Who should get the Covid-19 vaccine first? The equality vs. equity debate, explained.

Some ethicists are taking issue with the World Health Organization’s proposal.

When we finally find a safe and effective Covid-19 vaccine, every nation in the world will want it. But for a while, there won’t be enough to go around. So who should get access to the first doses?

One way to answer that question is to say: The nations that discover the vaccine — or that can pay those who discover it — will get first dibs. All the other nations will just have to wait until more doses can be manufactured.

This is “vaccine nationalism,” where every nation just looks out for itself, prioritizing its citizens without regard to what happens to the citizens of lower-income countries that can’t afford to buy up doses. It’s a path that most ethicists think is wrong. It’s also the path the United States is currently on.

September 18 was the deadline for governments around the world to join the Covax Facility, a unique financing mechanism that asks countries to pool their resources together so that humanity has a better shot at discovering a successful vaccine quickly. In return, all participating countries are promised that when that day comes, they’ll get equal access to the vaccine.

Some 156 countries signed agreements with Covax, representing 64 percent of the global population. The US did not.

“Bad! Bad!” is how Ezekiel Emanuel, a medical ethics expert at the University of Pennsylvania, characterized America’s decision. “This is an opportunity for low- and middle-income countries to get a vaccine and not just have it as a rich boys’ club,” he told me.

Ruth Faden, founder of the Johns Hopkins Berman Institute of Bioethics, also bemoaned the decision. “It’s just incredibly shoot-yourself-in-the-foot,” on two levels, she said.

Economically, Faden argues, it’s in America’s self-interest to help ensure every other country’s population is vaccinated because until the fear of Covid-19 dissipates, trade and travel won’t go back to normal. And health-wise, nobody is safe until everybody is safe. That’s because any Covid-19 vaccine we find is not going to be 100 percent effective. It can’t fully protect everyone from getting infected, so one infected traveler entering the US can still cause an outbreak.

For these moral and pragmatic reasons, ethicists generally reject vaccine nationalism (though some think it’s fine for a government to prioritize its citizens within certain limits). Instead, they say we should think about distributive justice, figuring out how to get lifesaving resources to every human being in a fair way.

But that unobjectionable-sounding notion actually obscures a key question, one that ethicists are now fiercely debating: When we say we want to distribute a vaccine fairly, do we care more about equality or about equity?

Equality would mean each country gets the same proportion of vaccine doses relative to its population size, and at the same rate. Equity would mean we drive more vaccine doses to the countries most in need.

The distinction between these two approaches — and which one wins out — will shape who gets a vaccine quickly and who’ll have to wait around, hoping they don’t get sick in the meantime. Let’s get clear on each approach, and understand why groups like the World Health Organization are pushing for equality right now, while some ethicists say that’s a mistake.

Why the WHO is focusing on equality

The WHO is one of three groups leading the Covax Facility. The other two are Gavi, a public-private partnership that spearheads immunization efforts in developing countries, and the Coalition for Epidemic Preparedness Innovations, an international collaboration (formed as a Gates Foundation initiative after the West African Ebola epidemic) to make vaccines available quickly when outbreaks happen.

Covax is kind of like a mutual fund, but for vaccines. It’s creating a diversified portfolio of vaccine candidates (currently, nine are in development and a further nine are under evaluation), the idea being that it’s better to back many candidates, knowing that some won’t pan out.

“Very few countries can do what the US is doing: We’re backing seven horses at this point, so we can create our own diversified portfolio,” Faden said. “But many countries don’t have the resources to do that for themselves. This is the answer to that problem.”

Covax asks wealthier countries to fund the development and manufacturing of the vaccine candidates. Lower-income countries don’t have to pay; they’ll be supported through voluntary donations to a dedicated Covax mechanism called the Advance Market Commitment. Covax aims to buy and make available 2 billion doses by the end of 2021.

If that happens, it’ll be a huge deal. Covax’s effort to get countries to work with each other instead of against each other could save many lives worldwide. According to Gavi CEO Seth Berkley, it’s the biggest multilateral effort since the Paris climate agreement; certainly, it’s a big step in the right direction.

Here’s how the WHO says Covax allocation should work: Once a safe and effective vaccine is discovered, there should be an initial phase where all participating countries get doses in proportion to their population, at the same rate. Essentially, 3 percent of every country’s population would get access to the vaccine before any country moves on to 4 or 5 percent. This proportional allocation would continue until every country has enough doses to vaccinate 20 percent of its population.

The WHO suggests the initial tranche of doses, aiming to cover 3 percent, would likely go to health care workers. The tranche covering 20 percent would likely go to high-risk adults, like older people and those with underlying conditions. (The WHO says 20 percent would be enough to cover these groups in most countries, though some countries have older populations and might need more. They can request enough doses for up to 50 percent of their population, but they won’t receive doses for more than 20 percent until all other countries have been offered that amount.)

Soumya Swaminathan, the WHO’s chief scientist, explained the rationale to a panel of reporters on September 15.

“What we’ve done in the Fair Allocation Framework, at least in the first phase, is to go with the principle of equality,” she said. “Because in this case, the disease has spread across the world. It has not spared any country, high-income or low-income, whereas diseases like TB and malaria disproportionately affect low- and middle-income countries.”

However, she said that after countries have received enough doses to vaccinate 20 percent of their populations, she expects to shift toward “more allocation to those countries which appear to be needing it much more than other countries” — that is, equity.

Pressed as to why Covax doesn’t adopt an equity model right from the get-go, Swaminathan candidly explained that the reason is pragmatic: If wealthier countries are told they’ll have to wait in line for vaccine doses behind poorer countries, they may reject Covax.

“There’s a big, big risk that if you propose a very idealistic model, you may be left with nothing,” she said. She recalled the 2009 swine flu pandemic, when wealthy countries like the US scooped up most doses of the H1N1 vaccine. Low-income countries couldn’t get access until later, by which point the acute phase of the pandemic was already over.

“That’s the historical reality. We are trying to create a new reality,” Swaminathan said. “But you cannot leave behind the high-income countries. To say to them, ‘You don’t have a big problem right now and therefore you don’t need the vaccine,’ may not be acceptable to them because the virus is there and waiting to spring back the moment people go back to normal. … Without their agreement, it’s not going to be successful.”

In other words, the WHO is conscious of the politics at play here.

Faden co-drafted the WHO’s Values Framework for vaccine allocation, which does list equity among its guiding principles, even though it wouldn’t kick in till later. “Look, there is a real-world problem,” she told me. “We currently live in a global order that is profoundly unjust. We need a strategy that appeals to and works for high-income countries. The Covax Facility’s principle of simple equality for the first 20 percent is this strategic attempt to incentivize countries to get in — the kind that can pay.”

Why some ethicists say we should focus on equity

Other ethicists are pushing for a more idealistic framework, one that prioritizes equity from the start. Chief among them is Emanuel, the University of Pennsylvania expert. Even as he participates in several WHO working groups on Covid-19, he’s trying to get the international body and other players to rethink their model.

There’s a very obvious problem, he says, with the WHO’s approach: Two countries can have similar-size populations but very different Covid-19 case counts. Should they really both get enough doses to vaccinate 3 percent of their populations right off the bat? Or should we drive more help toward the country with the greatest disease burden so we save as many lives as possible?

Emanuel explained the problem with the former approach via analogy. “Imagine you’re an ER doctor,” he told me. “You’re very busy, so you walk into the ER and say each person gets five minutes of time irrespective of how sick they are. That makes no sense.”

In a paper published September 11 in Science, he and a diverse group of experts propose an alternative framework called the Fair Priority Model. (Though there are a couple of other proposals out there putting forward frameworks for vaccine distribution, this is the only one that offers as substantive a model as the WHO’s.)

The experts lay out a plan for distributing the vaccine in three phases. Positing that our main goal should be to avert premature deaths, they suggest using standard expected years of life lost (SEYLL) averted per dose as the criterion in phase one. They say we should give priority to countries that would reduce more SEYLL per dose.

In phase two, which aims to reduce pandemic-induced economic deprivation, they give priority to countries that would reduce more SEYLL and reduce more poverty. In phase three, which aims to end community spread, they give priority to countries with higher transmission rates.

This model offers a concrete way to reduce serious harms and prioritize disadvantaged people on an international scale. Emanuel said it’s more ethical than the WHO’s current approach.

“I wasn’t born yesterday. I understand that sometimes you can’t do exactly what’s ethical because you need to get people to the table,” he told me. “But political expediency is one thing and ethics is another thing. What I object to is claiming this [WHO approach] is an ethical position. And they do claim that — they use the ethics language of ‘we’re being equitable’ and all this. But that’s not transparent; that’s actually false advertising.”

Some might object that Emanuel’s own proposal is not equitable to countries with more elderly citizens: Saving them will save fewer years of life (thus netting less SEYLL per dose), but older citizens are still morally valuable.

Emanuel told me that he’s heard this ageism critique “a million times” but that it’s ill-founded. (He has, it may be worth noting, idiosyncratic personal views about aging.) He noted that many surveys conducted around the world suggest that, all things being equal, the public prioritizes youth over older adults in the distribution of health resources. As a global society, we seem to value investing in youth, both because investing in them when they’re young yields greater dividends later on and because we don’t want to cheat them of the chance at significant life experiences — a deprivation that arguably constitutes a moral harm.

Emanuel contends that his group has arrived at the best way to enshrine three fundamental values: benefiting people and limiting harm, prioritizing the disadvantaged, and equal moral concern.

“We met every week, arguing, and we had a very diverse group,” he said. “You had utilitarians, you had people who are more Rawlsian, you had cosmopolitans who believe national borders are basically ethically irrelevant, and you had people who believe borders are very relevant. I think our position represents the best of ethics and a consensus about principles that transcends lots of different specific moral commitments.”

Ultimately, is this proposal better than the WHO’s? How you answer that depends somewhat on your specific moral commitments. From a utilitarian’s standpoint, for example, whichever proposal will do the best job at maximizing benefit and limiting harm to all people is the best approach. If the WHO’s realpolitik enables it to get more paying countries into the Covax Facility, thus eventually enabling more vaccines for people who couldn’t otherwise afford them, it might actually be the most ethical model.

Either way, Covax is now in business, and its multilateral, cooperative approach comes as a welcome counterpoint to the vaccine nationalism we’ve seen in other quarters. For countries that have signed agreements with the Facility, the next step is to cough up the cash: Payments are due October 9. This money will hopefully accelerate the development and manufacturing of the vaccine we’re all awaiting.

Jen Kirby contributed reporting to this article.

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