The Troubled History Of Vaccines And Conflict Zones

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Doctors administer the Johnson & Johnson COVID-19 vaccine to patients at the Wazir Akbar Khan hospital in Kabul, Afghanistan in July. Paula Bronstein/Getty Images

Paula Bronstein/Getty Images

On March 23, 2020, with the deadly coronavirus reported in 167 countries and territories, United Nations Secretary-General António Guterres called for a global ceasefire to support a public health response. It was the first global ceasefire appeal since the agency was founded in 1945, in the aftermath of World War II. "The fury of the virus illustrates the folly of war," Guterres said. "End the sickness of war and fight the disease that is ravaging our world."

On the ground, little changed. More than a dozen armed groups, from the National Liberation Army in Colombia to the Communist Party of the Philippines, initially endorsed Guterres' appeal, but most offers to lay down arms were either one-sided or did not culminate in a formal ceasefire agreement. A U.N. Security Council resolution that July, which affirmed Guterres' plea, also went nowhere. By fall 2020, the idea of a global ceasefire â€" which, in all of world history, has never taken place â€" was off the table.

On Feb. 26, 2021, the Security Council tried another tack. It passed Resolution 2565, which less ambitiously but more pragmatically called for a "sustained humanitarian pause" in order to immunize the world. In this case, there were recent historical precedents: In the 1960s, representatives from the World Health Organization launched its intensified program to eradicate smallpox â€" focusing on countries such as Ethiopia and present-day Bangladesh, where the disease was endemic and where public health officials had to work around conflicts in order to bring lifesaving vaccines to civilians.

This triumph of public health diplomacy will have to occur once again, humanitarian professionals say, in order to bring the COVID-19 pandemic to an end. From Afghanistan to Myanmar, Nigeria to Azerbaijan, people caught amid violence and instability will need to be immunized. Public health experts fear that if conflict zones don't receive vaccines soon, these places could become hot spots for transmission and incubators for potentially dangerous variants of SARS-CoV-2, the virus that causes COVID-19.

But hammering out temporary ceasefires won't be easy. The political situation is more complex now than in the past, in part because of the abundance of nonstate actors like al-Qaida and the self-proclaimed Islamic State that control large swaths of land, and are not necessarily eager to give governments credit for vaccination campaigns. Additionally, public health officials say, vaccine hesitancy and other pressing needs threaten to sabotage vaccination efforts. In Afghanistan, where the Taliban has recently taken over, COVID-19 vaccinations have already slowed.

Still, humanitarian negotiators are pressing ahead. "That's the reality of our profession â€" that we never give up," said Katia Papagianni, director for mediation support and policy at the Centre for Humanitarian Dialogue, a Swiss-based private diplomacy organization. These negotiations are informed by the growing recognition that, in order to successfully broker timeouts in fighting for "humanitarian access," mediators must engage with teachers, respected elders, women's groups, local businesspeople and other community leaders.

"It is not rocket science," Charles Deutscher, a policy adviser for the International Committee of the Red Cross (ICRC), wrote on the organization's Humanitarian Law & Policy blog in March. "It's investing time and showing empathy â€" drink more tea, sit with people and listen to them to understand their concerns, cultures and creeds before coming at them with a needle."

And when it comes to dealing with warring factions, those in the field say it's essential to stay politically neutral and to continually nurture the conditions for peace. "You literally have to negotiate every day," said Papagianni. "You may negotiate every morning and every afternoon, if that's what's needed."

Dee Goluba, senior director of field security for the humanitarian aid organization Mercy Corps, added that conflict parties will only allow aid workers access who have proven themselves to be outside of the fray, completely impartial. Humanitarian personnel must be "perceived as not helping the other combatants," she said. "Trust is everything."

Wars have stopped for mass vaccination campaigns before.

Though the WHO's smallpox eradication campaign was not history's first global vaccination drive â€" that honor belongs to the Spanish government's worldwide immunization effort against smallpox, which began in 1803 and deployed Edward Jenner's early vaccine â€" the WHO's program was the first and only to eradicate a human infectious disease.

Smallpox was the ideal target, in large measure for reasons that distinguish it from COVID-19. The smallpox virus can only be spread by people, meaning there were no hidden animal reservoirs, unlike the various species of bats and other mammals that harbor strains of coronavirus that have jumped to humans. Smallpox's symptoms were distinct and easy to identify, and the virus was not spread by asymptomatic carriers. There was a stable and highly effective vaccine. And smallpox lesions, which could scar a victim for life, were universally feared, regardless of politics. The United States and the Soviet Union â€" bitter Cold War adversaries â€" joined forces to rid the world of the disease.

Even with these advantages, expunging smallpox from the planet was a formidable undertaking. "It required the cooperation of all countries throughout the world and the active participation of more than 50," wrote the campaign's director, the legendary Donald A. Henderson, in 2011. The final push of smallpox eradication â€" one of the landmark achievements in public health â€" took place from 1976 to 1977 and had to work around wars in Ethiopia and Somalia.

In 1995, former President Jimmy Carter negotiated the Guinea Worm Ceasefire during a fierce civil war in Sudan. The nearly six-month-long pause in fighting was, at that time, the longest humanitarian ceasefire in history. It enabled health workers to care for those suffering from Guinea worm disease, a gruesome parasitic infection, and distribute aid and preventive health measures.

Perhaps the most fitting contemporary precedent was the 1980s launch of a series of pauses in fighting to facilitate childhood immunization campaigns. The first attempt was in 1985 in El Salvador, a country then in the throes of an ongoing civil war. UNICEF director James Grant was inspired by the concept of "children as a zone of peace," which called for children to be protected in conflict zones â€" an ideal he thought even antagonists with guns could agree on. Shuttling between the government of then-president José Napoleón Duarte and the Farabundo Martí National Liberation Front rebels, and relying on support from the Catholic Church, Grant negotiated three "days of tranquility" â€" temporal islands of calm that allowed health workers to immunize children against polio, measles, diphtheria, tetanus and whooping cough. Those first three days saw at least 250,000 children receive vaccinations; the pause in fighting occurred every year through 1991, dramatically reducing the incidence of measles and tetanus and helping eradicate polio in the country.

The "days of tranquility" model was taken up by the Pan American Health Organization for its Health as a Bridge for Peace program, which drew on effective communications and broad partnerships with local communities around planning and vaccine rollout to ensure success; the framework was adapted by the WHO for other parts of the world. During cessations of hostilities in the 1980s and 1990s, standard immunizations reached children in countries including Afghanistan, Cambodia, Lebanon and Sudan.

Today's conflicts are more complicated, making it tough to distribute COVID-19 vaccines.

In 2021, the notion of COVID-19 "days of tranquility" seems inconceivable. That's because most armed conflicts of late are waged not between countries but within the boundaries of nation-states, according to a 2018 report from the Peace Research Institute Oslo. The ICRC estimates that more than 50 million people live in territories fully controlled by armed nonstate authorities, and some 100 million live in areas where control by these groups is more fluid.

This breed of conflict is protracted and open-ended. An ICRC assessment in 2016 found that the average length of time the agency spent in the countries hosting its 10 largest operations was more than 36 years. As of August, the organization counted 605 armed groups in 44 nations that posed a concern to its humanitarian work; ICRC negotiators have maintained contact with 415 of these groups. Experts from the organization noted in March that "in some of the most complex recent conflicts, analysts have observed hundreds, if not thousands" of armed contingents present in a single country.

These groups "rapidly factionalize; opposing sides lack the funds or command structure to achieve definitive dominance; the conflicts multiply and move across populated terrain; and the fighting drags on for decades," said Jennifer Leaning, a senior research fellow and former director of the François-Xavier Bagnoud Center for Health and Human Rights at Harvard University, at a workshop on mental health in the Middle East in 2014. Nowadays, she continued, it's clear that "the primary pattern of war is intrastate, communalized or sectarian. These conflicts are waged by nonstate actors untrained in or dismissive of the laws of war, or are waged by oppressive, brittle or failing states against stigmatized groups of their own citizens or residents."

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A girl in Afghanistan is vaccinated against smallpox in the 1970s, a part of the WHO's smallpox eradication campaign. P. Almasy/WHO Photo

P. Almasy/WHO Photo

Hichem Khadhraoui, director of operations for Geneva Call â€" a humanitarian non-governmental organization focused on protecting civilians in armed conflict â€" borrowed, consciously or not, a word from current public health headlines to describe the situation. "The conflicts are mutating," he said in an interview posted to the organization's website. Negotiators for the ICRC, for example, may need to parley with 10 different commanders harboring 10 different opinions along a 10-kilometer road, said Esperanza Martinez, head of the organization's COVID-19 crisis team â€" a cast of combatants that, according to Khadhraoui, may change completely from one year to the next.

Such shape-shifting dampens the prospects of pandemic peace. "Who stands to benefit? I mean that's always what it comes down to, especially in ceasefire negotiations: pretty cynical cost-benefit analysis on the side of the conflict parties," said Tyler Jess Thompson, a senior expert on negotiations and peace process support at the United States Institute of Peace, a nonpartisan institute founded by Congress. "If you have a territory that's controlled by a nonstate armed group or a rebel group, more likely than not, the rebel group will welcome some kind of humanitarian assistance," he said, explaining that it can boost their legitimacy. "The flip side challenge to that is a government party not wanting rebel-controlled territory to be seen as governed or services being provided there. So there's a legitimacy battle."

"You have this very kind of difficult situation that we have in front of us now of who gets the credit for bringing in the vaccines," said Govinda Clayton, executive director of the Conflict Research Society. "It might be that, in the end, both parties decide it's just in both of their best interest just to continue fighting and not allow the vaccination campaign to happen, because they don't lose anything by doing that and they don't let the other side gain anything."

Some United Nations policies may be making the situation worse. February's Security Council Resolution 2565 explicitly excludes pandemic pauses in military operations against terrorist groups such as al-Qaida and the Islamic State. Many humanitarian organizations think that's a bad idea. "COVID-19 should reinforce the notion that, even when living under the control of armed groups and governments categorized by other states as terrorist, criminal or rogue, civilians remain simply that: civilians," noted a report published by the ICRC earlier this year.

"My personal opinion is that in order to solve COVID-19-related problems, humanitarian actors should engage with the authorities of these armed nonstate actors on the distribution of the vaccine," said Ezequiel Heffes, a senior policy and legal adviser at Geneva Call. But, he conceded, "This is where law and politics kind of split." According to international law, each party to a conflict is obliged to ensure that everyone within the territories it controls gets access to basic health care. But politically, some government authorities may not want to allot precious vaccines to people who seek to overthrow them.

Other observers questioned the secretary-general's rhetorical attempt to tie the humanitarian goal of providing aid to the political goal of promoting peace. "The more decoupled that can be, the better," said Thompson.

NGOs that work in conflict zones draw a glaringly bright line between politics and humanitarianism. "Humanitarian actors are very, very attentive to the importance of maintaining the space, what they call the 'humanitarian space.' And that means ensuring that they will never be accused of being partial to one side or another," Papagianni said. The four fundamental principles of humanitarianism are humanity, neutrality, impartiality and independence. This distinction and distancing from politics has become "even more acute the past few years," Papagianni noted, "given the fact that major humanitarian actors have been attacked in the field."

A report from the Safeguarding Health in Conflict Coalition found that 185 health workers died in conflict settings in 2020, more than in either of the previous two years. It also cited more than 400 attacks on health care efforts that specifically responded to the pandemic. In these incidents, health care workers "were abused, injured, threatened and harassed, and health facilities were attacked, damaged and/or set on fire," according to the report. Violence against health care efforts erupted, among other places, in Afghanistan, the Democratic Republic of the Congo, India, Mexico, Syria and Yemen.

People living in conflict zones have bigger problems to worry about â€" like poverty and hunger.

Another stumbling block to pandemic ceasefires is that civilians and combatants alike face threats that they regard as far more urgent than the coronavirus. In most areas affected by conflict, the leading causes of death are not combat-related but rather the indirect consequences of war: malnutrition, chronic diseases that go untreated because of failing public health programs and common childhood infections, to name a few.

Consider the catastrophe in Yemen, where the world's worst humanitarian crisis has been dragging on for years amid a vicious civil war. More than 100,000 people have been killed and 3.6 million displaced as a result of the conflict, according to a report written by Thompson for the United States Institute of Peace. The country has suffered the worst documented cholera epidemic in recorded history, with more than 2.5 million suspected cases since the outbreak began in 2016. Mothers and children are dying from preventable complications during pregnancy and birth. Famine is bearing down, with tens of thousands of people starving to death and another 5 million on the brink. In May 2020, according to The Lancet, of an estimated 30 million Yemenis, 24 million â€" 80% of the population â€" needed humanitarian assistance.

Yemen's ordeal transcends COVID-19. At the same time, the humanitarian disaster and the war that accelerated it have obstructed the pandemic response. Yemen's health system has been shattered by fighting, economic collapse and a recent shortfall in humanitarian funding. The Houthi movement based in the north â€" which has been fighting the pro-government coalition and controls Sanaa, the constitutional capital â€" has downplayed the coronavirus threat, withheld data on cases and deaths, and undermined international efforts to provide vaccines in areas under their control. Before agreeing to accept 10,000 vaccine doses, "one of the conditions the Houthi authorities set was that there should be no media coverage or social mobilization for a vaccination campaign," noted a June article from Human Rights Watch, a non-governmental organization that tracks human rights abuses around the world. "As of writing, the vaccination campaign hasn't happened in the north," it said.

On the same day in 2020 that the U.N.'s Guterres made his ceasefire appeal, a small Yemeni organization called Food for Humanity Foundation issued its own desperate ceasefire call. "With the world being engulfed in the coronavirus pandemic, the little attention that the Yemen war is getting has all but disappeared," it said. "But the war itself has not."

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Yemeni children from families who are affected by the war talk to a worker to receive their lunch meals at a charitable center in April. Tens of thousands of the country's people are starving to death and another 5 million are on the brink. Mohammed Hamoud/Getty Images

Mohammed Hamoud/Getty Images

Yemenis are not alone in objectively weighing the threat of COVID-19 against other perils. In Mali last year, after gunmen struck villages and killed at least 12 civilians, a local mayor said, "What is killing us isn't coronavirus, but war." This past February, a Somali cattle herder, who has lived most of his life in a region controlled by Islamist insurgents, told Reuters: "Before we get the vaccine, we need other things. We need food, water, health care and shelter. Our people are dying because of the basics in life. We will need the vaccine when we are liberated, now we are basically under siege."

Syria has been ravaged by 10 years of conflict and spent 21 years under the authoritarian rule of President Bashar al-Assad. According to a commentary published in April in The Lancet, since the beginning of the conflict in 2011, more than 585,000 people have died, child life expectancy has dropped by 13 years, more than half of the country's pre-conflict population has been displaced and at least half of public hospitals and public health centers are either "partly functioning or not functioning at all as of November 2020." Other reports from the Syrian American Medical Society note that almost 80% of Syrians live in poverty and three-quarters of health care workers have either left the country or been killed. A study last fall by Imperial College London estimated that only 1.25% of COVID-19 deaths are being reported in Damascus. Not surprisingly, coronavirus cases are now surging. As an article last year in Newlines Magazine foretold, "Syria appears to be headed into a desultory experiment with herd immunity."

Syrian feminist activist Hanadi Alloush said that many women in northern Syria whom she's spoken with don't even know about COVID-19 vaccines. She also underscored the near-collapse of the country's health system, the precarious fate of internally displaced people and the silence surrounding COVID-19 â€" a silence that has descended, she said, because civilians living in areas controlled by the Assad regime fear that if they so much as mention the virus by name, they will be detained. "What I want to share is that it is a very complicated situation that is beyond COVID," Alloush said, speaking through a translator. "A more holistic approach to address it is needed."

Part of that holistic approach, for all conflict zones, is public health support for non-pandemic emergencies. For example, humanitarian officials want to piggyback COVID-19 vaccinations on top of standard childhood immunizations, which have been severely interrupted by the pandemic. Gavi, the Vaccine Alliance, a global health partnership that aims to provide vaccinations to poor countries, estimated last year that 10.6 million children had not received a single dose of basic vaccinations in 2019, before the pandemic made the shots even more difficult. Measles â€" a vaccine-preventable disease that mostly kills children under the age of 5 â€" hit a 23-year global high in 2019, killing 200,000. According to a March report from the Johns Hopkins Center for Health Security, as of October 2020, 30 countries had "either fully or partially postponed" vaccine campaigns against measles during the pandemic. And according to the CDC, 41 nations have either "already put off, or may put off" their measles immunizations campaigns that had been scheduled for 2020 or 2021.

"For the last couple of years, Congo has been facing its largest measles epidemic," said Maria Guevara, the international medical secretary at Doctors Without Borders (also known as MSF). She added that a recent outbreak in the northwest of the country prompted MSF to run, amid coronavirus spread, measles vaccination campaigns. "That was their issue, not COVID," she said. "Measles were the thing, because kids were dying." And that's setting aside the country's other recent crises: Ebola, malaria, a volcanic eruption and scores of volcano-triggered earthquakes.

"It's a balancing act," said Guevara. "We need to just remember that in many parts of the world, COVID is not the only problem they're facing, unfortunately."

COVID-19 misinformation and vaccine supply add to the challenges.

Vaccine hesitancy could also impede pandemic ceasefires, experts say. The hesitancy is partly driven by mistrust in public authorities in places where long-standing corruption or abuses of power have amplified political grievances. Such mistrust was a major hurdle in containing the Ebola epidemic which emerged in West Africa seven years ago.

Misinformation is false or inaccurate information that is spread, regardless of the intent to mislead. Disinformation is false or misleading information that is deliberately disseminated. Both abound in places of instability. "Part of it is the globalization of the anti-vaccine movement. That has thrown a lot of cold water on immunization programs and has worked to discredit them or devalue them," said Peter Hotez, dean of the National School of Tropical Medicine at Baylor College of Medicine and author of the new book Preventing the Next Pandemic.

Falsehoods come in many forms. In Nigeria, some believe that both COVID-19 and its vaccines were engineered to wipe out Africans. In Somalia, the militant group al-Shabab has rejected the AstraZeneca vaccine as unsafe and has instead prescribed black seed and honey for COVID-19 sufferers. In Syria, a state-run radio station assured listeners that the coronavirus "loses potency in the Middle East's hot climate," according to Newlines Magazine. Meanwhile, in Myanmar, some citizens have decided to forego immunizations, not because of weaponized disinformation, but because the vaccines would be delivered by a military government that has in recent months killed hundreds of civilians.

Delays in vaccine production and distribution pose an additional challenge. While affluent nations pre-purchased more than enough doses to fully protect their populations, the COVID-19 Vaccines Global Access initiative, or COVAX, is desperately short of doses, and those it has acquired have not always reached the places that need it most. COVAX's distribution model is based on an equity paradigm. The plan is for the partnership's 92 low- and middle-income countries to receive proportionally similar allotments that would cover 20% of their populations. It prioritizes health care workers and other vulnerable groups first, with additional vaccine doses to follow as they become available. A "humanitarian buffer" of up to 5% of available doses will be set aside for certain populations â€" such as those living outside government-controlled areas.

According to a June report in The Lancet, of the 2.1 billion vaccine doses administered globally by that point, COVAX had facilitated less than 4%. As of July, COVAX estimates to have some 1.9 billion doses available for distribution by the end of the year, though this volume is not guaranteed. If the plan goes forward, COVAX should be able to reach at least 23% of the populations in 91 of those 92 low- and middle-income countries. (India was excluded from that estimate but will receive a "tailored package of support.") But 23% protection still leaves these nations well short of the coverage they need to achieve herd immunity.

At a National Press Club event in March, Mercy Corps CEO Tjada D'Oyen McKenna warned that the longer vaccines are delayed in reaching conflict-affected countries, the greater the risk for violence within those nations' borders. Mercy Corps teams have also seen that measures intended to curb the pandemic's spread have unintentionally fueled conflict, she said: "Government responses to the pandemic, including lockdowns and border closures, are fraying community trust; misinformation is proliferating; and competition for resources has intensified."

Why conflict zones must be prioritized for COVID-19 vaccination.

Conflict areas harbor the very conditions that promote viral spread. They are crowded. They may lack basic sanitation and health services. And people are on the move, often fleeing for their lives. "Getting displacement sites set up â€" water access, food, provisions â€" can take time," said Jennifer Chan, the director of global emergency medicine at Northwestern Medicine. "And knowing what we now know of COVID, that can increase the risk for transmission."

"The virus has a mutation rate that's almost clock-like," said Caroline Buckee, associate director of the Center for Communicable Disease Dynamics at the Harvard T.H. Chan School of Public Health. The more that the airborne SARS-CoV-2 is transmitted, the greater the risk that new â€" possibly more virulent, or more contagious â€" strains will evolve.

According to Buckee, an infectious disease modeler, it will be difficult to monitor new variants' circulation. Buckee's work depends on sound data: particularly, accurate viral sampling. Obtaining those samples requires a robust surveillance system â€" another casualty of war. "Without surveillance, you can't do models," she said. "In places where the health system is damaged or almost destroyed, surveillance is out the window." In the COVID-19 pandemic, she later added, that's been a defining feature: "You can't trust the data, especially the case data."

Chan, who has worked for years on humanitarian programming in disaster areas, added that poor internet connectivity in conflict zones makes it difficult to send out for expert analysis whatever data does exist.

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Health workers carry supplies as a part of the COVAX vaccination campaign in May in Goma, Democratic Republic of the Congo. In recent years, Congo has also faced a large measles epidemic and outbreaks of Ebola. Guerchom Ndebo/Getty Images

Guerchom Ndebo/Getty Images

Many public health experts fear that conflict zones will end up on the bottom of the global vaccine distribution list, because it is more problematic and more expensive to reach these places. If pockets of COVID-19 cannot be contained, they could spawn no-go zones around the world reminiscent of off-limits locales going back a century or more, said Leaning, the senior research fellow from Harvard. "It will be like the world was post-World War II to about 1970 â€" and certainly, actually, throughout much of the 19th century as well â€" where if you wanted to go to regions that were remote, you had to prepare to die from contagious or infectious disease." In 19th-century British India, for example, endemic malaria, plague, cholera and leprosy were major threats, while yellow fever and malaria on the West African coast helped give rise to the odious epithet "the White man's grave."

Claude Bruderlein, director of the Geneva-based Center of Competence on Humanitarian Negotiation, wants to change COVAX's equity model to one based on efficiency, prioritizing areas prone to major outbreaks. War zones and otherwise fragile states are precisely where alarming variants could develop, "but they are the last ones on the list," he said. "When are they going to vaccinate in Afghanistan?" he asked back in May, when battles between government troops and the Taliban were in a brutal phase, but the fundamentalist organization had not yet overrun the country. According to Our World in Data, a project of the nonprofit Global Data Change Lab, as of Aug. 11, only 0.6% of Afghans have been fully immunized against COVID-19. "This is a petri dish for variants," Bruderlein said.

Bruderlein also pointed out that many of today's conflict zones lack clear borders â€" meaning that people and the viruses they harbor can move around. He worries, for example, about Cox's Bazar in Bangladesh. With a population of nearly 900,000, it is the world's largest refugee settlement, housing in numerous camps mostly Rohingya who fled from neighboring Myanmar. "Five people in three square meters," Bruderlein said. If Bangladesh's health system collapses, the refugees in Cox's Bazar will simply leave.

According to Bruderlein, the same is true in most of the Horn of Africa and the Sahel, the semi-arid belt of land that lies between the Sahara to the north and savannas to the south. Here, state control is often nonexistent and some of the most protracted conflicts in the world are playing out. "The border doesn't exist, basically," he said. "You have hundreds of thousands of people moving over a few weeks."

How COVID-19 vaccines can be rolled out in conflict zones.

When the U.N. Security Council passed Resolution 2565 this year, calling for pauses in fighting to conduct mass vaccinations, it was, in effect, a green light for humanitarian agencies to do what they do best. "In contrast to the secretary-general's 'global ceasefire' idea in 2020, which was a welcome but ultimately quixotic appeal, Resolution 2565's focus on vaccination campaigns is rooted in decades of humanitarian action," Richard Gowan, U.N. director at the International Crisis Group, wrote in April.

Humanitarian professionals are primed for the task. But in conflict zones, their work requires earning and sustaining the confidence of all sides â€" coincidentally, the very same requisites for successful public health campaigns. "Localized approaches to conflict resolution are now widely accepted as the gold standard for building peace," wrote Amanda Long and Tyler Beckelman in a United States Institute of Peace commentary last fall. In his March post on the ICRC blog, Deutscher wrote: "Community engagement takes time, effort and money." That interpersonal investment, he said, is as important as cold-chain management â€" storing the vaccine under proper temperatures from the time it is manufactured until it is administered â€" and fielding enough qualified health workers.

Although Mercy Corps is not currently conducting broad-scale COVID-19 vaccination campaigns, the NGO has gleaned trust-building lessons from the past. According to Dee Goluba, it means reaching out to parent-teacher associations, soccer teams, Muslim clerics and many others. "We employ women who are local â€" mothers and daughters, schoolteachers â€" and we engage with women in our work on a day-to-day basis," she said. "Once you get mothers on board, the sons come on board, often. Once the sons are on board, their friends have a dialogue that makes its way to combatants, it makes its way within the community." The goal, Goluba said, is to sow accurate, science-based information throughout the local population.

Alloush, the Syrian activist, knows the dynamics of homegrown conversations firsthand. She directs the social and women's program at Damma Foundation, a community-based women's network founded in Syria but now based in Lebanon, where she has lived since seeking refuge from the war in 2015. Its mission is to support women engaged in peacebuilding and to provide humanitarian aid, education and relief services.

Between 2015 and 2017, Alloush said, Damma was active in the small mountain town of Madaya, Syria, which had been under siege for months by Syrian government forces and Hezbollah militia fighters â€" a total blockade that brought starvation and other horrors. Negotiating with suppliers that monopolized local trade, Damma volunteers helped bring in essential supplies â€" baby formula, milk, flour â€" according to Alloush. In 2012, in the nearby town of Zabadani, Damma contributed to temporary ceasefire negotiations that called for a halt to random sniping. The volunteers were able to achieve these demands, Alloush explained, because they were not perceived by combatants as acting out of self-aggrandizing motives. "Women, yes, they are the peacemakers," she said. "All our demands were purely civilian. We didn't have any military asks."

Young people, too, may have a role to play in vaccination campaigns â€" yielding another kind of peace dividend. "If you've got lots of young men and women putting their energy into the common good," such as vaccinating thousands of local people, "that's a really creative and pro-peace activity for them to be doing," said Hugo Slim, former head of policy and humanitarian diplomacy at the ICRC, and now a senior research fellow at the Institute of Ethics, Law and Armed Conflict at the University of Oxford.

He cited surges of youthful altruism in places such as Nigeria, South Sudan and Yemen. "It'll be the young people who do all this," Slim said, "because there's so many of them and because they're the ones that are going to have the energy and the agility and commitment to put on a Red Cross vest or a Caritas vest or an Islamic Relief vest," and help their local health service "for days and days and days."

Leaning can envision a grassroots network of competent volunteers to help administer the vaccine. Locals with deep roots in the community â€" from schoolteachers and students to long-haul tradesmen and women vendors in the market â€" could be trained to assist in immunization campaigns, with dedicated health workers on the ground to supervise and follow strict cold storage and distribution guidelines. All you need, Leaning said, is simply "any cadre of people who have an ethic of caring for a population."

Why ceasefires matter more than ever.

In the 17 months since António Guterres linked the "fury of the virus" and the "folly of war," a shadow has crossed the globe. On the viral side of the ledger, as of Aug. 24, the world has seen more than 212 million confirmed cases of COVID-19 and 4.4 million deaths. On the war side, according to the Armed Conflict Location & Event Data Project, political violence killed nearly 90,000 people in 2020 alone.

Did Guterres' poetic plea make any difference at all?

"Secretary-generals of the U.N. have to give those lofty calls. We know that very often, they're sort of calling into the abyss, as it were. But when they make that call, it does help give people an idea, potentially change a discussion, an environment," Slim said. "Even if, out of 50 conflicts, his call helps two conflicts to come to some arrangement â€" you know, that's good. That's good."

The fact that Guterres even broached the idea of a global ceasefire could have deeper reverberations. "The more you keep talking about these ideas â€" that you can have humanitarian ceasefires, that there are these things called humanitarian pauses â€" the more you keep them as real and as normal and as possible," Slim said. "If you never talk about them, they disappear from being options." When the next inevitable pandemic strikes, he added, people could point to instructive ceasefire precedents from today's crisis.

Esperanza Martinez, the ICRC COVID-19 crisis team head, grew up in Colombia, where, since the mid-1960s, violence has raged between the government, far-right paramilitary groups, crime syndicates and far-left guerilla groups. By some accounts, the civil war claimed more than 260,000 lives.

In the 1990s, Martinez earned her medical degree in the capital, Bogotá, where, she said, bombings were a fact of life in the narcotics trade and the war against drugs. To cap her medical training, she was sent to a rural community in the southern part of the country. The town was under the control of the army, but a few kilometers away, down by the river, it was ruled by left-wing guerillas. Martinez said she had to cross the frontlines of war to negotiate the safe passage of wounded patients.

What has stayed with her from her upbringing, and from her work as a medical doctor, she said, "is the deep appreciation for the resilience of people." Amid violence and deprivation, "They still send their children to school," she said. "They still hope to have a better future."

Martinez was grateful for the secretary-general's 2020 ceasefire call, "because anything that allows to diminish the suffering of people affected by armed conflict is very welcome," she said. But she harbors no illusions about the tangible results of Guterres' plea. "The reality is that, if we look at what has happened during COVID," armed conflict has not decreased, she lamented. "We have Nagorno-Karabakh, we have Tigray, we have devastating attacks in Afghanistan, we have growing violence in Iraq, persistent violence in Yemen. So wherever you look, really, the situation hasn't diminished." Indeed, she said, fighting has escalated in many places.

Martinez believes it's crucial to support these conflict-plagued regions â€" not only with COVID-19 vaccines, but with health care services, education, jobs and long-term investment in development programs that will eliminate the drivers of poverty, violence and migration. "Just work on the root causes â€" on inequality," she said. Today's disparity in vaccine distribution, she suggested, is merely one glaring example among many such inequities: "One thing that COVID has done is to underline that, disregarding of where we live, we are all exposed and we are in all of this together."

This story originally appeared in Undark, a non-profit, editorially independent digital magazine exploring the intersection of science and society. Madeline Drexler is a Boston-based journalist and a visiting scientist at the Harvard T.H. Chan School of Public Health. She is the former editor of Harvard Public Health magazine.

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