What went wrong?

At year’s end, that’s the question being asked about the global effort to make sure that all countries get vaccines against COVID-19.

Almost as soon as the pandemic began, the world’s leading health organizations joined forces to ensure an ample supply of the vaccines for all nations regardless of income level. The program they created is known as COVAX – short for the COVID-19 Global Access Facility. It was supposed to pre-purchase doses from the manufacturers while the vaccines were still being developed, and then – once the doses became available – distribute them to countries according to their need and charge according to their ability to pay, with the lowest income countries getting the doses for free.

Yet as 2021 comes to a close, and the omicron variant spreads across the globe, the vast majority of people in lower income countries remain unvaccinated.

NPR spoke with two public health leaders with unique perspectives on this issue.

Seth Berkley is head of GAVI the Vaccine Alliance — one of the organizations that formed COVAX (along with the World Health Organization, UNICEF and the Coalition for Epidemic Preparedness Innovations or CEPI.) Krishna Udayakumar directs Duke University’s Global Health Innovation Center – which helped create an independent hub for tracking both the progress and the obstacles to COVID vaccine access.

Here are eight takeaways:

The world is way behind on vaccination targets

In September President Joe Biden proposed a global goal of vaccinating at least 70% of the world’s population by autumn of 2022. The United Nations and the World Health Organization argued the target should be met even sooner – by mid-2022 – and that by the close of 2021 at least 40% of people in every country should be vaccinated.

It’s now clear that more than 90 countries will miss even that more modest 40% target. “Some of these countries are in South and Southeast Asia, as well as some in Central and South America,” notes Udayakumar. “But the majority are in Sub-Saharan Africa.”

What’s more, he says, these countries haven’t just missed the 40% target – they are often well below it. In the lower-income countries that qualify for free or highly subsidized vaccines from COVAX, “the average vaccination rate is closer to 20% than 40% right now,” says Udayakumar. And in sub-saharan Africa, many countries are stuck at vaccination rates in the single digits.

“It’s quite concerning because we know that this is leading to exactly the type of situation where infections are raging around the world,” says Udayakumar. “We’re losing lives unnecessarily. We’re seeing enormous economic damages. But it’s also setting up the petri dish in essence to create new variants over time. All of us remain unsafe so long as we’re not doing everything possible to more aggressively vaccinate.”

The situation would have been worse without COVAX …

As disappointing as the progress has been, says Udayakumar, “we would be in a worse situation than we are right now if COVAX didn’t exist.” To date it has distributed more than 800 million doses of vaccine to more than 140 countries – “many of which wouldn’t get access to vaccines as quickly or in the amounts that they have otherwise.”

… but COVAX was doomed to fall short

Udayakumar says COVAX has “fallen short” due to “naive thinking” behind its set up – specifically a failure to anticipate that wealthy countries were going to rush to buy up virtually all of the vaccine supply from manufacturers through pre-purchase agreements.

GAVI’s Seth Berkley recalls how fierce the contest was. “We were competing against countries that had opened their treasuries and had the [clout] to demand that vaccines flowed to them,” he says.

The result was that once vaccines started becoming available, that early supply was almost entirely earmarked for wealthy countries. And vaccines are still only slowly making their way to the rest of the world, as wealthy countries continue to bring in many more doses than they are actually using each month.

Indeed, says Udayakumar, the same problem has hampered a similar effort by African nations to band together to buy vaccines for their continent. The initiative – called the African Vaccine Acquisition Trust, or AVATT – “has agreements for hundreds of millions of doses. It has been able to deliver many fewer than that,” notes Udayakumar. “It’s a matter of having paid for doses that haven’t arrived yet. So the real challenge comes back to decision-making by high-income countries, as well as the manufacturers themselves, when they have sold three, four or five times what they can produce at any point in time, they’re having to make decisions about who is getting doses first. And almost across the board those doses have gone to high-income countries first.”

Early funding for COVAX could have helped

Adding to COVAX’s difficulties, says Berkley: “You’d want to have financing on day one. We started with zero, and of course that meant we couldn’t put orders in early,” he says.

Eventually COVAX was able to raise funds from donor countries and organizations. But, says Berkley, “it took us until the end of [2020] to get the first $2.4 billion in commitments.” Even at that point the cash actually delivered to COVAX was “very low,” he adds. “I think $400 million.”

If COVAX had been fully funded from the start, says Berkley, “even if you couldn’t compete with the U.S. treasury or the European union, you might be able to do technology transfers.” Specifically, COVAX could have more quickly expanded the pool of vaccine suppliers by identifying manufacturing plants with the capacity to produce vaccines – then providing them the funding and assistance to learn how to produce some of the vaccine candidates.

As it was, COVAX only had the resources to work with a few companies, says Berkley – the most prominent of which was Serum Institute of India or SII. Then, last spring, soon after SII began producing doses of AstraZeneca vaccine, India was hit with a massive wave of cases. The government mandated that all of SII’s COVID vaccines be redirected for India’s domestic use. “It meant that all of a sudden, the 350 million doses we had expected to have for [COVAX-supported] countries wasn’t there,” notes Berkley. The situation delayed the roll-out of vaccines to African countries in particular by months. And although India lifted the export ban last October, SII is only just ramping up the number of doses it is sending to COVAX.

The Serum Institute of India debacle may have been unavoidable

As problematic as COVAX’s reliance on SII has proved, says Berkley, “If today I was doing it, I would do exactly the same thing.” That’s because faced with such limited funds, COVAX had to go with the company most likely to be capable of scaling up quickly. SII well suited to doing so – “it’s the largest manufacturer in the world [of vaccines] by volume,” notes Berkley. But there also simply weren’t that many other candidates.

There’s a need for more vaccine manufacturers

This paucity of vaccine makers in developing countries needs to be fixed, says Udayakumar. “The place where the vaccines are manufactured makes a huge difference,” he says. “We’ve seen manufacturing that’s been mostly in high-income countries as well as in India and China. And those are the regions that have gotten access to vaccines most quickly. We need now much more sustainable vaccine manufacturing across Sub-Saharan Africa as well as Latin America and south and Southeast Asia.”

What it will take to make that happen is now the subject of lively and complex debate. But Udayakumar says at best it will take “months to years” to achieve.

Donated doses are a short-term solution – but only if done right

To ease the current supply crunch COVAX is facing, it would be helpful for wealthy countries to to ramp up donations of excess vaccines that they’ve already purchased, says Udayakumar. And already, he notes, “almost 2 billion doses of vaccine have now been pledged to be donated mostly from high-income countries with over 1.1 billion of that pledge coming just from the U.S The U.S. has also shipped more than 300 million doses of donated vaccine, which is more than every other country combined at the moment.”

Unfortunately, adds Udayakumar, “maybe a quarter of what’s been pledged has actually been shipped – much less gotten to the countries that need them.”

Berkley adds that another difficulty is that those donated doses arrive “sometimes with short shelf life. Also, he says, “one of the challenges is to try to make sure those donations ideally, are not earmarked [for specific countries] … and that we get enough time for countries to know they’re coming, so countries can plan.”

Getting enough vaccines is only the first hurdle COVAX faces

While supply delays remain the biggest obstacle to increasing vaccination rates in lower income countries, Udayakumar says he’s optimistic that the problem will soon be eased.

“I think there are at least some glimmers of hope on the horizon in that the supplies are increasing rapidly.”

More worrying, he says, is a continued lack of adequate financing and preparation for the logistical task of administering doses. “The greatest challenge is less about getting the vaccines from manufacturers to airports, and now much more about getting vaccines from airports to arms.”

When Pam Mandel got the phone call this week that her cousin couldn’t make the trip to Seattle to share New Year’s Eve with her, she said it felt like a low blow.

“I have to tell you, I laughed because it was so weirdly predictable given how bad things have been,” Mandel said.

The omicron variant is making the New Year’s holiday hard for millions of Americans. As infections surge around the country, celebrations have been canceled.

Omicron is spreading rapidly

Cases of omicron are surging. The seven-day average is 240,408, a 60% increase over last week. Although the percentage of cases that require hospitalization or cause death remain relatively low, the sheer infectiousness of the disease means many people will suffer.

“This virus has proven its ability to adapt quickly and we must adapt with it,” Dr. Rochelle Walensky, the head of the Centers for Disease Control and Prevention, said at a White House briefing on Wednesday.

Meanwhile, the latest pandemic-muddled holiday has left a lot of Americans seriously bummed. Air travel is a mess. College football bowl games have been scrubbed. The ball drop celebration will go forward in New York’s Times Square, but with a much smaller crowd and strict mask rules.

It will be a suboptimal New Year’s Eve for many

Even in Florida, a state that has tried to go full steam ahead through much of the pandemic, the Miami Hurricanes had to pull out of a football game and a production of the Nutcracker was canceled.

“We’re probably just going to be at home,” said Lala Tanmoy Das, who lives in New York City with his husband, Eric. “It’s suboptimal, but here we are.”

Das said he and his husband — both health care workers — scheduled some much-needed time off for a trip to Philadelphia to attend a New Year’s Eve bash and a wedding the next day.

Then they tested positive for the coronavirus.

“It’s sad … we wanted to be with our friends,” Das told NPR. “So all that is canceled. The couple also ended up postponing their wedding because so many people have tested positive from their guest list.”

Experiencing feelings of disappointment, anger and isolation

People told NPR they tried to navigate Hanukkah and Christmas with good cheer and a stiff upper lip. But many said the disappointments of New Year’s Eve left them feeling angry and isolated.

“We’re afraid to have feelings about what’s happening right now and that seems really unhealthy,” Mandel said. “We’re navigating this incredibly difficult experience and everybody is sitting at home quietly by themselves and I feel often that I would like to scream about it.”

It’s not just individuals trying to balance safety and health versus a sense of isolation and disappointment.

For the second year in a row, Susan Patterson was forced to shut down the “First Night” festival in Saranac Lake, N.Y., that she helps organize.

“We had a couple hundred people who would usually go,” she said, noting that winters in her region of that state’s north are long and social gatherings are important.

Canceled celebrations might be losing their momentum

“People have been calling to say how sad they are,” she said. “I’m sort of afraid after two years of not doing [it], we’re going to kind of lose the momentum and the excitement.”

Patterson, who lives alone, said organizing the festival is also an important part of her winter — a way of connecting and celebrating.

Asked what she’ll do now on New Year’s Eve, she shook her head and laughed ruefully. “I don’t know. Nothing.”

Even without the pandemic, experts say the holidays can be a tough time emotionally for many people. Magdalena Bak-Maier, a neuroscientist and wellness coach, told NPR it’s especially important this year to reach out and connect with others whenever possible.

“When people are feeling helpless in any situation, if we can’t do it alone, we should certainly reach out for help through any possible means and not find ourselves isolated and alone and trying to deal with these emotions on our own,” Bak-Maier said.

Get through the holiday and worry about the big picture later

She also said it can be helpful to focus on treating yourself well right now to get through a frustrating few days, without worrying too much about the big picture.

“I would invite people to really think about how do you construct the next 24 hours,” she told All Things Considered host Elissa Nadworny. “How do you plan to make sure you have some things you can look forward to and begin to take that control back?”

Meanwhile, for people who choose to gather and celebrate despite the rise in omicron cases, public health officials are urging caution.

People who are vaccinated and have had their booster shots are most safe. Wearing high-quality masks and maintaining social distance whenever possible can also help lower risk. At a briefing this week, New York Gov. Kathy Hochul also urged people to gather outside if weather allows.

“It’s a little chilly, especially in upstate New York, but it’ll be worth it when you have a chance to be together with your loved ones and friends this time next year,” Hochul said.

Officials also say anyone feeling under the weather should definitely sit out this year’s parties.

“If you’re sniffling, if you’re not feeling good, just stay home,” Hochul said. “Watch the ball drop on television, get a nice glass of champagne and know you’re doing the right thing.”

“This is how I’m going to die.”

That’s what U.S. Capitol Police Sgt. Aquilino Gonell thought on Jan. 6, 2021 as an angry mob stormed the Capitol and dragged him by the leg.

“I could feel myself losing oxygen and recall thinking to myself, ‘This is how I’m going to die, trampled defending this entrance,'” he said last July before a House Select Committee investigating the riot that disrupted a joint session of Congress as it affirmed the results of the presidential election.

On that January day, Gonell was assigned to guard the west entrance to the Capitol, which he’s described as a “medieval battleground”.

Nearly a year later, the emigrant from the Dominican Republic still can’t raise his left arm due to injuries he sustained during the attack, and the psychological wounds have also not healed for him or his family.

“They see me cry. They cry with me. They see me in pain. And they also cry because they can’t do anything for me other than try to make me feel a little bit better,” Gonell told NPR this week. “This whole year has been horrific.”

Gonell returned to work 10 months after the insurrection –- in an administrative position because of his hurt shoulder. He’s in therapy for his mental health, and as the one year anniversary of the riot approaches, he says what’s on his mind is “anxiety”.

“A lot of the officers have in mind the possibility of this being a recurring annual or every four year thing, which is why officers like myself are being outspoken about it, because we don’t want to go through this again,” Gonell said.

Nevertheless, he says he would, if it’s required of him.

“It’s mind boggling to hear some of the things that are coming from some of these elected officials. But at the end of the day, our job is to make them safe and make their work environment safer, regardless of our opinion or political affiliation,” Gonell said.

While he’s considered leaving the Capitol force, Gonell has decided instead to try to move up in the ranks to lieutenant. Still, he says showing up to work every day is difficult. About a week ago, he was doing his rounds when he was arrested by the sounds of a construction crew dismantling metal scaffolding.

“Every time that those metal rods hit the ground, it triggered me,” Gonell said. “It brought me back to Jan. 6. That particular sound was something I was hearing when they were breaking the barriers to use as projectiles to hit us.”

He said it’s also tough to run into the members of Congress who voted not to certify President Biden’s election and who continue to cling to the lie that ex-President Trump won.

“We risked our lives to give them enough time to get to safety. And allegedly, some of them were in communication with some of the rioters and with some of the coordinators or in the know of what would happen,” Gonell said. “And it makes you question their motives and their loyalty for the country, as we were battling the mob in a brutal battle where I could have lost my life and my dear fellow officers, as well.”

The House committee investigating the Jan. 6 attack recently requested information from two sitting lawmakers: Ohio Rep. Jim Jordan and Pennsylvania Rep. Scott Perry, both Republicans. Jordan, the ranking Republican on the House Judiciary panel and a longtime ally of former President Donald Trump, has been asked to provide information about his communication with the ex-President on Jan. 6, while Perry is being questioned about his role in attempting to install a Trump appointee as attorney general in the days leading up to the riot. The idea was to replace acting Attorney General Jeffrey Rosen, who stood by the election results, with Jeffrey Clark, the acting chief of the Department of Justice’s civil division, who was sympathetic to the fallacious idea that the election had been stolen.

“Any other time in our history, this would have called for a national unity moment. Instead, we are being polarized and some people believe that what happened wasn’t that bad, [that] it was a tour,” Gonell said. “Well, they need to come talk to me. I’ll show them my injuries. I’ll show them who I was fighting with because these people were not pacifists. These people were intent on overthrowing the government.”

Prosecutors have brought cases against some 650 rioters for their role in the attack, resulting in dozens of misdemeanor and felony obstruction pleas. Gonell said the penalties for many are not enough.

“Their jail time is less than my recovery time,” Gonell said. “The charges they’re getting do not compare to the mental and physical injuries some of the police officers, including myself, got.”

Gonell said it galls him to hear people downplay the events of Jan. 6, an idea that’s progressively gained traction with some Republicans. “They’re telling us, oh, it wasn’t that bad. It was that bad when they were running for their lives. It was that bad when we were struggling to hold them [the rioters] off so they could have a chance to escape to safety,” he said.

While former Vice President Mike Pence has called Jan. 6 a tragic day and thanked law enforcement, including the Capitol Police, for quelling the violence, Gonell was offended by Pence’s recent comments to media outlets that Gonell perceived as minimizing the day’s importance.

“I’m not going to allow the Democrats or the national media to use one tragic day in January to demean the intentions of 74 million people who stood with us in our cause,” Pence told the Christian Broadcasting Network. “And I’m not going to allow the Democrats to use one tragic day in January to distract attention from their failed agenda and the failed policies of the Biden Administration. We’re going to focus on the future. We’re going to stand on the constitution. And we’re going to stand for the liberties and commitment to life that have always made this country great.”

“That one day in January almost cost my life,” Gonell said.

As rioters stormed the Capitol they called for Pence to be hanged because he did not block the certification of the presidential election.

“And we did everything possible to prevent him [Pence] from being hanged and killed in front of his daughter and his wife. And now he’s telling us that that one day in January doesn’t mean anything. It’s pathetic. It’s a disgrace,” Gonell said.

“He swore an oath to the country, not to Donald Trump.”

Come this Jan. 6, Gonell hasn’t decided how he’ll commemorate the anniversary. He’s put in for leave from work.

“I can fight if I need to, but I think I’d be a liability in terms of not having my issued equipment to defend myself and my fellow officers,” he said.

Going forward, Gonell hopes the ongoing prosecutions lead to stiff penalties. “What I don’t want is for some of these people to think it’s OK, regardless of what the political figures are saying,” he said.

“If these people don’t get some type of deterrent, it will happen again, and that’ll be on us.”