More than 3bn doses of the Covid-19 vaccine have now been administered worldwide. But as the campaign forges ahead, one continent lags far behind the rest. Africa, home to 17% of the global population, accounts for less than 2% of the shots given to date. In the scramble for vaccines, wealthy countries have come out on top, shoving Covax – the global procurement mechanism on which most of Africa relies – to the end of the queue. The continent’s drive was dealt another blow when India, overwhelmed by a wave of infections, suspended the export of Oxford/AstraZeneca doses manufactured by Covax’s largest supplier, the Serum Institute of India. With shipments unlikely to resume until the end of 2021, only seven out of 54 African nations are on track to immunise even 10% of their populations by September. The G7’s pledge to donate 1bn doses over the coming year is a welcome break from the vaccine nationalism that has marred the battle against Covid-19. However, it offers little immediate relief in settings such as Uganda and Zambia, where coronavirus is surging but the resources required to respond – vaccines, oxygen, diagnostics, ICU beds – are not. With the highly transmissible Delta variant detected in 16 countries, the consequences of vaccine scarcity are growing direr by the day. Hobbled by broken promises and reliant on foreign suppliers, Africa’s vaccination drive reflects an acute lack of global solidarity. It should further compel us to reckon with a more chronic disparity: Africa, the continent with the largest burden of infectious diseases, has the scantest capacity to make the tools needed to lessen it. An exploratory study published in 2017 identified just eight African companies with “existing or potential vaccine manufacturing capacities”. Most could perform only downstream steps, such as packaging, labelling and distribution. More than 99% of the vaccines administered on the continent were imported from overseas, leading study authors to warn that such “dependency on suppliers outside Africa is a source of vulnerability” in the face of outbreaks. Current struggles against Covid-19, like previous ones against Ebola and pandemic influenza, have thrown this vulnerability into sharp relief. They also provide an impetus to redress the balance. The spread of dangerous variants and the potential for waning immunity make clear that a strategy based solely on dose donations won’t suffice. Bringing the pandemic to heel ultimately requires a dramatic expansion of the global vaccine supply, which in turn requires an expansion of global manufacturing capacity. And at least some of that capacity should be built in Africa. Messenger RNA vaccines, such as those made by Moderna and Pfizer/BioNTech, are especially attractive candidates for scaling-up. These latest breakthroughs in vaccinology are proving remarkably effective against both symptomatic and asymptomatic infection, with early evidence supporting the likelihood of long-lasting protection. Unlike other inoculations, mRNA vaccines don’t rely on cumbersome production processes involving cell culture; their manufacture is thus faster, simpler and less prone to biological variability, and can occur in smaller facilities with lower upfront capital costs. Although their long-term storage is relatively more demanding – Pfizer/BioNTech vials must be kept frozen at around -70C – cold chain requirements need not preclude their use or production in Africa. Health authorities in Rwanda, which in March became the first African nation to receive Pfizer/BioNTech doses through Covax, acquired five new ultra-cold freezers, along with refrigerated vehicles and specialised coolers, in advance of the shipments. Storage needs are expected to become less stringent as the thermal stability of mRNA vaccines is better understood and as improvements are made to their formulation. For instance, both the Moderna and Pfizer/BioNTech vaccines can now be safely stored in a standard refrigerator for up to a month. What’s more, the mRNA platform allows for swift adaptation against emerging variants, and for rapid vaccine development to counter novel pathogens. It also holds promise against more familiar infectious killers, including HIV, influenza, Ebola, Zika, dengue, rabies, malaria and tuberculosis. Prioritising the adoption of this technology can help ensure that Africa doesn’t miss out on the “mRNA revolution” now unfolding in medicine. African leaders took a step toward this goal in April, when a conference hosted by the African Union and Africa Centres for Disease Control spawned an ambitious partnership to accelerate continental vaccine manufacturing. Rwanda, for example, expressed keen interest in serving as a regional production hub for mRNA Covid-19 vaccines. But with mRNA vaccine research, development and manufacturing knowhow concentrated in the United States and Europe, Africa shouldn’t be left to go it alone. Sustained partnerships are required in at least four key areas. First and perhaps most pressing is the need for technology transfer – the sharing of vaccine recipes, industrial processes, technical guidance and related intellectual property – from those currently making coronavirus jabs to those wishing to do so in places like Rwanda, Senegal and South Africa. To facilitate this exchange, the World Health Organization is establishing a tech transfer hub, which will train personnel from developing countries in the manufacture of mRNA vaccines. Moderna, Pfizer and BioNTech should lend their expertise to this effort. Governments, especially those that made massive public expenditures to yield coronavirus vaccines in record time, should also assume a more proactive role in brokering technology transfers with African partners. Second, local production demands ready access to financing. A number of supporters have recently joined the African Development Bank and other pan-African organizations in pledging resources toward a homegrown vaccine industry. These include the European Union, the Mastercard Foundation, the International Finance Corporation and several bilateral development-finance institutions. Other governments, donors and investors should follow suit. Third, investments in manufacturing must be accompanied by a strengthening of regulatory systems. Though almost all African nations have authorities responsible for overseeing the safety, efficacy and quality of medical products, many lack the wherewithal to meet international standards. Nevertheless, Ghana and Tanzania are now certified by the WHO as having “stable, well-functioning and integrated regulatory systems”, and rapid gains toward this benchmark have been recorded in Rwanda, among other countries. The pandemic has also renewed momentum to inaugurate the African Medicines Agency, which will harmonise regulatory activities across the continent and integrate vaccine markets. Fourth, a vibrant vaccine industry depends heavily on the cultivation of capacity for biomedical research and development. The pace at which Covid-19 vaccines were developed was due in large part to basic scientific research that had been under way long before a novel coronavirus arrived on the scene. Also pivotal was a robust infrastructure for clinical trials. Yet both of these elements are scarce in sub-Saharan Africa: there are only about three masters-level vaccinology training programmes, and a meagre 2% of vaccine clinical trials are conducted in the region. Resource-rich universities and medical research institutions are well positioned to accompany their African counterparts in addressing these gaps. Vaccine production in Africa isn’t without challenges. Chronic underinvestment has entrenched a uniquely complex system of vaccine procurement and financing that may deter the growth of local producers. Approximately 70% of Africa’s routine vaccines originate in a single country, India, whose impressive drug-makers can crank out low-cost, high-quality vaccines at massive scale. To emerge in this ecosystem, African manufacturers will require multiyear commitments from funders and partners, a rarity in a field of global health that’s fixated more on short-term solutions than on long-term accompaniment. Moreover, an expanded supply of vaccines, whether homegrown or imported, doesn’t invariably guarantee their equitable distribution. That neglected task requires a community-based health system capable of serving those at highest risk of affliction but least likely to receive the interventions known to reduce it. In the US, where coronavirus jabs are abundant, the weakness of said system has led to a rollout patterned by glaring social inequalities. Although several African health systems have demonstrated superior rollouts – Rwanda began vaccinating a mere 48 hours after receiving its initial Covax doses and administered them all within three weeks – others will require more support if the benefits of local production are to reach those in greatest need. While such obstacles warrant scrutiny, none are insurmountable. Cynicism about the feasibility of vaccine production in Africa only legitimates inaction. Besides, there is ample cause for optimism. Demand for vaccines in Africa is likely to soar in the coming decades, driven by rapid population growth, development of new vaccines (like those against malaria or Lassa fever) and efforts to broaden access to underutilised ones (like those against rotavirus or human papillomavirus). A handful of manufacturers have also succeeded in striking agreements to help make Covid-19 vaccines, including the Institut Pasteur de Dakar in Senegal, and Aspen Pharmacare and the BioVac Institute in South Africa. No formal partnerships have yet been announced for African manufacture of an authorised mRNA vaccine, though momentum for it is gathering force. As we contend with a scandalous divide in access to coronavirus vaccines, we are reminded that while microbes readily cross borders, their remedies (and the cumulative scientific knowledge underlying them) are often blocked at customs. Nowhere has this paradox been more marked than in Africa, where the vaccine apartheid of today is just the latest in an enduring chain of medical injustices to befall the continent. But if pandemics invite “humans to break with the past and imagine their world anew” – to cite the novelist Arundhati Roy – then Covid-19 affords us an opportunity to rethink how and with whom the fruits of modern science are shared. We can start by letting Africa make the vaccines needed to end this pandemic and stave off the next one. Paul Farmer, infectious disease physician and anthropologist, chairs the Department of Global Health and Social Medicine at Harvard Medical School and co-founded the nonprofit organisation Partners In Health. Ishaan Desai is Farmer’s research assistant and supports his teaching and advocacy. Dr Agnes Binagwaho is vice-chancellor of the University of Global Health Equity and a former minister of health of Rwanda