By Dr Angela Ballantyne, Visiting Senior Research Fellow, Centre for Biomedical Ethics
It is hard to think of a question that more people will care about right now, all around the world.
Vaccine distribution must meet ethical and pragmatic considerations. Vaccine distribution should be fair, but it must also be ‘seen to be fair’. Perception matters—it is necessary for compliance, cooperation and the political stability of governments who sign up to any multilateral distribution strategy. A global vaccine distribution plan must aim for efficiency, cooperation and fairness. But this will be difficult to achieve against the backdrop of significant global inequity, and within a political system based on nation states and national interests. National governments are already under pressure to secure supply for their populations.
What is Vaccine Nationalism?
Vaccine nationalism is when national governments prioritise the interests of their own citizens and compete with other countries to lock up the vaccine supply by signing advance agreements with pharmaceutical manufacturers or other national governments. Experts estimate that we can reasonably hope to have two billion doses of effective COVID-19 vaccines by the end of 2021. Rich countries are hedging their bets by signing deals with multiple different companies, not knowing which candidate vaccines will prove successful. In total, wealthy buyers such as Japan, the US, EU and UK have already signed supply deals to secure 3.7 billion vaccine doses, which are expected to tie up much of the world’s production capacity.1
Vaccine nationalism can also take the form of national governments implementing exports controls to render multilateral or bilateral purchasing agreements ineffective. In 2019, during the H1N1 pandemic, governments in high income countries, with local vaccine manufacturers, ensured domestic demand was satisfied prior to permitting the export of vaccines.2
A global vaccine distribution plan must aim for efficiency, cooperation and fairness.
Vaccine nationalism makes intuitive sense in our global political structure where governments are primarily responsible for protecting national interests and, particularly in democratic electoral systems, are reliant on public popularity for retaining power. But vaccine nationalism has three problems.
First, vaccine nationalism is not an effective or efficient response to a global pandemic. Vaccines serve two related functions. They protect individuals against infection and they reduce community transmission of the virus by interrupting transmission pathways. Effective distribution of a vaccine therefore impedes community spread of the virus both within and between countries. Many hold out hope that vaccines will allow life to return to some semblance of normality, including amplification of global trade and the resumption of previous freedom to travel. But this will only happen if there is sufficient global immunisation coverage. We cannot substantively shift the trajectory of commerce, tourism, travel and trade without global control of the pandemic. Vaccine nationalism is therefore not in countries’ economic self-interests; instead we need a plan for expedited distribution and delivery on the global level.
While some of the international political debate about COVID-19 seems to pitch health considerations against economic considerations, this is a false dichotomy. The World Health Organisation says “introduction of a vaccine will prevent the loss of US$375 billion to the global economy every month”3 and this in itself will save lives. The economic costs of lockdowns and recession indirectly contribute to morbidity and mortality. Economic analysis suggests that the global lockdown has slowed the economy and global aid donations such that millions of children, already at risk of malnutrition, will die as a result.4 A protracted downturn in the global economy will likely lead to millions of people starving in Africa, a region where only 6% of the population is over 65.5 The quickest route back to pre-pandemic global trade and economic activity is a globally coordinated vaccine effort.
Second, bilateral deals and global competition are likely to drive up the prices of vaccines exponentially, compared to co-ordinated and centralised purchasing and distribution. This competitive approach makes vaccines more expensive for everyone, and especially inaccessible for poorer countries.
Third, vaccine nationalism is unfair because it leaves people in poorer countries without access to vaccines. 171 countries have signed the Covenant on Economic, Social, and Cultural Rights (1966) which entails the obligation to provide international assistance in realising the “right to health and the right to enjoy the benefits of scientific research and its applications”.6
We should care about fairness on ethical grounds, but also pragmatically. Fairness is one of our primary human moral instincts. Fairness is essential to harmonious social life, which requires cooperation, co-ordination and trust. A perception of unfair distribution of the vaccines will damage trust in global institutions and systems. This will be problematic for other aspects of pandemic control such as public health data sharing, collaborative research efforts, and the coordination required to re-establish safe travel and trade protocols. Global trust and cooperation matters not just for COVID-19, but for future pandemics, which experts suggest will increase with rising temperatures, and for the more significant challenge of addressing climate change.
2 billion
doses of effective COVID-19 vaccines
are expected to be available
by the end of 2021
3.7 billion
vaccine doses have already
been committed to
wealthy countries
Loss of
US$375 billion
to the global economy every month
can be prevented
with the introduction of a vaccine
An Alternative to Vaccine Nationalism
The COVAX (COVID-19 Vaccines Global Access) Facility is a scheme co-led by the World Health Organization, GAVI (formerly the Global Alliance for Vaccines and Immunisation) and the Coalition for Epidemic Preparedness Innovations (CEPI), to plan for coordinated, equitable and expedited distribution and delivery of a vaccine globally. CEPI was established after the Ebola crisis and has expertise in financing and co-ordinating the development of vaccines and ensuring fair global access.
COVAX’s strategy is to prevent vaccine hoarding and prioritise vaccinating high-risk people in every country first, a strategy that they argue could lead to better health outcomes and lower costs.7 COVAX’s aim is to distribute sufficient doses to cover the first 3%, and then at least 20%, of participating countries’ populations. Over 170 countries have signed up, but have not necessarily made a binding commitment or provided funds to support vaccine research.8 But the United States and Russia have refused to join COVAX. Funding is required immediately to invest in dispersed manufacturing capacity, sufficient supply chains, storage facilities and cold chain delivery pathways.
COVAX does not prevent countries from also signing bilateral deals and several countries, including Singapore, are actively participating in COVAX and simultaneously exploring alternative avenues to secure their own vaccine supply. Singapore has not released the details of these direct contracts with manufacturers, citing confidentiality.9 Singapore also has its own vaccine candidate in the race: Lunar-Cov19 is being developed in partnership between Duke-NUS Medical School and the US pharmaceutical company Arcturus Therapeutics.10
3 Problems of Vaccine Nationalism
Problem 1:
While vaccine distribution impedes local spread of the virus, we cannot substantively shift the trajectory of commerce, tourism, travel and trade without global control of the pandemic.
Problem 2:
Bilateral deals and global competition are likely to drive up prices of vaccines exponentially, compared to co-ordinated and centralised purchasing and distribution.
Problem 3:
A perception of unfair vaccine distribution will damage trust in global institutions and systems, causing problems for public health data sharing, collaborative research efforts, and coordination to re-establish safe travel and trade protocols.
We will clearly not avoid vaccine nationalism completely. Even countries supporting COVAX are pursuing their own supplies. But we should hold out hope for sufficient global vaccine distribution to bring the pandemic under control.
Recently an international group of bioethicists and health economists proposed the Fair Priority Model11, as an alternative to the COVAX plan to give every country an equal share of a vaccine supply. As Emanuel and colleagues aptly point out, the COVAX plan is problematic because different countries and regions are suffering at differential rates so this approach fails to give priority to those most in need. By comparison, the Fair Priority Model prioritises vaccination of individuals most likely to die early from COVID-19. But proponents of the Fair Priority Model do not provide modelling to show which countries would actually be prioritised. This remains opaque. Distribution depends on the details of which mathematical and epidemiological models are used to estimate the premature loss of life years due to COVID-19 relative to global life expectancy.
The difference between COVAX and the Fair Priority Model is helpful in illustrating the distinction between fairness and perceived fairness. The Fair Priority Model prioritises vaccination for those with the greatest need, and this is ethically defensible. But the lack of transparency about who would actually get the vaccines, and the reliance on complex technocratic models, generates a pragmatic problem regarding public buy-in. Each country would get a different amount of vaccine based on a complicated data driven equation. Pandemics are political as much as they are biological.12 Therefore an alternative to vaccine nationalism must be politically palatable. It will be hard to convince the public that vaccines have been distributed fairly, if only epidemiologists understand how the formula actually works. The simplicity and clarity of the COVAX approach is preferable in this regard. Here, each participating country gets an equal amount of vaccine based on their population. This straightforward distribution system is more likely to be perceived as fair, because it is easier to provide people with an adequate explanation of the vaccine distribution process.13
Over
170
countries have
signed up for
COVAX
We will clearly not avoid vaccine nationalism completely. Even countries supporting COVAX are pursuing their own supplies. But we should hold out hope for sufficient global vaccine distribution to bring the pandemic under control.
There is a narrowing window of time in which countries can negotiate a multilateral vaccine distribution plan, before we know who has developed a successful vaccine. Philosopher John Rawls proposed the ‘veil of ignorance’ test as a thought experiment to see what social systems people would endorse as just, if they knew nothing about their own place in that system—whether they were rich or poor, healthy or sick, old or young. National governments and pharmaceutical companies are currently negotiating under a partial veil of ignorance—they do not know whether they will be winners or losers in the race to find a vaccine. So we have a short window of time to ask, “What terms of cooperation and vaccine distribution would countries agree to, under relatively fair conditions?” Once we have a successful vaccine, the power balance within this negotiation shifts dramatically.14
Demand for a COVID-19 vaccine will be intense and global. This is a critical moment to negotiate the terms for fair distribution of the vaccine, as well as strengthen global institutions, trust and cooperation. Vaccine multilateralism is necessary to protect high-risk populations in all countries—rich and poor.
REFERENCES
1 Shah S. 2020. In Race to Secure Covid-19 Vaccines, World’s Poorest Countries Lag Behind. The Wall Street Journal. Sept. 1, 2020. https://www.wsj.com/articles/in-race-to-secure-covid-19-vaccines-worlds-poorest-countries-lag-behind-11598998776 Accessed 16 Sept. 2020.
2 Phelan A et al. 2020. Legal agreements: barriers and enablers to global equitable COVID-19 vaccine access. The Lancet. On-line https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31873-0/fulltext. Accessed 16 Sept 2020.
3 World Health Organisation. 2020. COVAX: Working for global equitable access to COVID-19 vaccines. https://www.who.int/initiatives/act-accelerator/covax Accessed 16 Sept 2020.
4 Wrigth Y, Harman L. Coronavirus is a devastating blow to children in poverty [Internet]. United Kingdom: Save the children. 2020 Mar 26 [cited 2020 Apr 14]. Available from: https://www.savethechildren.net/blog/coronavirus-devastating-blow-children-poverty
5 Broadbent A, Smart BTH. Why a one-size-fits-all approach to Covid-19 could have lethal consequences [Internet]. United Kingdom: London School of Economics. 2020 Mar 27 [cited 2020 Apr 14]. Available from: https://blogs.lse.ac.uk/africaatlse/2020/03/27/coronavirus-social-distancing-covid-19-lethal-consequences/
6 Phelan A et al. 2020. Legal agreements: barriers and enablers to global equitable COVID-19 vaccine access. The Lancet. On-line https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31873-0/fulltext. Accessed 16 Sept 2020
7 Rauhala E, Abutaleb Y. 2020. U.S. says it won’t join WHO-linked effort to develop, distribute coronavirus vaccine. The Washington Post. 2 Sept 2020. https://www.washingtonpost.com/world/coronavirus-vaccine-trump/2020/09/01/b44b42be-e965-11ea-bf44-0d31c85838a5_story.html Accessed 16 Sept 2020
8 Kamradt-Scott A. 2020. Why ‘vaccine nationalism’ could doom plan for global access to a COVID-19 vaccine. The Conversation. 9 Sept 2020. https://theconversation.com/why-vaccine-nationalism-could-doom-plan-for-global-access-to-a-covid-19-vaccine-145056 Accessed 16 Sept 2020
9 Goh T. 2020. Coronavirus: Supply of vaccine likely to be limited when made available in Singapore. The Straits Times. Aug 22, 2020 https://www.straitstimes.com/singapore/health/moh-supply-of-vaccine-likely-to-be-limited-when-made-available Accessed 16 Sept 2020
10 DukeNUS Medical School. Arcturus Therapeutics–Duke-NUS clinical trials for COVID-19 vaccine candidate approved to proceed. 21 July 2020 https://www.duke-nus.edu.sg/about/media/media-releases/media-releases/arcturus-therapeutics-duke-nus-clinical-trials-for-covid-19-vaccine-candidate-approved-to-proceed Accessed 16 Sept 2020
11 Emanuel E et al. 2020. An ethical framework for global vaccine allocation. Science (New York, N.Y.). 10.1126/science.abe2803.
12 Kapiriri L, Ross A. The Politics of disease epidemics: a comparative analysis of the SARS, Zika, and Ebola outbreaks. Glob Soc Welf. 2020;7:33–45. doi: 10.1007/s40609-018-0123-y.
13 David C. 2011. Perceptions of Fairness. Civil Service College Singapore. https://www.csc.gov.sg/articles/perceptions-of-fairness#:~:text=First%2C%20our%20perceptions%20of%20fairness,employees%20or%20citizens%20are%20treated.&text=Given%20that%20negative%20effects%20are,in%20the%20organisation%20or%20society. Accessed 16 Sept 2020.
14 Rawls J. A Theory of Justice. 1971. Cambridge, MA: Harvard University Press. Revised edition, 1999.