The Biden administration has announced that it will work with the World Trade Organization (WTO) to negotiate a deal to suspend intellectual property rights associated with the Covid-19 vaccines — a surprise move for the administration, which had initially resisted taking such a step.

The reversal came as Covid-19 deaths are mounting in India and elsewhere. The vaccination program in the US is going well, but much of the world is still waiting for vaccines, which has made the role of pharmaceutical companies and intellectual property in the global vaccine effort the subject of intense debate.

There is unanimous agreement on one thing: There is a lot of work to be done to speed up vaccine manufacturing and vaccinate the world. As the WTO’s General Council meets this week, patents have risen to the top of the agenda. India and South Africa have asked the WTO to waive intellectual property (IP) rules relating to the vaccines so that more organizations can make them.

The case for waivers is simple: Waiving IP rights might enable more companies to get into the vaccine-manufacturing business, easing supply shortages and helping with the monumental task of vaccinating the whole world. The case against them: Taking IP rights from vaccine makers punishes them for work that society should eagerly reward and disincentivizes similar future investment. Opponents have also argued this step would do very little to address the vaccine supply problem, which has largely been the result of factors such as raw material shortages and the incredible complexity and tight requirements of the vaccine-manufacturing process.

The debate has raged for the past several weeks — with Bill Gates as a notably outspoken defender of IP rights — but recently intensified as the Covid-19 crisis in low-income countries worsens.

Wednesday’s announcement unambiguously puts the US on record in support of such a waiver, a reversal from its previous position. “The Administration believes strongly in intellectual property protections, but in service of ending this pandemic, supports the waiver of those protections for COVID-19 vaccines,” US trade representative Katherine Tai said in an announcement.

Done correctly, making the IP associated with these vaccines available to the world can be a good first step — the more information-sharing here, the better. But it’s a small thing to do at a time when bigger commitments are needed. Waivers might help, but ending the pandemic worldwide is going to require so much more.

While the Biden administration’s decision is a positive development, but debates over intellectual property can also distract the world from the policy measures that could really end the pandemic: building our vaccine-manufacturing capacity, committing to purchase the doses the rest of the world needs, and working directly with manufacturers to remove every obstacle in their path.

Patents, trade secrets, and what you need to know to make a vaccine

To unpack what the Biden administration’s move means, it’s important to understand the role patents play in vaccine manufacturing.

When a pharmaceutical company makes a drug, it applies for a patent. The patent protects its intellectual property for a fixed amount of time, typically 20 years, after which others can make “generic” versions of the drug, which are generally a lot cheaper.

Simple enough, right?

When it comes to Covid-19 vaccines — and many modern pharmaceutical products — the situation is much more complicated than that.

First, a modern vaccine is often in a web of different intellectual property rights, with the vaccine manufacturer having purchased the rights to some elements of its vaccine from either other pharmaceutical companies or researchers.

The lipids (shells that contain the mRNA molecules) used for mRNA vaccines, for example, are licensed to Pfizer and Moderna, but other companies have the rights to them. Patents held by the vaccine companies are actually a fairly small share of what’s going on in this IP web. It’s better to talk more broadly about all of the intellectual property that goes into a vaccine: licensing deals, copyrights, industrial designs, and laws protecting trade secrets.

The other complication is that, while there are legal barriers to copying the existing vaccines, that’s not what’s really making them impossible for other companies to start manufacturing. Experts I spoke with emphasized that, generally speaking, the world’s entire supply of critical raw materials is already going into vaccines, and there are no factories “sitting idle” waiting for permission to start making them. What’s more, changing a factory’s processes to produce a new kind of vaccine is a difficult, error-prone process — which went wrong, for example, when a plant converted to make Johnson & Johnson vaccines spoiled millions of doses.

Moderna is an instructive example here. The pharmaceutical company made a splashy announcement in the fall that it would not enforce its Covid-19 vaccine patents. Despite that move, there is still no generic Moderna vaccine, and none of the experts I talked to believed one was on the horizon. (It turned out well for Moderna — get the PR bump from the announcement without suffering the financial drawbacks.)

In the long run, though, a world where everything Moderna, Pfizer, Novavax, AstraZeneca, and Johnson & Johnson know about manufacturing their vaccines was freely available online would make vaccines easier for other manufacturers to make. It would also make them cheaper and more accessible to countries that have had trouble getting them.

At a meeting this week, the WTO is considering requests from India and South Africa to waive the patents for the duration of the emergency. Most countries have their own patent laws, but international agreements about how they enforce each other’s patents — and disputes when countries suspect each other of ignoring IP concerns — tend to be mediated by the WTO.

Although the Biden administration’s announcement is a win for the pro-waiver side, the US isn’t the only country that needs to be persuaded for the WTO to agree on a patent waiver. For their part, the EU, the UK, Japan, and Switzerland have expressed opposition. But the US is influential in these debates, and the Biden administration’s about-face may well be decisive.

The case against IP waivers

Many global health researchers, Bill Gates (and the Bill and Melinda Gates Foundation), and some within the Biden administration have vocally opposed waiving IP rights on the Covid-19 vaccines, generally with two arguments.

First, they argue society should want pharma companies to invent vaccines like the ones they did for Covid-19, and waiving rights will make that less likely in the future by making similar projects less appealing targets for investment. Second, they contend that patent waivers will set that precedent without even speeding up vaccine manufacturing.

“For the industry, this would be a terrible, terrible precedent,” Geoffrey Porges, a research analyst at SVB Leerink, an investment bank, told the New York Times. “It would be intensively counterproductive, in the extreme, because what it would say to the industry is: ‘Don’t work on anything that we really care about, because if you do, we’re just going to take it away from you.’”

Perhaps most prominent among those who’ve taken this stance is Bill Gates. “The thing that’s holding things back, in this case, is not intellectual property,” Gates said in a controversial interview on Sky News. “It’s not like there’s some idle vaccine factory with regulatory approval that makes magically safe vaccines. You’ve got to do the trials on these things, and every manufacturing process has to be looked at in a very careful way.”

Instead of intellectual property, Gates’s argument goes, the problem is deep technical know-how: the important details of the process that goes into making a vaccine. This is an especially critical problem for the mRNA vaccines Pfizer and Moderna created because they use a new technique. (The mRNA vaccines give the body instructions it can use to make the spike protein on the coronavirus. From there, the body can recognize it and fight it off. This is different from the vaccines we’re all familiar with, which expose a patient to a dead or weak virus, or a chunk of a virus, to help prime the immune system.)

Moderna and Pfizer know not only the exact formula of their vaccines but also countless procedural details about making them successfully: equipment modification, temperature settings, how to troubleshoot common problems, different kinds of failure and what problems they indicate, and so on. Waiving IP protections won’t make this information available.

This isn’t an instance of Bill Gates going off message; it has consistently been the stance of his foundation. Last year, it worked to convince Oxford to partner with AstraZeneca on vaccine production, a partnership that has come under heavy criticism for having held back the Oxford vaccine’s potential for wider, cheaper sharing as AstraZeneca scaled up production slower than was hoped.

Why would advocates for global health want partnerships with for-profit pharmaceutical companies?

They contend that, if the world predictably waives patents for sufficiently critical medications and vaccines, companies will find it harder to attract investment when they work on those problems. And vaccines developed without a pharmaceutical partner — say, by a university — might have no luck being manufactured at the needed scale. “At our foundation, we believe that IP fundamentally underpins innovation, including the work that has helped create vaccines so quickly,” Mark Suzman, CEO of the Bill and Melinda Gates Foundation, wrote in February.

“From early in the pandemic, there were lots of smart people at the Gates Foundation thinking about how to structure financing and incentives for accelerating vaccine development,” Justin Sandefur, senior fellow at the Center for Global Development, a nonprofit think tank based in London and Washington, DC, told me. “To their credit, they worked on this really early on. They convinced themselves that IP was important.”

(In May, after the Biden administration’s reversal, the Gates Foundation actually reversed course, too, expressing support for a limited waiver.)

Many other global health experts have also made the case that waivers would be a bad idea. Vaccine makers “are already cooperating widely with competitors and generic manufacturers, including via voluntary licenses, contracted production, and proactive technology transfer,” the CGD’s Rachel Silverman argued in a CGD-hosted debate about whether to waive IP. “Diluting that commercial incentive may reduce their interest in pursuing the voluntary horizontal collaborations that are already driving scale.”

The case for IP waivers

The case for IP waivers is that, while there are definitely many other barriers to getting the world vaccinated, removing even one is better than letting it remain in place. As part of a no-holds-barred effort to get the vaccine to everyone, the world should do everything in its power to cut through some of the restrictions delaying vaccines, even if it will take additional steps for this particular action to make a big difference.

“There’s a question of where the onus of proof lies in this situation,” Sandefur told me. “The standard line you hear is, ‘Well, there aren’t that many factories that can do this.’ And I can’t point you to the [specific] factory that’s ready to produce AstraZeneca, but we want to free up the market to let the discovery happen.”

If you really want to get something done, it makes sense to address every possible thing standing in the way of getting it done, even if it’s not the biggest or most significant barrier. And while the vaccines genuinely are incredibly difficult to manufacture, those from Novavax, Johnson & Johnson, and AstraZeneca aren’t quite as out of reach as the mRNA vaccines from Pfizer and Moderna, and years of this fight are still ahead — time during which some company could, perhaps, pull off what has been dismissed as too difficult or even impossible and get generics off the ground a little faster.

What’s implicit in that argument is there’s actually only a small chance of seeing benefits from waivers. But, proponents of waivers argue, there’s also not much chance of harm. If it’s true other companies can’t make the vaccines easily, the IP waivers won’t undercut sales for the existing companies or disincentivize future R&D. Conversely, the only way the IP waivers could actually cut into existing companies’ profits is if they successfully incentivize more vaccine development. If that actually happened, the thinking goes, that’d be worth it.

Some supporters of IP waivers have argued the debate is essentially a matter of class warfare: Gates and Big Pharma against the global poor. But there are passionate defenders of the interests of low-income people on both sides of the IP waiver debate: Many experts who’ve spent their careers fighting for the world’s poor also see IP waivers as a counterproductive step. Smart people disagree on whether this approach does, in fact, increase vaccine access where it’s needed most, and whether it damages our preparedness for the next pandemic.

What the intense focus on IP waivers misses

Regardless of whether they were for or against IP waivers, everyone I spoke to agreed on one thing: IP waivers are much less important than just directly funding poor countries’ access to the vaccine.

Many people who aren’t opposed to IP waivers nonetheless caution against advocating for them because it could distract from better solutions. Silverman called waiver advocacy “an inefficient use of limited global advocacy/political capital for vaccine access.” IP is “not the point in the medium term,” Amanda Glassman, director of global health policy at CGD, tweeted Wednesday.

Her focus: urging governments to give money to Covax so there’s clear demand for increased manufacturing. Covax is supposed to purchase vaccines for the world but has found them scarce; the overwhelming majority of vaccines have been distributed in rich countries. Despite the devastating consequences of letting the pandemic rip through poorer nations, richer countries have been stingy with Covax, and it needs more resources to succeed.

“I think [waiving IP protections] is almost as much of a PR move as anything else,” Derek Lowe, a medicinal chemist who works on drug discovery in the pharmaceutical industry, told me. “There are a lot of people who are convinced that the only thing that’s holding back the generic vaccine is the patents, so the Biden administration said, ‘Okay, let’s see.’”

Indeed, the attention the debate over patent waivers has generated in the past week has obscured an important point: There’s no one trick to making vaccines widely available. Doing so is going to require commitments to buy billions of doses once companies make them, and months of hard work easing the supply bottlenecks that slow down production. Even if companies can manufacture generic versions of vaccines, they won’t do so without committed buyers — and that’s where committing to help poor countries purchase them really becomes essential.

In other words, it would be a mistake to take a victory lap following the Biden administration’s announcement. Even if legal barriers are addressed, countless practical barriers remain between here and vaccinating the world. If the IP waiver is a first step, great. But there are many steps to go if we’re to conquer Covid-19 in every corner of the globe.

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The world may have undercounted Covid-19 deaths by a staggering margin, according to an analysis released Thursday by the Institute for Health Metrics and Evaluation (IHME) at the University of Washington School of Medicine. The actual count may actually be 6.9 million deaths, more than double official tolls.

The United States alone is estimated to have had 905,000 Covid-19 fatalities, vastly more than the 579,000 deaths officially reported, and more than any other country. The calculation is based on modeling of excess mortality that has occurred during the pandemic.

The drastic difference highlights how difficult it is to keep track of even basic metrics like deaths when a deadly disease is raging. The higher toll also means the ripples of the pandemic have spread wider than realized, particularly for health workers on the front lines who have repeatedly faced the onslaught with limited medical resources and personal protection. And the undercounts have important consequences for how countries allocate resources, anticipate future hot spots, and address health inequities.

Researchers who weren’t involved with the analysis say it confirms what many already presumed: that official death counts were far, far off.

“Big picture, it’s not really surprising,” said Jennifer Nuzzo, an epidemiologist and a senior scholar at the Johns Hopkins Center for Health Security. “We’ve long suspected that the tolls of Covid are undercounted for a number of reasons, but probably a big part is having capacity to diagnose infections and count them.”

Now, with the number of reported cases around the world reaching new highs, the findings should serve as a stark reminder that disease surveillance and tracking remain dangerously inadequate, and that the world may have already overlooked some of the greatest tragedies of the pandemic. Preventing deaths going forward demands a coordinated international effort to contain Covid-19, vaccinate as many people as possible, and monitor the spread of the virus, led by countries with the most resources helping those with the fewest.

Otherwise, an even greater toll may lie ahead.

Almost every part of the world is underreporting Covid-19 deaths

To come up with the new estimate of 6.9 million total Covid-19 deaths so far around the world, the IHME team constructed a model that incorporated observations about the pandemic. They also constructed a baseline estimate of how many deaths there would have been in a world without Covid-19. The team drew on weekly and monthly death records from 56 countries and 198 sub-national locations — city, state, and provincial records — from places like the US and Brazil.

Researchers also drew on previously published death estimates. They then subtracted the anticipated deaths from the actual number of deaths to find the excess mortality stemming specifically from the disease.

Excess mortality is mostly due to deaths directly from Covid-19, but it also includes deaths indirectly caused by the pandemic like people unable or unwilling to receive medical care, a decline in vaccination rates for other diseases, an increase in drug use, and a rise in depression. So researchers tried to correct for these factors to get their Covid-19 death estimate.

It’s a well-worn approach in public health circles and has been used to calculate other health indicators like the global burden of disease.

The model showed that, around the world, more than half of Covid-19-related deaths are not labeled in the official tallies. And the actual number could still be higher.

According to Christopher Murray, the director of IHME, while just about every part of the world missed cases of Covid-19, some countries missed more than others.

“In many parts of the world — sub-Saharan Africa, India, Latin America, differences by state in Brazil and Mexico — you can account for much of the under-reporting because of lower testing rates,” Murray said during a press conference. “But there is this phenomenon — Egypt stands out, as do a number of different countries in Eastern Europe and Central Asia — where these excess mortality rate numbers suggest dramatically larger epidemics than have been reported that cannot be accounted for through testing.”

Egypt has officially reported just over 13,000 Covid-19 deaths, but IHME found its estimated death toll was more than 170,000. It’s not clear why the discrepancy is so large, but it shows Covid-19 epidemics in different countries can be far worse than the death reports reveal.

“We are absolutely, absolutely undercounting deaths,” said Ruth Etzioni, a professor and biostatistician at the Fred Hutchinson Cancer Research Center who was not involved in the study.

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IHME’s Covid-19 models missed the mark before, but researchers say they’ve improved

Scientists have also been critical of IHME’s past modeling work during the Covid-19 pandemic.

IHME’s forecasts last spring were criticized for projecting many fewer deaths than actually occurred. In March 2020, the organization projected fewer than 161,000 deaths total in the US. Then in April 2020, the group revised their death toll projections through August to be 60,415, with an uncertainty range between between 31,221 and 126,703 deaths. The projections were out of step with other epidemiological models, which were anticipating far more casualties from Covid-19.

The Trump White House, however, was eager to use the rosy IHME projections as the basis for planning for the pandemic and lifting public health restrictions, as well as a political tool to downplay the severity of Covid-19. “I was furious with [IHME], and I’m still kind of getting over it,” Etzioni said. “In the beginning, it was unacceptably un-rigorous.”

By the end of August 2020, more than 180,000 Americans had died of the disease.

“So far as I can tell, IHME has substantially improved their modeling from the early days of the pandemic,” said Alexey J. Merz, a professor of biochemistry at the University of Washington, in an email. “My major criticisms pertain to those early efforts, and IHME’s ongoing failure to address what went wrong, or to assess the (in my opinion, considerable) damage arising from those flawed estimates.”

Asked about IHME’s track record, Murray explained how his team’s Covid-19 forecasting improved and even outperformed other models. “For example, if you go back to August last year, we were forecasting the winter surge, and nobody else thought there was going to be a winter surge in the United States,” he said. “We spend a lot of time on our model trying to look at what are the long-term drivers so we have been able to pick up these long-term trends quite a bit sooner than others.”

Why the US official count is so low compared to the new analysis

It makes sense that countries with less robust health care systems and fewer resources would struggle to keep track of how many people are dying of Covid-19. But the US, a wealthy country that has a national Covid-19 death reporting system, also missed almost 40 percent of Covid-19 deaths, according to the IHME model.

That’s because while death can seem like a pretty obvious health indicator, the causes of death can be mercurial.

The problems start with the death certificate. Ivor Douglas, chief of the Pulmonary Sciences and Critical Medicine division at the Denver Health Medical Center, explained that death certificates emphasize the primary cause of death, which is the most immediate condition leading to the fatality. Death certificates also have space for secondary and indirect causes.

As the Covid-19 pandemic has revealed, the disease can manifest in myriad ways and leave lasting damage, even in people who had a mild illness.

So a Covid-19 death certificate could list something like a blood clot in the lungs as the primary cause of death, with Covid-19 as a secondary or indirect cause. Whether that specific death is then coded as a Covid-19 fatality could differ depending on the state. That local-level reporting has sometimes become politicized and led to discrepancies in death tolls.

And when Covid-19 first arrived in the US, many health workers didn’t realize what they were dealing with and thus didn’t include it in their paperwork. “I think the preponderance of missed cases were early on in the pandemic,” Douglas said. “Often, certainly early in the pandemic, there was the primary diagnosis without Covid-19 attribution.”

The missing Covid-19 deaths are also another manifestation of the inequities in US society. “If you’re poor, don’t have access [to health care], and die at home, you’re much less likely to have an attribution of Covid pneumonia as a cause of your death than ‘oh, you’re a sad old person with diabetes’ and that was the cause of death,” Douglas said.

That means that the groups that are being most severely harmed by Covid-19 may also be underrepresented in the official numbers. That makes it harder to properly allocate resources like tests, vaccines, and treatment to the most vulnerable people, forcing them to bear an even greater health burden.

“There’s real policy implications, it has political implications, and social justice implications, in my mind,” Douglas said. On the other hand, accurate monitoring could help mitigate the harms of the Covid-19 pandemic, helping health officials figure out not just where to deploy vaccines and treatments, but other factors driving transmission, like crowded living conditions. Intervening before infections begin to spread is what will yield the greatest dividends in containing the disease. “You cannot simply vaccinate your way out of this problem,” Douglas said.

Finding the true toll of Covid-19 is more urgent than ever

Regardless of how high the actual number of deaths is, the devastation of Covid-19 is clear. “Even the reported numbers are so utterly staggering that I’m not even sure doubling it should make us even more horrified,” Nuzzo said.

Still, the fact that Covid-19 deaths appear so vastly underreported should be a warning that the virus can still take millions more lives, and why containing Covid-19 is imperative for every country in the world. “We should feel more personally threatened by these numbers. And we should recognize it as a societal threat,” Etzioni said.

The devastating Covid-19 outbreak in India is all the more urgent now that multiple variants of Covid-19 that are more transmissible and better able to evade immunity are spreading around the world. As the virus continues to spread, the likelihood of even more dangerous variants arising will grow.

What’s more, the countries that have been reporting lower deaths so far deserve more attention. “Many of us contend that sub-Saharan Africa has been extensively devastated by the pandemic but because of lack of testing medical reporting, it appears as if there has been a relatively minor event there,” Douglas said.

As for countries that have so far been genuinely spared from Covid-19, they must remain vigilant and take active measures to keep the disease at bay. “It may be that they haven’t yet been hit or it could be that we don’t fully understand how they’ve been hit, but I want to put to bed this idea that any country has simply escaped the worst of it,” Nuzzo said. “The countries that have done the best are ones that have been very, very aggressive in responding to it.”

There’s a scene in The West Wing’s second season in which one of the protagonists is told a Chinese satellite is falling to Earth, but no one knew exactly when or where.

“A satellite is crashing to Earth, and NASA sent us a fax?” Donna Moss says, clearly concerned. But few in the show shared her fear, because debris in space often falls out of orbit and is either burned up upon reentry or lands harmlessly somewhere on the planet.

The US government estimates around 200 to 400 tracked objects enter Earth’s atmosphere every year — roughly one a day — out of the 170 million pieces of space debris floating above our heads. The fallen items rarely make news, though, since they usually crash into the ocean, which covers about 70 percent of the Earth’s surface, or sparsely populated areas.

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Yet news of a Chinese rocket falling uncontrollably to Earth has awakened the Donna Moss in many of us.

A section of the Long March 5B rocket, which launched China’s new space station into orbit last week, is expected to hit somewhere on the planet either on Saturday or Sunday, experts say. At 10 stories and 18 tons (36,000 pounds), it’s one of the largest items in decades to spiral in an undirected dive toward the Earth.

It could cause serious damage if it hits a major population zone, but so far few governments — especially the one in Beijing — seem overly concerned.

“The probability of this process causing harm on the ground is extremely low,” Chinese Foreign Ministry spokesperson Wang Wenbin said on Friday. The White House and Pentagon, meanwhile, say they’re tracking the rocket and have no plans to shoot it out of the sky.

After speaking with experts, two things have become clear about this episode.

The first is that the idea of a large rocket hurtling toward Earth is understandably scary. It conjures up images of a city devastated by the impact, potentially injuring thousands.

Importantly, the chance of anything like that happening is infinitesimally small — like 1 in a 196.9 million chance small. While there have been a few bad incidents in the past, nothing on that scale has ever happened, and very likely won’t now.

The second is that it’s troubling this scenario could happen in the first place. Why is it possible for China, or any other space-faring nation, to launch massive rockets and let them fall to earth willy-nilly?

The answer to that is policy failure: Despite regulations on space flight and conduct, the issue of rocket reentry is loosely and poorly regulated, so countries cut corners and take their chances that a falling rocket won’t hit anything major.

“We’re in the realm of risk management, and states are willing to swallow the risk,” said Christopher Newman, a professor of space law and policy at Northumbria University in Britain.

But there’s always the more-than-zero chance that their luck runs out and a falling rocket sparks a catastrophe. Experts are unanimous that the falling Chinese rocket is a symptom of a much larger problem that needs solving sooner rather than later.

“If you don’t want any more of this kind of thing to happen, we need the big powers to step up,” said Bleddyn Bowen, a professor of space warfare and policy at the University of Leicester in the UK.

How to stop the next falling rocket

There’s a trope about space that it’s the “Wild West,” a phrase I often catch myself using. But the truth is that there have been rules governing operations in space for decades.

In the Outer Space Treaty of 1967 and Liability Convention of 1972 are guidelines for how to punish a country that lets one of its rockets cause damage on Earth. Basically, those rules say that the offending state can be held liable by the victim nation. So, in this case, if the Chinese rocket were to land in the middle of New York City (which, again, is extremely unlikely to happen), the Biden administration could ask China to pay for damages and demand other recourse.

In other words, this is a state-to-state issue. “If the rocket lands on my house, I can’t go and sue China,” Northumbria’s Newman told me. That’d be UK Prime Minister Boris Johnson’s job to call up Chinese President Xi Jinping.

But that’s really it. There’s nothing in international law to stop any nation from letting any of the 900 rockets currently in orbit from falling in an unplanned way. “This isn’t illegal,” Newman said about the current saga of the Chinese rocket. “There is no sort of regulation on an international level on reentry.”

Individual countries essentially govern themselves when they make plans to launch a rocket into space. If the Chinese government is fine with the plan of an unplanned reentry, then that’s what’ll happen at the end of the mission.

Naturally, such plans cause frustration among space experts. “I think it’s negligent of them,” Jonathan McDowell, an astrophysicist at the Center for Astrophysics in the US, told the New York Times on Thursday. “I think it’s irresponsible.” Last year, in fact, another Chinese Long March 5B rocket burned up and pieces of metal fell onto a few buildings in the Ivory Coast.

But it’s important to remember two things.

First, China — and other leading space-faring nations like the US, Russia, Japan, and the European Union — know that the chance of hitting people or infrastructure is so small that they don’t feel the need to spend extra money and time to plan for a controlled reentry.

Ensuring a rocket splashes into, say, the Pacific Ocean, requires more fuel and staff work, which increases the cost of missions. For most space agencies grappling with small budgets, cutting costs on that part of the operation is worth the risk.

Second, and relatedly, China isn’t the only country taking their chances here; others, including the US, have as well, leading to some scary scenes.

In 1978, a Soviet satellite carrying a nuclear reactor crash-landed in northern Canada and spewed radioactive waste. The next year, the NASA-launched Skylab space station — America’s first one — fell out of orbit, with parts landing in the Indian Ocean and in Western Australia, though luckily hurting no one.

“Bad behavior was quite typical by the Americans and Soviets during the space race,” said Leicester’s Bowen. “Those who live in glass houses should not throw stones,” he said of current complaints about the Chinese rocket.

While there are more safety measures now and technology has improved, experts say the main problem is still that space law is too lax on this issue. They point to the Ivory Coast incident last year, where the country decided not to seek recourse from China, potentially out of the desire not to anger a key economic partner.

So what has to change?

Experts say countries like China, the US, and others should leverage this moment and work through the United Nations to regulate rocket reentry. They should compel space programs to spend more to ensure their rockets land far away from people, and even wildlife, when possible. Even if the risk of a calamity is extremely low today, the fact that it’s more than zero is already too high.

“If this is good for anything, it’s an opportunity for everyone to take ownership of space as a domain of human activity and to want a say in how it’s governed,” said Northumbria’s Newman. “We’re now at the stage where this is generating concern.”

But until there’s political will for such action — and governments take the rocket reentry problem seriously — we’ll have more Chinese-rocket-type scares.

While here in the US some are tentatively removing their masks and resuming small outdoor gatherings, others around the world are searching for air. In India, people need oxygen, and they need it now.

Last week, Covid-19 became India’s No. 1 killer. One million people in a country with a population of 1.3 billion are predicted to die of Covid-19 by August. As of May 7, 150 people were reportedly dying every hour, and while 29 million have been fully vaccinated there, vaccines are not what is most urgently needed right now.

When people are sick with Covid-19, many have trouble breathing, and the most important treatment is oxygen. But in India there is debate over whether there’s an oxygen shortage or a problem with accessing the existing supply.

Regardless, many people can’t get the lifesaving treatment they need just to breathe. Some oxygen systems, whether for hospitals or for individuals, require refills. Global systems of production, movement of goods, and tariffs all regulate who can get oxygen. In this case, people waiting outside hospitals are dying for oxygen, and this is perhaps why some in India are calling death from lack of oxygen a genocide.

The shortage of oxygen in India is not an unusual event. It is a reminder of interconnected networks that regulate production and supply, and that inequality means life for some and death for others.

Calls for solutions to the oxygen shortage from India’s top court and elsewhere continue, as do urgent messages like #SOSoxygen on Twitter and other social media where people list what they need.

As Ruchit Nagar, founder of Khushi Baby, an Indian NGO headquartered in Udaipur, Rajasthan, explains, “smaller hospitals are pleading, saying, ‘We only have a day of oxygen left and [many] people at risk of dying if we don’t get it in 24 hours.’ In some cases, that cry for help is met on time, but in other cases people literally run out of oxygen. … There’s no easy solution.”

All this is set against a backdrop of climate change, environmental racism, and poverty causing a scarcity of clean air. Poor air quality in India and elsewhere causes childhood asthma and adult lung disease. Housing shortages, overcrowding, and inadequate access to sanitation infrastructure contribute to fine particulate matter, raising risks for poor outcomes from Covid-19 and even increase the likelihood that the virus will spread. This combined with the lack of oxygen creates a dire threat.

As a group of researchers, writers, and medical providers in the US, we are watching these events unfold with grief, horror, and a painful sense of déjà vu from when the US experienced its own horrible surges in hospitalizations and deaths. This will not be the last crisis. But the steps we take to stem the suffering and devastation will inform how we handle future Covid-19 surges and other disasters in other countries. Today the lesson is about oxygen, something none of us can live without.

Why some Covid-19 patients need oxygen

Oxygen is a critical resource because Covid-19 can inflame the lungs and sometimes fill them with fluid, making it hard to breathe. Even asymptomatic people with Covid-19 can have signs of lung infections in X-rays and CT scans that may contribute to a sudden worsening of symptoms. The virus may also bind to hemoglobin, the protein in red blood cells that transports oxygen through the blood and delivers it to the body.

A person’s oxygen level should be 95 to 100 percent at sea level, though patients with chronic lung problems, like emphysema, can live at an oxygen level of 88 to 92 percent. But the National Institutes of Health considers people with Covid-19 who have oxygen saturation levels less than 94 percent to have “severe illness.”

Why? Lower oxygen levels force the body to work harder to supply enough oxygen to vital organs like the heart and brain. Death from Covid-19 is often from hypoxia — a form of tissue suffocation where the lungs are unable to absorb enough oxygen from the air being breathed — or respiratory failure, when the body is unable to get enough oxygen and basically exhausts itself trying. By contrast, early access to oxygen can help prevent patients from becoming critically ill.

How we get oxygen for medical use

The New York Times recently reported on a looming global oxygen crisis, but there were concerns about India’s oxygen supplies dating back to September.

In areas with more resources, oxygen is purified off-site into a liquid form, transported by trucks with massive tanks, and stored in hospitals. This oxygen is then delivered as a gas through piping built into hospitals. Patients receive oxygen through nasal cannulas (plastic tubes that go directly into their noses), masks on their faces, or ventilators.

Some remote hospitals have small plants that can continuously purify oxygen on-site. However, many lower-income communities globally are dependent on smaller individual tanks that need to be refilled. This is the most expensive form of oxygen delivery, costing about 10 times as much as the large-scale liquid version.

Individuals can purchase oxygen tanks, or “cylinders,” which don’t require electricity for use but need to be refilled when they are empty. Tanks last anywhere from less than one hour to nearly 40 hours, depending on how much oxygen the person needs.

Another option — one people are desperately seeking in India — is oxygen concentrators, smaller machines that can provide oxygen to one or a few patients. They are easy to use, are portable, can be placed near bedsides in homes and clinics, and can make oxygen on the spot from air and water. They are ideal for less severe cases of Covid-19.

Since they draw oxygen from the surrounding air, concentrators can cut down the need for constant refilling of oxygen cylinders and free up supply for more severely ill patients. They require batteries or an electrical source, but some designs can supply oxygen 24/7 for five years or more.

The response so far isn’t enough

The Indian government and the international community have been scrambling to increase the supply of available oxygen through multiple means. By the beginning of May, New Delhi’s daily oxygen demand surged to 976 metric tons, more than double its current supply.

Other countries have been donating liquid oxygen, and the Indian government announced plans to dramatically expand oxygen manufacturing abilities, but as of April 24 there were only 33 oxygen plants out of 150 requested. Hence, the majority of the country is relying on the more expensive, single-use forms of oxygen.

The biggest problem may not be the supply itself as much as access. Most oxygen production is on the coast, and special tankers are required to deliver it in larger quantities to population centers. The Indian Army and the Railways Ministry are assisting with the logistics of transporting oxygen tankers to the worst-hit areas.

Previously, hospitals might need a refill once a week, but now they need it daily. Unfortunately, it can take six to seven days for one tanker to make a round trip, and with increased demand, government officials and oxygen plant leaders expressed concerns about tanker shortages during the surge as well.

India temporarily exempted importing personal oxygen concentrators from customs clearance until July 31, paving the way for efficient donation and capacity for better crisis response. While the country’s finance ministry removed both customs fees and the goods and services tax (GST) for oxygen cylinders, the GST of 12 percent — down from 28 percent — still applies to oxygen concentrators, priced at $550 to $4,000. The courts are arguing that concentrators should be treated the same as oxygen cylinders and the GST removed.

With lockdowns creating barriers, raw materials imports are challenging. On top of that, the fractious to and fro between the central and local government on supply and demand worsens oxygen delivery gaps.

Meanwhile, on social media, families and communities are using #SOSOxygen and #OxygenShortage to make requests. With over half of India living without access to the internet, these requests are coming from those with the resources to ask, and they’re taking a significant risk to do so.

In Uttar Pradesh, India’s most populous state, individuals and hospitals can be punished for speaking out about the oxygen shortage, and at least one person has been arrested for tweeting a request for an oxygen cylinder, though this hasn’t stopped people from turning to this last resort.

“Some of the damage can be mitigated, but it’s a bleak situation,” says Nagar. “We’re not going to be able to stop the tsunami. We can try to save some lives, but the tsunami is going to hit. It already has.”

A quicker response to India’s crisis requires flexibility and knowledge from the ground

Today’s oxygen crisis in India feels similar to last year’s personal protective equipment (PPE) shortage in the US and Europe. But wealthier countries are no longer in desperate need of supplies. This gives the US an opportunity to renew its commitment to global health.

More oxygen doesn’t solve the pandemic, but it does save lives. And, in partnership with substantial prevention measures, it is part of a toolkit of strategies to stem the surge.

Technology has facilitated access to some oxygen and other supplies, including crowdsourcing of cylinders and hospital beds. Rural areas with high cellphone use now play public service announcements before each call encouraging the use of masks. And Nagar explains that some local and international organizations, like Khalsa Aid, “have been procuring oxygen concentrators, and some have been able to set up a drive-through situation, where … you can get access to a cylinder or refill your own.”

Perhaps most important to long- and short-term solutions is the ability to listen to on-the-ground needs and work with organizations, like Give India, that are already using locally appropriate tools to address the problems.

Effective international collaboration, like waiving regulations to speed up thoughtful production, helps. So does shipping and distributing the right kinds of technologies for acute care, such as oxygen concentrators, suction tubing, pulse oximeters, antibiotics, and PPE.

China and India, often at odds with border disputes, are collaborating to increase the supply of oxygen concentrators, Nagar says. The World Health Organization Covid-19 Essential Supplies Forecasting Tool can be used for country-level detailed supply calculations. Khushi Baby is also helping with data collection to predict the demand for oxygen and other supplies in upcoming weeks, and it is part of a network of NGOs collaborating to bring support where it is needed most.

The need for global solutions

The surge in India highlights our global interconnectedness, and the need for both global and local solutions to stem the pandemic. India was previously the primary manufacturer of vaccines but now is desperately trying to re-import them.

Meanwhile, other countries are waiting on contracts from India that can’t be filled. At the same time, the new variants that appear with each new surge of cases put all of us at risk, including the variant recently found in four states in India. These variants may lower the efficacy of our vaccines over time. India’s problem is everyone’s problem.

Gaurab Basu, a physician and global health leader at Harvard University, explains that we must shift from thinking about charity to thinking about justice, “not chasing global tragedy with oxygen containers.” He adds that our global experience right now parallels “the lack of federal government in the US for much of 2020 and how the states suffered from that.”

Global leaders and local health care workers can continue to improve triage and clinical care driven by local data. This, coupled with interventions like screening, testing, contact tracing, quarantining, and public service announcements focused on individual behaviors, provides a comprehensive, proactive approach to save lives.

These courses of action pave the way for a proactive and collaborative response to disasters in the future. There is a need for interconnected global systems designed to allow for listening to what’s needed on the ground. And right now, that’s oxygen.

Lisa J. Hardy is an associate professor of medical anthropology and director of the Social Science Community Engagement Lab in northern Arizona conducting international research on Covid-19.

Lawrence Weru is a consultant and digital storyteller who illustrates the sciences for a more just and sustainable world.

Nazia Sadaf is a family physician at PISES Riyadh, integrating patient care with artificial intelligence as a Forbes Ignite Impact fellow and change maker.

Jennifer Kasper is an assistant professor of Global Health and Social Medicine at Harvard Medical School with expertise in health and human rights issues in India.

Francesca Decker is a family physician with a master’s in public health who works in student health at Cornell University.

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White House chief medical adviser Anthony Fauci said he will not go into restaurants or movie theaters, even though he’s vaccinated. The Centers for Disease Control and Prevention says vaccinated people should continue masking up indoors and avoiding large gatherings. News outlets have reported on “breakthrough infections” of Covid-19 among the fully vaccinated.

All of this can make it seem like getting vaccinated may not be enough to liberate people from the fear of getting sick and the precautions they’ve taken to avoid the coronavirus in the past year. So I posed a question to experts I’ve talked to throughout the pandemic about Covid-related precautions: How worried are you about your personal safety after getting vaccinated?

They were nearly unanimous in their response: They’re no longer worried much, if at all, about their personal risk of getting Covid-19. Several spoke of going into restaurants and movie theaters now that they’re vaccinated, socializing with friends and family, and having older relatives visit for extended periods.

“I’m not particularly worried about getting ill myself,” Tara Smith, an epidemiologist at Kent State University, told me. “I know that if I do somehow end up infected, my chances of developing serious symptoms are low.”

Instead, experts said they mostly remain cautious to protect others who aren’t yet vaccinated. The vaccines are extremely effective — dramatically cutting the risk of any symptoms, and driving the risk of hospitalization and death to nearly zero. There’s some evidence that these vaccines also reduce the risk of transmission, but we’re still learning how much they prevent someone who is vaccinated from infecting another person. When experts are still taking precautions, it’s this concern for others that primarily drives them.

But, over time, they see even those concerns for others becoming less necessary, too.

“It’s about protecting others. Vaccination makes me essentially safe,” William Hanage, an epidemiologist at Harvard University, told me. “There’s accumulating evidence, too, that breakthrough cases are less likely to transmit (they have lower viral loads), so by being vaccinated I’m already helping protect others. But I’m also going to continue with behaviors consistent with lower contact rates in the community overall. As more and more are protected through vaccination, I’ll feel less and less of a need for that.”

As vaccination rates climb and daily new cases and deaths drop, experts said that people should feel more comfortable easing up on precautions, shifting the world back to the pre-pandemic days. That might happen sooner than you think — Israel’s experience suggests that cases could start to sustainably plummet once about 60 percent of the population is vaccinated, a point that could be just a month or two away in the US. And with 46 percent of Americans getting one dose so far, cases in the US have already started to decline.

As more of the population gets the vaccine, it’s prudent to keep masking and avoiding large gatherings, and for people who’ve been vaccinated to share their stories and encourage their friends and family to get vaccinated, too. But that’s not because those who are vaccinated are in any trouble. Even with the spread of the variants, the consensus among experts is that vaccinated people shouldn’t worry much about their own risk of Covid-19.