The first year of the pandemic was an emergency. The arrival of vaccines that might end the emergency relaxes the pressure a bit—and in the pause, problems that got submerged in last year’s chaos are now bubbling up. Even though vaccines are still scarce—in the US, most people who want a shot still can’t get one—the rich nations of the world have promised manufacturers to buy many times more doses than they need. That is threatening to choke off vaccine supply needed by the global south.
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By Eve Sneider
Up to this point, vaccine-related ethical questions have mostly been about taking them: Should you accept a shot that’s about to be thrown away? Does increasing herd immunity justify jumping the line? Now the focus is turning to giving. Will affluent countries contribute to the greater good by releasing their hold on so much of the world’s vaccine supply? If they don’t, that could extend the pandemic—and depress global trade, keep borders closed, and provide variants the opportunity to evolve.
“This is a question of global justice, fairness, and morality,” says Gavin Yamey, a physician and director of Duke University’s Center for Policy Impact in Global Health. “There is a very powerful ethical reason why people everywhere should have the right to vaccines as a global public good, and that vaccines should not just be hoarded by rich nations. I know that that argument alone may not be persuasive to rich people in rich countries, but it is one that we need to keep reminding rich nations about.”
It is a tricky conversation to have, because any country can ethically claim a duty to protect its own citizens. That is how the ownership of forthcoming vaccine doses came to be: The US, Canada, Western Europe, China, and Japan individually executed advance deals with manufacturers, placing orders with multiple companies as hedges against the bet that some vaccine candidates wouldn’t make it through trials. Now some countries find themselves in line to receive enough doses to protect their residents many times over. Since vaccine manufacturing capacity is a finite resource, that means other countries will have to wait.
And that means the virus can keep finding populations in whom it can thrive. “Current forecasts show that at the current rate, there will not be enough vaccines to cover the world's population until 2023 or 2024,” Nancy S. Jecker, a bioethicist and professor at the University of Washington School of Medicine, wrote by email. “That is bad news, not just for affected nations, but for everyone. The virus does not stop at borders. It simply seeks viral pathways where it can thrive and spread.”
This collision between protecting one’s own homeland and inoculating the world has been coming for a while. Last December, researchers at the Johns Hopkins Bloomberg School of Public Health estimated that the advance contracts written by the US and a few other nations would suck up more than half of the doses that manufacturers planned to produce. As a result, they predicted, nearly one fourth of the world’s population would not get a chance at a shot until next year.
In February, the director-general of the WHO and executive director of UNICEF issued a scathing statement meant to shame Western countries into letting go of prebooked doses. “This self-defeating strategy will cost lives and livelihoods, give the virus further opportunity to mutate and evade vaccines, and will undermine a global economic recovery,” they scolded. On the day they made their statement, WHO officials estimated that 128 million vaccine doses had been administered in the world, but more than three-fourths of those vaccinations took place in just 10 rich countries—while just under 130 countries housing 2.5 billion people had not received a single dose.
Those two organizations have aimed to right the imbalance by sponsoring an organization called Covax, a partnership of the WHO and UNICEF with two nonprofits, the Coalition for Epidemic Preparedness Innovations and Gavi, the Vaccine Alliance. Covax, which launched last June, bundles donor money from high-income nations with purchase commitments from low-income countries to guarantee those countries will receive vaccines. (The Trump administration refused to join Covax; President Joe Biden reversed that decision on his first day in office and last month committed $4 billion.)
On February 24, Ghana became the first country to receive vaccines from the Covax scheme, 600,000 doses of the Oxford-AstraZeneca single-dose formula; that was followed a few days later by doses arriving in Côte d’Ivoire. By last week, the cooperative had sent vaccines to 14 countries in sub-Saharan Africa, southeast Asia, and the Pacific Rim, and predicted it will be able to distribute 237 million doses worldwide by the end of May.
Still, the amount of vaccine that Covax can command is a fraction of what rich countries have agreed to purchase directly. As of March 1, according to the Launch and Scale Speedometer at the Duke Global Health Innovation Center, the high- and upper-middle-income countries of the world—including the US, Canada, the United Kingdom, the European Union, and Japan—have collectively booked 5.8 billion doses. Covax has secured contracts for 1.1 billion.
This is “an abject moral failure,” says Ruth R. Faden, a Johns Hopkins professor and founder of its Berman Institute for Bioethics, who serves on a WHO working group on Covid-19 vaccines. “It’s as if the wealthy countries of the world have gone shopping and cleared the shelves before the other countries of the world could even get inside.”
The problem isn’t only that manufacturers’ shelves are bare (and, to extend the metaphor, that rich countries’ panic pantries are full). By pulling multiple countries into a buying collective, Covax was supposed to gain the ability to negotiate lower prices that poor nations could afford. Rich countries’ cutting their own deals undermines that. And in a further twist, some of those countries are using their vaccine commitments as levers for diplomacy. Both Russia and China have encouraged their manufacturers, which are state-affiliated, to cut deals with Asian and Latin American nations, a subtle way of gaming political influence. (Vaccine nationalism cuts both ways, though. Last Thursday, invoking a European Union compact, the Italian government refused to let AstraZeneca sell vaccines made in the EU to Australia, contending that Italy needs them more.)
Multiple proposals are circulating to solve the international imbalance, by imposing a universal ethical framework for distribution, prioritizing by each country’s population or number of health care workers, or sharing technology and loosening countries’ hold on vaccine IP. Yamey has suggested rich countries be required to tithe their purchases, redirecting one dose to Covax out of every 10 purchased. Norway’s government already has done a form of this, pledging to donate doses at the same rate that it uses them at home, and UK officials have proposed donating extra doses once their domestic vaccine campaign ends. “If there was political will, or if there was a greater urgency or a willingness to step away from vaccine apartheid,” Yamey says, “we would all be better off.”
Meanwhile, globally and within the US, a second ethical question is rising. It has always been understood that delivering doses to some of the most difficult places to reach would be much easier with a vaccine that can be transported at room or refrigerator temperature, instead of the home-freezer temperatures required by the Moderna formula and the ultra-cold lab-freezer levels needed to preserve the Pfizer-BioNTech one. Ideally, a vaccine for the most difficult-to-reach last miles would also deliver protection in a single dose, to solve the problem of having to track people down a second time or require them to walk long distances or travel over rough terrain.
The world has those vaccines now. Both the Johnson & Johnson formula authorized by the FDA in the US and the Oxford-AstraZeneca vaccine already in use elsewhere in the world can be held at refrigerator temperatures, and the J&J vaccine uses only one dose. But in an apparent quirk of their viral-vector platforms, those formulas show lower efficacy when all the participants’ results, from moderate illness to severe illness to death, were assessed. The numbers were 77 percent for J&J and 70 percent for AstraZeneca, compared to 94.5 to 95 percent for the messenger RNA formulas made by Pfizer and Moderna.
It prompts a question: Is the industrialized world asking places that can spend less money to accept lesser protection in exchange?
“People are starting to ask if the vaccines are created equal and, if not, who is accessing ‘better’ ones,” Jecker says. “The newly authorized Johnson & Johnson vaccine has been called ‘the poor man's vaccine,’ and people may think it’s inferior when they compare its overall efficacy rate with the mRNA vaccines.”
This is not a hypothetical. Last week, Mayor Mike Duggan of Detroit—a majority-Black city with significant poverty that was hit hard by the virus—declined a shipment of the J&J vaccine, saying at a press conference: “Johnson & Johnson is a very good vaccine. Moderna and Pfizer are the best. And I am going to do everything I can to make sure the residents of the city of Detroit get the best.” (On Friday, Duggan reversed course, saying in a statement that he would accept the J&J vaccine when the state sends a new allocation.)
This is difficult terrain to navigate, because it evokes histories of colonial oppression in the global South and persistent racism in the US—and also because the clinical-trial results are not as clear as they might seem. Leave aside AstraZeneca for the moment, as its vaccine candidate hasn’t been authorized in the US. The Pfizer, Moderna, and J&J trials aren’t strictly comparable, because the first two ended before more-transmissible variants were circulating in the world; the J&J vaccine was tested later, and its sites included South Africa, where one potent variant emerged. Faden calls comparing the data “not oranges to apples, exactly, but maybe clementines and grapefruits.”
Plus, for the outcomes that matter most, the J&J vaccine protected at least as well as the other ones, preventing 100 percent of hospitalizations and death at four weeks post-vaccination. Its effectiveness in preventing severe disease also seemed to increase over time, to 90 percent at six weeks.
“Because the variants of coronavirus change from place to place and over time, the fact that the clinical trial data do not prove equal efficacy don't necessarily mean that these vaccines are not equally efficacious today,” says Janet Malek, a bioethicist and associate professor at Baylor College of Medicine’s Center for Medical Ethics and Health Policy. “We honestly just don't really know for sure whether one is more efficacious than the other in today's environment.”
So communities that receive the J&J vaccine might not suffer an efficacy disadvantage. In fact, Malek points out, they might benefit from better vaccine effectiveness, the measure of how well an intervention does in the real world versus under controlled conditions. Being able to bring a more deployable vaccine to a rural or poor community now would mean that more shots go into arms more quickly, compared to waiting to build infrastructure to protect the more fragile, more efficacious formulas.
That would be an ethical good, a small counterbalance against the long record of racial injustice in US health care. But for that equity goal to be accomplished, communication about vaccination needs to get out in front of the emerging narrative that the J&J vaccine is inferior. In an op-ed published Friday, Faden and colleague Ruth A. Karron, founder of the Johns Hopkins Vaccine Initiative, argue that this will require offering both types of vaccine to all communities in the US, so that residents can choose—and if the J&J vaccine is the only one that can be sent, offering it only after discussions with community advocates and local leaders.
“It’s good practice in public health to engage with communities as you begin immunization programs,” Faden says. “And it's especially important right now, in communities that have justified distrust in public health authorities generally.”
It’s critical to address this now, because the supply-demand imbalance could shift soon. In this moment of scarcity, people are jostling to be at the front of the line—but once the eager are vaccinated, public health leaders will face the task of convincing the vaccine-hesitant. Defusing the impression that one vaccine’s for the rich and another for the poor could make a difference in how soon the US achieves broad protection.
The equity imbalance internationally needs rapid attention, too. The longer it takes to reach population-level immunity, the greater the likelihood that virus variants will evolve in those who are still vulnerable. It is possible those variants will differ enough from the original virus to require rounds of booster shots. It would be wise to solve the vaccine-sharing challenge now, and not have it follow us through the years.