Paxlovid, which Pfizer expects to earn it $22 billion this year, is a combination of two antiviral drugs called nirmatrelvir and ritonavir. Recent trials have shown that for high-risk patients with mild to moderate COVID infections, it reduces the risk of hospitalization by 85%. Hence the “strong recommendation” that the WHO announced Friday.

However, the United Nations public health agency is deeply unhappy with how Pfizer is rolling out the lifesaving pills and called on the pharma giant to make sure Paxlovid doesn’t end up going predominantly to rich countries.

“WHO is extremely concerned that—as occurred with COVID-19 vaccines—low- and middle-income countries will again be pushed to the end of the queue when it comes to accessing this treatment,” it said in a statement.

There are good reasons for the WHO to be worried.

There may now be a global glut of COVID-19 vaccines, but that’s a recent development; the pandemic’s second year was largely characterized by rich countries hoarding doses, drugmakers refusing to hand over their intellectual property to other manufacturers to expand production, and poorer countries therefore being left in the lurch.

Now it looks as though history is repeating itself. This time round, there may not be implications for the emergence of new variants in the developing world, as was the case with inequitable vaccine distribution. But the moral argument—about people in poorer countries being denied the chance to avoid severe disease or death—is similar.

Unlike with its Comirnaty COVID-19 vaccine, Pfizer has opted to allow the production of licensed generic versions of Paxlovid in lower- and middle-income countries, by signing an agreement with the UN’s Medicines Patent Pool. (Rival drugmaker Merck did the same with its molnupiravir COVID therapy, after experts expressed fears about rich countries again pushing to the front of the queue.)

Pfizer’s deal with the MPP has limitations, however. It covers only 95 countries, and there are arguments underway about some that are not on the list, such as the Dominican Republic, where Pfizer has earned activists’ scorn by arguing that forcing it to issue a license would breach its “human rights.”

That’s one issue on the WHO’s radar. The agency also said Pfizer’s lack of transparency is making it hard to figure out “the availability of [Paxlovid], which countries are involved in bilateral deals, and what they are paying.”

“WHO therefore strongly recommends that Pfizer make its pricing and deals more transparent and that it enlarge the geographical scope of its license with the Medicines Patent Pool so that more generic manufacturers may start to produce the medicine and make it available faster at affordable prices,” it said.

In an emailed statement, Pfizer responded by saying its current strategy “considers the current evolution of the disease and the impact of infection prevention and control measures to optimize overall supply and access of a safe and effective treatment to the most vulnerable parts of the world.”

“Our work is not done,” it added. “We are in continued conversations with a number of private partners and international organizations to provide Paxlovid to lower income countries.“

But the People’s Vaccine Alliance, a group of NGOs that has pushed for greater COVID vaccine equity, says “rich countries have already reserved most of the [Paxlovid] doses that will be available this year,” thus replicating what happened with vaccines.

“Pfizer is abusing equity measures like the Medicines Patent Pool to gatekeep who can and can’t produce this lifesaving therapeutic,” said policy adviser Julia Kosgei in an emailed statement. “Many countries are excluded from the pool’s license, including most of Latin America. Yet Pfizer is claiming that issuing a compulsory license to produce the medicine in the Dominican Republic would be a breach of its human rights. It’s utterly shameless.

“Pfizer must expand the license with the Medicines Patent Pool to include all developing countries. And world leaders must agree on an intellectual-property waiver so that the global south can affordably produce COVID-19 vaccines, tests, and treatments.”

It’s worth noting that the WHO didn’t cite Pfizer’s policies as the only hurdles to the equitable deployment of Paxlovid. It also noted that a paucity of prompt and accurate testing in low-income countries made it difficult to catch COVID infections in their early stages, which is when Paxlovid is effective. “Improving access to early testing and diagnosis in primary health care settings will be key for the global rollout of this treatment,” it said.

Meanwhile, on Thursday it emerged that WHO Director-General Tedros Adhanom Ghebreyesus will directly address Moderna’s shareholders at the COVID vaccine producer’s annual general meeting next week, to urge them to support an Oxfam America proposal aimed at expanding access to Moderna’s vaccine technology.

A similar resolution, also calling for feasibility studies around technology transfers, will be put forward at Pfizer’s AGM, while Johnson & Johnson’s shareholders will be urged to back more transparency on J&J’s vaccine pricing.

Clarification: This article was updated on April 25 to clarify that the issue of rich countries pushing to the front of the queue for Merck’s molnupiravir was theoretical.