CAPE TOWN, South Africa — As a dangerous variant of the coronavirus first discovered in South Africa sickens and kills thousands across the country, Jan Matsena has shown up every day to stock the shelves at a Cape Town supermarket, terrified that he too will catch it.
A neighbor died in December, then a co-worker this month. Now Mr. Matsena is waiting for a vaccine so he can return home to his township and hold his baby daughter again. But in South Africa, the country hit hardest so far by the variant, inoculations have not yet started.
“The wait for this vaccine has been long, long now,” said Mr. Matsena, a first-time father who has been living away from his family for fear of exposing them. “People are passing away, people are losing jobs. It’s trauma.”
While more than 90 million people worldwide have been vaccinated, only 25 in all of sub-Saharan Africa, a region of about 1 billion people, have been given doses outside of drug trials, according to the World Health Organization.
But as new variants like the one discovered in South Africa migrate to more countries — including the United States — it is becoming ever clearer that the tragedy for poorer countries could become a tragedy for every country. The more the virus spreads, and the longer it takes to vaccinate people, the greater chance it has to continue to mutate in ways that put the whole world at risk.
Recent studies suggest that at least four vaccines that are effective at preventing infection with the original virus did not perform as well against the variant found in South Africa. That variant is also more infectious — as is another one, discovered in Britain — and it is now estimated to make up 90 percent of all cases in South Africa, according to data compiled by researchers. It has turned up in dozens of other countries.
Inoculation prompts the immune system to make antibodies to the virus, but as mutations change its shape, the virus can become more resistant to those antibodies. In the worst case, failing to stop the spread of the virus globally would allow more mutations that could make existing vaccines less effective, leaving even inoculated populations vulnerable.
“This idea that no one is safe until everyone is safe is not just an adage, it is really true,” said Andrea Taylor, the assistant director at Duke Global Health Innovation Center.
Even in the most optimistic scenarios, Ms. Taylor said, at the current pace of production, there will not be enough vaccines for true global coverage until 2023. The current rollout plans across Africa are expected to vaccinate only 20 to 35 percent of the population this year if everything goes right.
And while some wealthy countries have secured enough vaccine to cover their populations multiple times, South Africa has secured just 22.5 million doses for its 60 million people, and many nations lag farther behind.
That disparity is at the heart of what Tedros Adhanom Ghebreyesus, the head of the World Health Organization, says could soon become a “catastrophic moral failure,” as rich nations rush to buy up vaccine stocks while leaving poor and middle-income nations struggling to find supplies.
South Africa’s first million doses, made by AstraZeneca, are set to arrive there on Monday, and officials say it will take as long as two weeks to start giving the shots. AstraZeneca’s vaccine, developed with the University of Oxford, is currently the world’s most affordable option, developed with low and middle-income nations as its target. The company has not released any information about its effectiveness against the variant but is expected to do so soon.
Another 9 million doses are on order from Johnson & Johnson, whose shot does not yet have regulatory approval. On Friday, the company announced that the efficacy of its vaccine dropped from 72 percent in trials conducted in the United States to 57 percent in those conducted in South Africa.
There are some encouraging signs. A growing body of preliminary evidence — mainly gleaned from the lightning-fast rollout in Israel — suggests that vaccines are performing well not just in trials, but in the real world, driving down new infections.
But it remains to be seen how well they help contain the variants already in circulation. Scientists hope that if needed, vaccines can be modified and booster shots developed to tackle new variants, but that takes time. And for a world struggling to right itself, time is of the essence.
Dr. Tulio de Oliveira, a professor and geneticist at the Nelson Mandela School of Medicine in Durban, who had helped discover the variant originally found in South Africa, said its emergence should serve as a wake-up call.
“One of the things this variant should highlight to the whole world is the need to control transmission — not only in their own country but in the whole world,” he said.
And while nations have rushed to seal their borders, the variants are already spreading in dozens of countries — just as the virus eluded national boundaries last winter. Brazil, for instance, appears to have incubated at least two worrisome variants, which had already slipped its borders before many countries began to cut off air travel from there.
The burden of supplying vaccines to low- and middle-income nations hangs heavily on a nonprofit group, Covax, formed by a coalition of international organizations.
Although more than 190 countries have pledged to obtain vaccines through Covax, many of them are also striking deals directly with drug companies, or belong to multinational groups that are doing so. That threatens to drive up prices and delay delivery of doses through Covax.
Covax has announced that it has secured 2.1 billion doses for 2021, but it is unclear how many of those will actually be delivered in 2021.
The hope is that rollouts to poorer countries can begin in earnest in the next month or two.
“Covax is necessary but not sufficient,” Ms. Taylor said. “It is the only mechanism we have for global equity. We need it and we need it to succeed. But even if they are successful, it does not get countries close to herd immunity.”
Orin Levine, the director of global delivery programs at the Bill and Melinda Gates Foundation, said “the bare facts are that by the end of this year, probably 75 percent of population in high-income countries will be vaccinated,” compared to 25 percent in low-income countries.
Currently more than 150 million people — almost half the population — are eligible to be vaccinated. But each state makes the final decision about who goes first. The nation’s 21 million health care workers and three million residents of long-term care facilities were the first to qualify. In mid-January, federal officials urged all states to open up eligibility to everyone 65 and older and to adults of any age with medical conditions that put them at high risk of becoming seriously ill or dying from Covid-19. Adults in the general population are at the back of the line. If federal and state health officials can clear up bottlenecks in vaccine distribution, everyone 16 and older will become eligible as early as this spring or early summer. The vaccine hasn’t been approved in children, although studies are underway. It may be months before a vaccine is available for anyone under the age of 16. Go to your state health website for up-to-date information on vaccination policies in your area
You should not have to pay anything out of pocket to get the vaccine, although you will be asked for insurance information. If you don’t have insurance, you should still be given the vaccine at no charge. Congress passed legislation this spring that bars insurers from applying any cost sharing, such as a co-payment or deductible. It layered on additional protections barring pharmacies, doctors and hospitals from billing patients, including those who are uninsured. Even so, health experts do worry that patients might stumble into loopholes that leave them vulnerable to surprise bills. This could happen to those who are charged a doctor visit fee along with their vaccine, or Americans who have certain types of health coverage that do not fall under the new rules. If you get your vaccine from a doctor’s office or urgent care clinic, talk to them about potential hidden charges. To be sure you won’t get a surprise bill, the best bet is to get your vaccine at a health department vaccination site or a local pharmacy once the shots become more widely available.
That is to be determined. It’s possible that Covid-19 vaccinations will become an annual event, just like the flu shot. Or it may be that the benefits of the vaccine last longer than a year. We have to wait to see how durable the protection from the vaccines is. To determine this, researchers are going to be tracking vaccinated people to look for “breakthrough cases” — those people who get sick with Covid-19 despite vaccination. That is a sign of weakening protection and will give researchers clues about how long the vaccine lasts. They will also be monitoring levels of antibodies and T cells in the blood of vaccinated people to determine whether and when a booster shot might be needed. It’s conceivable that people may need boosters every few months, once a year or only every few years. It’s just a matter of waiting for the data.
For African nations, the slow pace of the rollout feels frighteningly familiar.
When another scourge — HIV/AIDS — was killing millions of people each year, Africa had the largest number of infections and deaths. Still, it took at least six years before the lifesaving treatment available in wealthy nations was made available for Africans.
AIDS killed 12 million people in Africa in a decade, even as mortality in the U.S. dropped drastically, according to analyses by the Africa Centers for Disease Control and Prevention. Disputes over international property rights delayed the production of more antiretroviral drugs or cost-effective generics.
Now, India and South Africa have teamed up to lobby the World Trade Organization to compel drug companies to share their intellectual property on coronavirus vaccines, as they eventually did with HIV/AIDS treatment.
“What you need right now is the explicit cooperation of every single government and every single pharmaceutical company that says we are in a pandemic, we are on the road to disaster,” said Fatima Hassan, a South African human rights lawyer who fought for HIV/AIDS drugs and has now pivoted to Covid-19 vaccines. “We’ve got to share the technology and spend billions to save trillions.”
Solomon Zewdu, deputy director for health in Africa at the Gates Foundation, said maps and charts showing global vaccination rates — with Africa almost completely absent — are fueling public anger and causing some leaders to look for additional vaccine sources besides Covax.
The African Union announced the purchase of 300 million vaccines this month, to be distributed through the regional body’s African Medical Supplies Platform, according to Nicaise Ndembi, senior science adviser for the Africa Centers for Disease Control and Prevention.
In countries like Mozambique, Zimbabwe and Zambia, where the variant found in South Africa has been thought to be driving surges in infections, authorities have no clear answers about when vaccines will arrive.
South Africa, meanwhile, has been relatively assertive in its pandemic response, taking steps that have caused controversy within the country. President Cyril Ramaphosa has reintroduced a 9 p.m.-to-5 a.m. curfew, limited attendance at funerals and religious gatherings, outlawed the sale of alcohol and made masks mandatory in all public spaces. Not wearing a mask can lead to a fine or six months in jail.
When vaccinations are expected to begin, about mid-February, health workers will be first in line, followed by those deemed most at risk of serious illness.
For Mr. Matsena, the supermarket employee, who is 31 and healthy, it could be a long wait.
“It would be better if it arrived earlier because now people are terrified of this pandemic,” he said. “It’s worse, much worse.”