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To cite: Fassler E, Larkin A, Rajasekharan Nayar K, et al. BMJ EvidenceBased Medicine Epub ahead of print: [please include Day Month Year]. doi:10.1136/ bmjebm-2021-111789 © Author(s) (or their employer(s)) 2022. Reuse permitted under CC BYNC. No commercial reuse. See rights and permissions. Published by BMJ. Introduction Massive economic inequality, poverty and structural racism, in addition to intellectual property laws and regulations, are creating the conditions for gaping inequities in COVID19 vaccine distribution. Journalists, activists and public health practitioners have characterised the largely preventable public health crisis as vaccine apartheid. At the time of this writing (January 2022), just 9.7% of people in lowerincome countries had received at least one shot of the COVID19 vaccine, compared with 60.6% globally. Vaccine inequities have also been observed within multiple countries such as India and South Africa. 3 Efforts to bridge the gaps are largely failing. In April 2021, with input from the World Bank and consultants including McKinsey & Company, the WHO and other allied organisations launched the COVID19 Global Access initiative (COVAX), in a stated attempt to address vaccine inequity by facilitating the global coordination of vaccine production and distribution. But COVAX is doing little to challenge the intellectual property regime or power of pharmaceutical companies and the World Bank. Wealthier countries are hoarding vaccines by placing advance orders for hundreds of millions of doses at the expense of poorer countries. As a result, many may not be able to vaccinate the majority of their populations until 2024. Without major structural changes to the global economic order, health inequities related to vaccination are likely to remain a grim reality. In this context, public health researchers, policymakers and other stakeholders could help generate evidencebased vaccine distribution strategies and identify barriers that prevent these strategies from being enacted.