Peruvians are at far higher risk right now than Ghanaians of similar age and health — and both are at far higher risk than, say, Canadians or Taiwanese. By ignoring differences in risk between countries, Covax undermines its stated aim of protecting “people most at risk and those most likely to transmit the virus.”
The ethics are clear: Peru and Ghana should not get the same number of vaccines: Peru’s greater needs mean that more vaccines should go there immediately.
That’s how other areas of medical care are managed. Emergency room physicians, for instance, assess patients based on need. Consider four patients, one with an earache, another with a broken arm, a third with chest pain and a fourth with slurred speech. A ER doctor doesn’t say, “OK, everyone is equal and each of you gets 5 minutes of my time.” Instead, the doctor first treats the heart attack and stroke patients, who have the greatest health needs. That is a key principle of medical ethics: allocate resources based on need.
And despite suggestions that this population-based vaccine distribution is a political imperative to encourage countries to participate in the vaccine alliance, neither patients nor physicians would accept a system that ignores need.
Need should be the principal criterion for distributing vaccines among countries, but not the only one. Before vaccines are sent, countries must be able to distribute and administer them. Vaccinations — not vaccines — are what save lives. Support must be provided to countries, like South Sudan, Malawi and the Ivory Coast, to upgrade their capacity to distribute vaccines.
In the face of exponentially growing outbreaks, when and not just whether vaccines become vaccinations also matters. Letting vaccines pile up may seem equitable, but is unacceptably wasteful. Indeed, the United States recognized this when it belatedly discarded its rigid population-based allocation to states for a “use it or lose it” approach. Countries with few cases or limited capacity to distribute vaccines now will not be doomed to receive fewer vaccines. They will receive more vaccines from a growing supply if they face rising cases or their delivery capacity improves.
Social considerations should also be weighed. Countries forced by the pandemic to postpone schooling, childhood vaccinations and malaria prevention efforts, or seeing a rise in poverty, should also receive more vaccines.