Glass bottles in production in the tray of an automatic liquid dispenser, a line for filling medicines against bacteria and viruses, antibiotics and vaccines.

Bioethics Forum Essay

Global Allocation of Coronavirus Vaccines

A Covid-19 vaccine developed by Pfizer and BioNTech has received emergency authorization in the United States and has been authorized in the U.K., Canada, and other countries, and a vaccine by Moderna is likely to be authorized soon in the U.S. and elsewhere. In spite of this good news, at least for the first couple of years, Covid-19 vaccines will be a scarce resource. Because low-income countries are likely to lose out in the scramble to get access to them, there have been calls for global solidarity. While equitable allocation of vaccines around the world would be ideal, it is unrealistic as a near-term goal.

We argue in a paper just published in the Milbank Quarterly in favor of a middle-ground policy based on two premises: 1) a “cosmopolitan” approach that rejects entirely nation-state priority is not only unrealistic but also fails to recognize that countries have a legitimate responsibility to give priority to their own citizens and residents and 2) unbridled vaccine nationalism, without an adequately funded effort to ensure the equitable global allocation of an effective vaccine over time, is unethical and likely to be counterproductive.

There will be no effective vaccine without substantial investment in research and development, which only national governments, especially those of wealthy countries, have the resources to fund. Countries and private companies have already invested billions of dollars in vaccine research and manufacturing capacity at unprecedented speed and amounts. They have done this by directly funding research, as the U.S. has done to support Moderna’s clinical trials. Or countries have committed to buy a certain number of vaccine doses from a specific company—an advance market commitment—should its vaccine turn out to be effective. This has given vaccine companies such as Pfizer an incentive to invest their own funds in research because they are guaranteed a market for their vaccine if it is effective. This rapid mobilization of substantial funds for research demonstrates nation-states’ ability and power to invest in health research and intervention development when it matters. Because no international organization can match this ability, any global distribution scheme should rely on and work with national government initiatives.

From a normative point of view, national governments have the responsibility and duty to promote health for their populations—a responsibility recognized in international human rights documents. Unlike international organizations, national governments have the ability to mobilize and redirect resources to address health emergencies and can be held responsible if they do not. Just as countries have legitimately taken extraordinary measures to protect their populations during the current pandemic, such as closing borders and providing economic relief, they also have the right and the duty to try to secure access to an effective vaccine for their citizens and residents.

However, there is also a recognized duty on national governments to global assistance. Unbridled nationalism should therefore be rejected, and nations should balance concerns for their own citizens with global obligations. In service of international coordination, COVAX is a partnership among the GAVI Alliance (Global Alliance for Vaccines and Immunizations), CEPI (Coalition for Epidemic Preparedness Innovations), and the World Health Organization. Its purpose is to accelerate the development and manufacture of  Covid-19 vaccines and to guarantee fair and equitable access for every country in the world. The COVAX model establishes a plausible link between wealthy governments’ interests and the interests of low-income countries. In COVAX, participating self-financing countries agree to additional contributions to fund the distribution of vaccines in the 92 eligible low- and lower middle-income countries. COVAX is a concrete and implementable framework for shared responsibility for the development and distribution of health care interventions of global importance, which contains specific mechanisms to ensure that an effective vaccine is identified and distributed as quickly as possible. It therefore can serve as an illustration of the challenges and difficulties with which any realistic distribution mechanism will have to deal, but more important, it provides a useful model for how governments can balance national against international obligations.

As of November 2020, COVAX has already received a commitment of $2 billion, with the goal of raising an additional $5 billion for advance market commitments in 2021. This amount, together with the initial contributions from self-financing countries, will be used to help support advance market commitments for participating countries.

It is not clear how COVAX would distribute the available vaccines between the self-financing countries and the eligible low- and lower middle-income countries

Valuable as it is, it is also unclear whether a collaborative scheme such as COVAX will be able to mobilize enough support for a joint and coordinated approach. Countries such as the U.S. and India are not yet on board, and even the European Union countries are making their own, separate, arrangements. With these individual approaches, there is uncertainty about which country or group of countries would get priority if they have committed to the same vaccine, with an indication that it would be on a “first come, first served” basis. That is, those that committed first would receive the first batches of vaccines once production had started. But if the estimate that 2 billion doses can be produced during the first year is correct, even with the relatively large number of advance market commitments, there should be enough production capacity during the first year to cover high-risk individuals in all participating countries. Long-term commitments to control the pandemic in all countries will be more challenging, however, leaving a gap of several billion people in low- and middle-income countries without access to vaccines. Additional resources are therefore urgently needed.

The COVAX partnership, therefore, deserves the support of both higher-income countries and big middle-income countries like China, India, Brazil, and South Africa. In particular, the U.S. under the Biden administration should reverse the decision by the Trump administration not to join the COVAX partnership, as has recently been recommended by the report on the equitable allocation of  Covid-19 vaccine by the U.S. National Academies of Science, Engineering, and Medicine.

Reidar K. Lie, M.D., Ph.D., is a professor of philosophy at the University of Bergen, Norway. Franklin G. Miller, Ph.D., is a professor of medical ethics in medicine at Weill Cornell Medical School. Both are Hastings Center fellows.

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