Equity and Vaccine Allocation: Beyond Ethics in Prioritization to Equitable Production, Distribution, and Consumption

As COVID-19 surged around the world, it exposed terrible global health inequalities that have hindered our ability to adequately respond to the pandemic.¹ With climate change increasing our exposure to risks from the natural world and rising drug resistance limiting our treatments’ effectiveness against pathogens, the world must better prepare for and respond to pandemics in the future by addressing these inequalities. We should consider this moment as an opportunity to invest for the future. In fact, we are not investing enough in fighting many other diseases, besides COVID-19, that already exist. AIDS, tuberculosis, and malaria continue to ravage regions of the planet even as the coronavirus pandemic surges.² Moreover, the COVID-19 pandemic is delaying screening, diagnosis, and treatment for many other diseases as well. To adequately address these problems, we must put in place the health systems necessary for people to get vaccinated against COVID-19 but also a host of other diseases. This requires addressing the need for improved manufacturing and distribution systems, health care workers, funding, trust in science, and community engagement as well as principles for prioritization. Moreover, it is essential to rethink how we support research and development and reward pharmaceutical innovation to fairly address the COVID-19 pandemic and many other major global health problems. Doing so is important for both moral and prudential reasons. In what follows, I first consider existing proposals for equitable vaccine allocation focusing on the COVID-19 Vaccines Global Access (COVAX) facility. I then argue that to better promote equity for individuals (as opposed to just treating states equally), it is essential to advocate for establishing basic healthcare systems to address the fundamental barriers to fair access for all.

Existing Initiatives and Proposals for Equitable Access to New Vaccines: Some Limitations

The COVAX facility is a collaboration that brings together governments, companies, international organizations, and others to accelerate the development and manufacture of COVID-19 vaccines. It is co-led by the World Health Organization (WHO), the Coalition for Epidemic Preparedness Innovations (CEPI) and Gavi, the vaccine alliance. So far, 186 countries have joined the facility and it has secured about $2 billion USD to be used for the COVAX Advance Market Commitment (AMC), a tool that will allow ninety-two low and lower-middle income countries to obtain vaccine doses as they are approved.[note]“EU Increases its Contribution to COVAX to €500 Million to Secure COVID-19 Vaccines for Low and Middle-Income Countries,” Press Corner, European Commission, November 12, 2020, accessed February 1, 2021, https://ec.europa.eu/commission/presscorner/detail/en/ip_20_2075#:~:
text=The%20European%20Union%20has%20announced,low%20and%
20middle%2Dincome%20countries. See also “Over US $2 Billion Raised to Support Equitable Access to COVID Vaccines with Additional US$ 5 Billion Needed in 2021,” Gavi, The Vaccine Alliance, November 13, 2020, accessed February 1, 2021, https://www.gavi.org/news/media-room/over-us-2-billion-raised-support-equitable-access-covid-vaccines-additional-us-5.[/note] The COVAX facility allows countries to support a broad portfolio of vaccine candidates. It has also proposed giving countries vaccines in proportion to their populations until each can vaccinate 20 percent of its population, aiming to distribute two billion doses by the end of 2021.³

The kind of global cooperation COVAX provides is important for combatting the pandemic, as it will help distribute vaccines to people in poor as well as rich countries. Pandemics do not respect national borders: until we are able to vaccinate the majority of the global population, COVID-19 will continue to circle the globe.⁴ Even with highly effective vaccines, it is essential to vaccinate people everywhere to secure, and maintain, herd immunity especially if people require regular booster shots.⁵ Since many existing vaccines are difficult to store and transport, COVAX is providing support for essential infrastructure improvements as well. (Several of the vaccines currently being administered must be stored at or below -20ºC and it is difficult to administer them to everyone, even in rich countries.⁶) Addressing the pandemic everywhere is especially important in our globalized world as our economic fortunes are also interdependent.⁷ Some estimate that the Covid-19 crisis will cost the world economy $9 trillion USD over the next two years, and it is currently costing the world US$375 billion monthly.⁸ Global partnership through COVAX remains the most viable strategy in overcoming the pandemic.

Unfortunately, COVAX is far from perfect. Although it invests in, procures, and helps distribute vaccines around the world, poor countries initially only got to vaccinate 3 percent of their populations through COVAX and there is currently no plan in place to help them vaccinate more than twenty percent. At the same time, rich countries were allowed to vaccinate up to 50 percent of their populations through COVAX.⁹ Moreover, the facility does not combat COVID-19 where the pandemic is worst. It does not prioritize giving doses to countries in a way that will plausibly have the greatest health impact—whether one measures that in terms of lives or life years saved. I will argue below that this is highly inequitable as well as insufficient to combat the pandemic. Together, the global community should ensure that everyone around the world can secure a COVID-19 vaccine in a timely fashion at a reasonable cost.

Perhaps because of COVAX’s limitations, there are several competing proposals for ethical allocation on the table. Another WHO proposal aims to reduce COVID-19 deaths and protect health systems by giving a country vaccines based on the proportion of its population that is over sixty-five years old, the number of essential health care workers, and the number of people who are at great risk of serious illness from COVID.¹⁰

A third proposal, the fair priority model, requires distributing the vaccine first to those countries where it is possible to save the greatest number of life years, at least after countries have their epidemics under control, considering countries’ Gross National Income (GNI) and poverty rates in later stages.¹¹ A fourth proposal by researchers at Vanderbilt University suggests prioritizing vaccine distribution to countries based on their capacity to provide care, ability to distribute vaccines, and their involvement in developing and testing interventions for COVID-19.¹² The Strategic Advisory Group of Experts (SAGE) of the WHO proposes the Values Framework based on the principles of concern for human well-being, equal respect, global and national equity, reciprocity, and legitimacy. An overarching goal of the framework is to reduce the number of deaths attributable to the COVID-19 pandemic by vaccinating those most vulnerable, including older adults, health care workers, and those in densely populated areas or facilities.¹³

I believe most of these proposals, like COVAX, are problematic because they fail to recognize the importance of having the largest possible health impact for individuals, irrespective of country of origin or residence.¹⁴ Several proposals aim to treat countries equally, when they should focus on having the largest health impact for individuals. It is individuals who suffer health problems, not countries. Moreover, some proposals fail to treat individuals equally for other reasons. For instance, some allow wealthy countries to prioritize their populations before contributing to efforts like COVAX. Instead, researchers should consider which distribution will have the greatest health impact for individuals irrespective of country of origin—whether this requires saving the most lives or life years. The question of how to have the greatest health impact for individuals is an empirical one, and it may require prioritizing certain geographic regions or marginalized populations. However, these regions or populations would be prioritized because targeting them has the greatest health impact for individuals, not because membership in these groups bestows on them some special priority, as it does in the country-specific proposals.

Data reveal that marginalized populations are often at higher risk from the virus.¹⁵ Data on COVID-19 deaths in New York City suggest, for instance, that Black and Hispanic/Latino New Yorkers are at higher risk of death than white people. There were 20 and 22 deaths per 100,000 people in Black and Hispanic/Latino populations, respectively, compared with 10 per 100,000 in white populations.¹⁶ Inequitable access to new COVID-19 vaccines will likely expand such inequalities and, thus, negatively affect the virus's aggregate health impact.¹⁷ For equitable global distribution, to have the greatest global health impact for individuals, we cannot ignore intra-country distribution.

So, recognizing the importance of how vaccination plans affect individuals, equitable allocation depends on how countries allocate vaccines within their borders. Those distributing vaccines to countries can either assume that the countries will distribute them equitably without assistance or try to assess the likely distribution when deciding how to allocate vaccines to countries. International allocation may be conditional on equitable distribution within countries.

I believe that even though distribution should not be conditional on good governance, countries should receive support for distributing vaccines equitably.¹⁸ Aid conditionality is often ineffective and unfair; sometimes, it is even counterproductive.¹⁹ But individuals in poor countries with bad governments are not less deserving of access to effective vaccines to fight a global pandemic because they are oppressed. Rather than make aid conditional on good governance, distributors might develop guidelines to encourage safe use and equitable vaccine allocation.²⁰ Moreover, they should consider partnering with non-governmental organizations that can assist in vaccine distribution (and otherwise help implement some of the suggestions below) when governments are unable or unwilling to assist effectively. Where poor nations lack the resources or facilities to vaccinate their populations, it becomes incumbent on the international community to support their efforts.

Beyond Ethics in Prioritization to Equitable Production, Distribution, and Consumption: Investing for the Future

Ethical vaccine allocation requires focusing on much more than principles for prioritizing patient populations. We need to question the fundamental assumption of scarcity—not by denying its existence, but by trying to increase the supply of essential health resources.²¹ The most important ethical questions may not involve figuring out how to allocate limited supplies in conditions of scarcity but how we can expand access and prevent tragic scarcity in the future. Health frameworks must be repurposed and reimagined to improve manufacturing and distribution systems, increase access to trained health care workers and funding, and foster trust in the scientific community and community engagement. We also need to fundamentally rework incentives for pharmaceutical research and development to overcome scarcity in the sector.²² Making these changes will allow us to better prepare for, and respond to, pandemics, and they constitute wise investments for the future.

To better address future pandemics, we must expand global manufacturing capacity. Consider the situation with COVID-19. Although many rich countries will vaccinate their populations in the coming year, poor countries may lack access to the vaccine for years, in part, because there is limited global manufacturing capacity.²³ The Serum Institute of India is one of the world’s largest vaccine manufacturers, but the Institute would need ten years to produce enough vaccine to supply the global population. Of course, many other manufacturers exist and India only produces 18 percent of the active pharmaceutical ingredients for all drugs, globally.²⁴ Still, manufacturers must also produce billions of doses for routine vaccinations for everything from chicken pox to measles. It is also essential to secure the vials, syringes, and ingredients necessary for vaccine administration.²⁵

Even if we can manufacture enough vaccines to combat not only COVID-19 but all the other pressing global health threats, many low-income countries lack sufficient cold-chain infrastructure for distribution—so we must work to improve global distribution capacity. For example, in sub-Saharan Africa only 28 percent of healthcare facilities have access to reliable electricity, making refrigeration facilities unreliable sources of vaccine storage.²⁶ Many vaccines, including several for COVID-19, require cold storage. Moderna and Pfizer’s mRNA vaccines, in particular, require storage at -20ºC and -70ºC, respectively.²⁷ If they are stored incorrectly, their active ingredients will denature, preventing patients receiving doses from developing immunity.²⁸ Furthermore, the majority of hospitals have refrigeration storage facilities that operate at temperatures of between 2ºC and 8ºC, but the Pfizer vaccine specifically has a shelf life of only five days when stored at this temperature.²⁹ Thus, all doses stored at such temperatures must be distributed quickly. The dry ice necessary to transport the vaccines by land or air may also be in short supply.³⁰It is, thus, important to reserve vaccines that are easier to store and transport for poor countries. But we should also invest in improving cold storage and transportation networks around the world to better prepare for, and respond to, future pandemics.

Besides vaccine manufacturing and distribution, countries need more health care workers to address pressing public health problems. According to the WHO, the world needs about 5.9 million more nurses, and 89 percent of the global nursing shortage is in low- and middle-income countries.³¹ A significant portion of the shortage is due to the out-migration of health care workers from poor to rich countries that shows no sign of abating. Some estimate that migration to Organization for Economic Cooperation and Development (OECD) countries from sub-Saharan Africa, for instance, “could increase from about 7 million in 2013 to about 34 million by 2050.”[note]Luc Ngwé, “African brain drain: is there an alternative?” United Nations Educational, Scientific and Cultural Organization, accessed May 2, 2021, https://en.unesco.org/courier/january-march-2018/african-brain-drain-there-alternative#:~:text=In%20October%202016%2C%20a%20report,
migration%20of%20young%20and%20educated.[/note] We should combat brain drain (the movement of trained health care workers from developing to developed countries) by investing more in health care provision in poor countries, fostering community engagement, and training more people to provide essential medical care around the world.³²

Many organizations are supporting global vaccination efforts but we need to do much more. Consider, again, just the global COVID-19 response. COVAX is partnering with the United Nations International Children’s Emergency Fund (UNICEF) to address some of the problems noted above and to help secure the equipment necessary to distribute COVID-19 vaccines—including syringes and refrigerators—but it will not be enough. UNICEF planned to purchase up to 520 million syringes by the end of 2020 and aims to distribute one billion vaccines by the end 2021.³³ They have also distributed 65,000 solar-powered refrigerators to remote parts of the world with unstable access to electricity.³⁴ Still, 520 million syringes and 65,000 more refrigerators is hardly sufficient to ensure that everyone secures the vaccine. Some experts therefore estimate that three billion people will lack access to a COVID-19 vaccine for years.³⁵ Several organizations, including the European Commission and the Gates Foundation, have donated hundreds of millions of dollars to address the pandemic, but $45 billion more is necessary to keep the COVAX initiative well-funded.³⁶

Even where proper health infrastructure is in place, it is important to partner with local community leaders to ensure broad vaccine uptake. Vaccine hesitancy is increasing especially in populations with little direct exposure to how diseases affect patients, and vaccine hesitancy may delay herd immunity.³⁷ To overcome vaccine hesitancy, it is important to engage local communities in our vaccination efforts. Experience with Ebola, Zika, and H1N1 outbreaks demonstrated that religious organizations, health committees, and other community leaders can foster trust and help discredit rumors about a wide variety of public health interventions, including vaccines.³⁸

It is of utmost importance to partner with civil society organizations and those with expertise in existing global vaccination efforts to reach people in remote communities. Consider how existing frameworks are being revamped to address the COVID-19 pandemic. The Global Polio Eradication Initiative (GPEI) is, for example, providing expertise gleaned in their polio vaccination efforts to COVID-19 prevention efforts—training COVID-surveillance staff for COVID prevention, detection, and containment through wastewater testing, distributing masks and hand sanitizer, and performing contact tracing using the tools from their polio-intervention programs.³⁹ And, as we have seen, other organizations such as UNICEF are helping improve infrastructure and distribute the vaccines. Globally, we should invest in these kinds of collaborations across many different parts of the health sector to build basic health systems that will serve people well beyond the current pandemic.

Again, we should consider this as an opportunity to invest for the future. There will be other pandemics. There have always been others and, as climate change modifies habitats in ways that bring people into closer contact with other species, we only increase our risk of future outbreaks.

We must invest more in fighting many diseases, beyond COVID-19. Diseases such as HIV, tuberculosis, and malaria are killing and maiming millions each year, even during the coronavirus pandemic.⁴⁰ Each of these three diseases cost the world more than 160,000,000 disability-adjusted life years in 2015.[note]“GBD Study Data Search Engine,” Institute for Health Metrics and Evaluation, 2015, accessed February 1, 2021, http://ghdx.healthdata.org/gbd-results-tool. See also “Disease: Summary,” Global Health Impact, 2017, accessed February 21, 2021, http://globalhealth.pythonanywhere.com/index/
disease/2015/summary#relocation_disease2015.[/note]

As policymakers shifted resources to fighting the COVID-19 pandemic, and the pandemic interrupted service delivery, the impacts of many other diseases worsened. The coronavirus pandemic has disrupted diagnosis, prevention, and treatment programs around the world.⁴¹ Some estimate, for instance, that malaria mortality has increased twofold, and more than 40 million new malaria cases emerged in 2020.⁴² Building sustainable health infrastructure is arguably just as important as building roads and providing adequate electricity and clean water. The necessary investments in health infrastructure will enhance our efforts to provide these latter improvements as well. We should be able to distribute essential medicines around the world to prevent and treat many devastating illnesses, not just COVID-19. Doing so will help us address not only the COVID-19 pandemic but also prevent and address many other terrible tragedies.

In the future, fair allocation proposals should also require companies to ensure open access to research and development data and resulting technologies.⁴³ We should reward research and development with monetary prizes (for example, through advance market commitments, as we have through COVAX). However, we should then require companies to allow generic production of resulting products.⁴⁴ The idea is to pay innovative companies enough, either per dose or in lump sum, to reward their research and development efforts (and ensure that they can invest in future research), but allow any company to produce and sell the resulting products at low prices.

One promising proposal is to tie rewards for new innovations to their global health impact, delinking companies’ rewards for new innovations from sales volumes.⁴⁵ Currently, companies profit most from treating (but not curing) chronic diseases of rich patients because they can indefinitely sell the treatments to those patients. This results in a plethora of allergy medicines and so forth. But companies lack incentives to focus on many of the greatest global health problems—such as malaria and tuberculosis—that primarily affect poor patients. If we provide sufficient rewards for new innovations, in proportion to their global health consequences, we align incentives with need and encourage companies to produce medicines that save the greatest number of lives and alleviate the most disability. Transparency about corporate research and development costs can help ensure that rewards are sufficient and good measures of global health impact exist.⁴⁶

In short, equitable vaccine allocation requires many things. Sufficient funding, manufacturing supply, transportation and distribution networks, health care infrastructure, and trained workers are all necessary to administer the vaccine. Trust and transparency are also essential for successful vaccine distribution and uptake. Transparency from world leaders—that is, openness, communication, and even accountability—regarding vaccines will be key in gaining the general public's trust.⁴⁷ We must also fundamentally rethink reward mechanisms for pharmaceutical companies. Fair allocation should help individuals everywhere and not just those who are fortunate enough to live in rich countries.

Conclusion

Ethicists interested in equitable international vaccine allocation have traditionally focused on principles for prioritizing patient populations, but to have the greatest health impact—whether one focuses on lives, life years, or something else—we must change the question. We should ask how we can vaccinate everyone most effectively. We need to address the need for adequate manufacturing and distribution systems, health care workers, funding, trust in science, and community engagement. We must rethink how we support research and development and reward pharmaceutical innovation to fairly address the COVID-19 pandemic and many other major global health problems. Doing so will in the long run protect individuals better than merely shifting resources around as several current proposals for equitable allocation suggest. It is also in the best interest of some of the world’s wealthiest countries to help develop basic health systems in countries that lack them and reconsider incentives for new pharmaceutical research and development. We need to foster global solidarity to overcome ongoing pandemics and to prepare for those that will surely come our way. We must do more to ensure that poor countries are not left behind. We should institute basic global health systems and support efforts to research, manufacture, distribute, and help everyone access vaccines and other essential medicines for COVID-19 and other major global health problems.⁴⁸ Anything less is inequitable.⁴⁹

—Nicole Hassoun

Nicole Hassoun is a visiting scholar at Cornell University and Professor of Philosophy at Binghamton University. She has published widely in philosophy, health, and economics journals and leads the Global Health Impact project (https://global-health-impact.org/new). Her first book, Globalization and Global Justice: Shrinking Distance, Expanding Obligations, was published with Cambridge University Press in 2012 and her second book, Global Health Impact: Extending Access on Essential Medicines for the Poor, appeared with Oxford University Press in 2020.

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