COVID-19 is now the second-leading cause of death in the U.S. for 2020. The virus has killed more than 90 people per 100,000, reports Johns Hopkins University.

But in other parts of the world, the virus hasn't been such a big problem. It's not a top killer. Some global health experts are beginning to askwhether immunizing large swaths of the population is the best use of resources for these countries.

That's a question that Dr. Chizoba Barbara Wonodi of Johns Hopkins University has been thinking about as mass nationwide vaccine campaigns begin rolling out in rich countries such as the United Kingdom and the United States.

The inequalities in global vaccine access are already in sharp focus. Over the past several months, wealthier countries have purchased or claimed enough COVID-19 vaccine doses to immunize their entire populations multiple times over, leaving little vaccine for low- and middle-income countries. That's left some governments and global health organizations scrambling to help poorer countries acquire doses.

Yet Africa, as a whole, has fared much better during the pandemic than North America and Europe. The continent, with 1.3 billion people, recorded only about 2.3 million cases, while the U.S., with only 330 million people, has recorded 15 million cases.

Wonodi directs the International Vaccine Access Center for Nigeria. She spent February to October in the country and is now based in Baltimore. She talked to NPR about her views on global vaccine inequities and what a potential immunization campaign could look like in Nigeria — which has 0.6 deaths per 100,000 people, 150 times fewer deaths per capita than the U.S.Her interview has been edited for clarity and length.

Do you see a big inequality in access to the COVID-19 vaccine, or do you think the situation isn't as concerning as the media has portrayed it?

That's a good question. And I think it's a question people are not daring to answer. Because then they would be upturning long-held narratives around inequality.

Most of the time, you hear that the burden of disease is in the global south. But now the tables have turned. Now the burden of disease — that is the burden of COVID-19 — is in the global north [Western or developed countries]. That's unfortunate. Nobody wants the burden of disease to be anywhere. But what that means is that in Nigeria, we have to recalibrate our default approach to solving the problem. And we have to reassess whether the long-held narrative of inequality still holds true.

I think, fundamentally, all countries should have access to vaccines. And then each country decides whether to use it and to what degree.

With COVID, even though the burden of disease is mostly in the north, you can't deny that some people are dying in the global south. And many countries are seeing knock-on effects of the pandemic, especially on the health care system.

In Nigeria, the pandemic has decreased people's confidence and trust in the system. So that has deterred people from seeking care. The vaccine might not alleviate a great burden of disease in Nigeria, but it might help us get back to normal faster. So, the imperative for equity still stands. It's just for a different reason.

Now that the tables have turned and the COVID-19 burden is in Western countries, you said that Nigeria needs to "recalibrate" its "default approach." Can you explain a bit more what you mean by that?

For one, I think that the African countries need to come up with their own solutions to the pandemic. Now that we know a bit more about COVID, we can't just copy what's happening in the rest of the world.

When the pandemic started, and we saw what was happening in Italy, everybody was scared. So Nigeria and other countries in Africa locked down, just like in Europe and America. But those lockdowns have been devastating economically for many people, just devastating. And that economic devastation has possibly spawned some social unrest. People are hungry.

We need to look beyond a copycat response. We need our own data to be able to make our own decisions about what works best in our context.

For example, the Africa Centres for Disease Control and Prevention is talking about acquiring doses for 60% of the population in Nigeria and other African countries. But it's not clear to me where the doses are going to come from, who's going to pay for them or even whether we need to vaccinate 60% of the population.

If you look at how low the disease burden is in Nigeria, including the mortality and morbidity, you start to question whether it's worth spending the money to vaccinate 60% of the people.

We need to run the numbers. We need to assess the relative benefits of widespread vaccination compared to addressing other pressing health care problems in Nigeria. Say you vaccinate 80% of the population at a given cost versus putting that money into another health care problem, such as malaria. What do we get? What's the bang for our buck for each of the two scenarios?

That all said, there are some priority groups, such as health care workers, for which vaccination will provide huge benefits. Immunizing these people will reduce the burden on the health care system and the mortality and morbidity.

What is the timeline for getting these high-risk populations vaccinated in Nigeria? When will the first doses become available?

I've heard that doses could become available as early as the middle of next year. So now, Nigeria and other countries are getting ready to roll out the vaccines. There are a number of things that need to be put in place.

This vaccine is going to be given to adults. The medical system is currently set up to focus on childhood vaccination. We're going to have to figure out how to deliver vaccines to adults and health care workers.

At the same time, all the people who are supposed to be vaccinating kids will now be working to get the COVID vaccine ready. We have to make sure routine immunizations for children don't suffer. We have to balance the two goals.

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