effort that has gone on up until now, and it's gonna be critical if we're gonna be prepared for the next, uh, epidemic slash.

One last thing if I can is that is cancer vaccines have now. Um, you know, I mentioned a few that have already been developed that are known to infectious agents, but people are actually beginning to put antigens from cancers. On vaccines and using them to stimulate the immune system. And frankly, to me this is much more elegant than giving a chemical that poisons hopefully the cancer before it poisons, you know, the normal cells.

And so this is another area that is moving forward rapidly and. The fact that the US is pulling away from this seems tragic. Of course. I'm very happy to see that the UK seems to be the prioritizing vaccines and vaccine research and um, you know, hopefully others will also keep this work moving forward.

Gavin: Yes. Let's hope so. Absolutely. Finally, what would you like readers to take away from your book? Is there like one big takeaway? 

Seth: Well, I think the most important takeaway is something we've talked about here is. The importance of vaccines as, um, a tool that can make a difference in everybody's life has made a difference in everybody's life.

And that there are future diseases that will also be amenable to the science and technology of vaccines and, and the priming of the immune system. And so, one, we need to continue to prioritize that. And the second message is, it is evolutionarily certain that we will have more outbreaks, more infections.

And so the world needs to prepare for those. And one of the challenges is we all understand, um, wars and defense needs, and we spend a lot of money on that. But you know, not only do we have to worry about naturally occurring affections like COVID, but with all of the advances in synthetic biology and ai, we're gonna have to worry about intentional bio-terrorism.

We're gonna have to worry about accidental release of agents, and all of these will be. Managed through a system of. Public health surveillance, distributing of tools that are necessary. And so what's critical is that we, um, make sure that we are prioritizing that as an effort. And you know, I worry that sometimes, you know, we think that that bombs are the, the better solution than are, um, uh, you know, health interventions.

But just like, you know, originally we were looking at different types of tools and then Ukraine occurred and now. Drone warfare becomes the norm and we can't use, you know, million dollar missiles to shoot down drones. I think we have to keep in mind that for, um, issues on, on spread of infectious diseases, we will need to have, continue to have better tools and, and better surveillance.

Uh, one last point for the readers to say, and people are always surprised when I say this, if I use the US example, um, more Americans died of COVID. Died in all wars in the US since the Civil War, you know, so people think of, oh, defense, yes. You know, wars and we have to protect against it. But these infectious diseases really can take a toll and, um, we need to prepare for them better.

Gavin: I think that's, that's an important point to end on. Well, uh, Dr. Seth Berkley, thank you so much for your time and for coming on the podcast. 

Seth: Thank you for having me.

Gavin: Thank you to Dr. Seth Berkeley for sharing his insights and expertise on vaccines, equity, and the future of global health. Dr. Berkeley's new book, fair Doses is out now. Thank you for listening to the Lance Voice, and we hope you'll join us again next time.