Author: John Barugahare, Ph.D.Department of Philosophy, Makerere University
Author: Joseph Millum, Ph.D., M.Sc.Clinical Center Department of Bioethics & Fogarty International Center, National Institutes of Health
The world’s best hope for bringing the Covid-19 pandemic under control lies in an effective vaccine. Right now, at least 148 vaccine candidates are in both preclinical and clinical stages of development and 17 are already being tested in humans. The ambitious goal is to have a safe, effective vaccine ready for distribution sometime in 2021. Meanwhile, many world leaders speak of a future vaccine as a “global public good,” with the optimistic implication that it will be made available to all those who need it in an equitable way.
The question of equitable access to a COVID-19 vaccine is a litmus test for morality in global health governance. The discussion so far has raised two critical questions. First, who will pay for developing countries’ access to COVID-19 vaccines? They are at risk of not getting access to the vaccine in time, or not getting enough doses, due to their comparative lack of resources. Second, who will get the first doses of the vaccine? Developing countries face the prospect of richer countries pushing them to the back of the queue despite their comparatively greater need.
The resource-scarcity problem calls for the definition, affirmation, and fulfilment of moral obligations of rich countries to support low-income countries to obtain the vaccines they need. On the other hand, the question of who gets vaccines first implicates the issue of the legitimate limits of nationalism in response to global public health emergencies. In this blog post we ask: in efforts to ensure equitable global access to a COVID-19 vaccine, how much is too much to ask of rich countries in terms of fulfilling their moral obligations?
Resource-Scarcity. With regards to the resource-scarcity problem, there is some progress, at least in principle, and partly in practice. This can be seen in the COVID-19 vaccine financing mechanisms, such as those being set up by the Coalition for Epidemic Preparedness Innovations (CEPI), and the Gavi Covax Advance Market Commitment (AMC). The goal of these financing mechanisms is to subsidize vaccines for low-income countries to enable them timely and less costly access. However, given current estimates of the amount of money that will be needed—for research and development, as well as manufacturing and delivery of the vaccines—there is a substantial risk of insufficient support. So far fundraising has relied exclusively on offers from nongovernmental charities and governments. While this mechanism of financing might raise sufficient resources, it does not guarantee them. This mode may need to be supplemented with explicit requests from the international community for high-income country governments to provide support proportional to their gross national products.
In the spirit of global cooperation and given the potential devastation in low income countries from COVID-19, a proportional COVID-19 vaccine resource contribution from national governments does not seem too much to ask. Even if the international community’s request cannot generate enforceable obligations on countries, at least international peer pressure and the threat of moral guilt for non-compliance with an explicitly assigned moral obligation is likely to induce some reasonable level of compliance. We accept that equity in global health financing entails that all countries should contribute according to their ability. It will be symbolically important to assign low income countries their proportionate share of financing responsibility too, howsoever small it may be.
Priority of Access. Global vaccine manufacturing capacity is limited. Even when we have a vaccine it will be months before sufficient doses can be produced to vaccinate the world’s population. Who should receive the first few millions of doses? The issue of priority of access to initial doses of a COVID-19 vaccine is complicated, and is likely to be one of the most difficult to resolve, more so if we do not tolerate certain ethical compromises.
A variety of frameworks have been proposed for distributing vaccines in a pandemic within countries. These frequently recommend prioritizing workers who are essential, especially health care workers, and the people who are most vulnerable to the disease. Arguably, if priority of access was to follow a ‘need criterion’ at an international level, developing countries would be at the very front of the queue. They have fewer health care workers, a greater burden of non-COVID-19 disease, and many more individuals for whom the economic consequences of extended lockdowns will be catastrophic.
Providing a vaccine first to priority groups in developing countries might be the moral ideal – “the right thing to do”, as Muhammad Ali Pate has put it – but it is not anybody’s right. Indeed, “expecting any country to export vaccine before serving its own population is simply wishful thinking”. In the world as we know it, asking a high-income country which has made a heavy investment of tax-payers’ money into the vaccine to surrender priority of access to developing countries would be too much to ask. Consequently, this view goes, “the best equitable access we can achieve is a fair global distribution after the first country gets it”. The question that remains is: if blind impartiality is too much to ask, how much partiality can we morally tolerate in responding to global public health emergencies? Or, put the other way, how much impartiality can we reasonably demand?
To balance pragmatic and ethical considerations in pursuit of equity in global access to COVID-19 vaccines, we may need a system of allocation which incorporates incremental quotas. This system would be based on the idea that within countries, there are segments of populations who will get priority for scarce supplies of vaccines. These might include frontline health workers, the elderly, those with underlying conditions, vaccine research participants, and so on. The incremental quota system would operate in such a manner that no country gets everything they need before others—especially developing countries—get anything. Each country would get their first quota of COVID-19 vaccine, just enough for their highest priority population segment, then each country would get a second quota for the population segment with second-highest priority, and so forth. In this case, it would be practically necessary to morally tolerate the first quota being received first by more wealthy countries that have substantially invested in vaccine development, in order to head off the much worse scenario of those countries hoarding all the vaccine supplies for themselves. Under this system a health care worker and a senior citizen with underlying medical conditions in a developing country would still get the vaccine before a healthy youth in a rich country. Hopefully, for anybody with at least a minimal sense of fairness, implementing such a system should not be too much to ask.
Disclaimer: The opinions expressed are the authors’ own. They do not represent any official position or policy of the National Institutes of Health, Public Health Service, or Department of Health and Human Services.


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