An ethical model for the global distribution of COVID-19 vaccine

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With nations wrestling for access to a successful COVID-19 vaccine when released, a group of global experts has proposed the Fair Priority Model to regulate distribution.

When effective COVID-19 vaccines are developed, their supply will inevitably be scarce. The World Health Organisation (WHO), global leaders, and vaccine producers are already facing the question of how to appropriately allocate them across countries. And while there is vocal commitment to “fair and equitable” distribution, what exactly does “fair and equitable” look like in practice?

Now, nineteen global health experts have proposed a new, three-phase plan for vaccine distribution – called the Fair Priority Model – which aims to reduce premature deaths and other irreversible health consequences from COVID-19. The research was led by Dr Ezekiel J Emanuel, vice provost for global initiatives and chair of medical ethics and health policy in the Perelman School of Medicine at the University of Pennsylvania.

Though little progress has been made to describe a single, global distribution framework for COVID-19 vaccines, two main proposals have emerged: Some experts have argued that health care workers and high-risk populations, such as people over 65, should be immunised first. The WHO, on the other hand, suggests countries receive doses proportional to their populations.

From an ethical perspective, both of these strategies are “seriously flawed,” according to Emanuel and his collaborators. “The idea of distributing vaccines by population appears to be an equitable strategy,” Emanuel said. “But the fact is that normally, we distribute things based on how severe there is suffering in a given place, and, in this case, we argue that the primary measure of suffering ought to be the number of premature deaths that a vaccine would prevent.”

In their proposal, the authors point to three fundamental values that must be considered when distributing a COVID-19 vaccine among countries: Benefiting people and limiting harm, prioritizing the disadvantaged, and giving equal moral concern for all individuals.

The Fair Priority Model addresses these values by focusing on mitigating three types of harms caused by COVID-19: death and permanent organ damage, indirect health consequences, such as health care system strain and stress, as well as economic destruction.

Of all of these dimensions, preventing death – especially premature death – is particularly urgent, the authors argue, which is the focus of Phase 1 of the Fair Priority Model. Premature deaths from COVID-19 are determined in each country by calculating “standard expected years of life lost,” a commonly-used global health metric. In Phase 2, the authors propose two metrics that capture overall economic improvement and the extent to which people would be spared from poverty. And in Phase 3, countries with higher transmission rates are initially prioritised, but all countries should eventually receive sufficient vaccines to halt transmission – which is projected to require that 60% to 70% of the population be immune.

The WHO plan, by contrast, begins with 3% of each country’s population receiving vaccines, and continues with population-proportional allocation until every country has vaccinated 20% of its citizens.

Emanuel and his co-authors argue that, while that plan may be politically tenable, it “mistakenly assumes that equality requires treating differently-situated countries identically, rather than equitably responding to their different needs.” In reality, equally populous countries are facing dramatically different levels of death and economic devastation from the pandemic, they say.

The authors also object to a plan that would prioritise countries according to the number of front-line health care workers, the proportion of the population over 65, and the number of people with comorbidities within each country. They say that preferentially immunising health care workers – who already have access to personal protective equipment (PPE) and other advanced infectious disease prevention methods – likely would not substantially reduce harm in higher-income countries. Similarly, focusing on vaccinating countries with older populations would not necessarily reduce the spread of the virus or minimise death. Moreover, low- and middle-income countries have fewer older residents and health care workers per capita than higher-income countries.

“What you end up doing is giving a lot of vaccine to rich countries, which doesn’t seem like the goal of fair and equitable distribution,” Emanuel said. The authors conclude that the Fair Priority Model is the best embodiment of the ethical values of limiting harms, benefiting the disadvantaged, and recognising equal concern for all people.

“It will be up to political leaders, the WHO, and manufacturers to implement this model,” Emanuel said. “Decision-makers are looking for a framework to ensure that everyone throughout the world can be vaccinated, so that we can stop the spread of this virus.”

Other institutions involved in work include the University of Denver, Princeton University, University of Arizona, University of Oxford, University of Melbourne, University of Toronto, University of Groningen, University of Manitoba, Jobs Creation Commission of Ethiopia, Facultad Latinoamerica de Ciencias Sociales (FLACSO) in Argentina, University of Bergen, Norwegian Institute of Public Health, National University of Singapore, Washington University in St Louis, and Georgetown University.

Once effective coronavirus disease 2019 (COVID-19) vaccines are developed, they will be scarce. This presents the question of how to distribute them fairly across countries. Vaccine allocation among countries raises complex and controversial issues involving public opinion, diplomacy, economics, public health, and other considerations. Nevertheless, many national leaders, international organizations, and vaccine producers recognize that one central factor in this decision-making is ethics (1, 2). Yet little progress has been made toward delineating what constitutes fair international distribution of vaccine. Many have endorsed “equitable distribution of COVID-19…vaccine” without describing a framework or recommendations (3, 4). Two substantive proposals for the international allocation of a COVID-19 vaccine have been advanced, but are seriously flawed. We offer a more ethically defensible and practical proposal for the fair distribution of COVID-19 vaccine: the Fair Priority Model.
The Fair Priority Model is primarily addressed to three groups. One is the COVAX facility—led by Gavi, the World Health Organization (WHO), and the Coalition for Epidemic Preparedness Innovations (CEPI)—which intends to purchase vaccines for fair distribution across countries (5). A second group is vaccine producers. Thankfully, many producers have publicly committed to a “broad and equitable” international distribution of vaccine (2). The last group is national governments, some of whom have also publicly committed to a fair distribution (1).
These groups need a clear framework for reconciling competing values, one that they and others will rightly accept as ethical and not just as an assertion of power. The Fair Priority Model specifies what a fair distribution of vaccines entails, giving content to their commitments. Moreover, acceptance of this common ethical framework will reduce duplication and waste, easing efforts at a fair distribution. That, in turn, will enhance producers’ confidence that vaccines will be fairly allocated to benefit people, thereby motivating an increase in vaccine supply for international distribution.

Ezekiel J Emanuel, Govind Persad, Adam Kern, Allen Buchanan, Cécile Fabre, Daniel Halliday, Joseph Heath, Lisa Herzog, RJ Leland, Ephrem T Lemango, Florencia Luna, Matthew S McCoy, Ole F Norheim, Trygve Ottersen, G Owen Schaefer, Kok-Chor Tan, Christopher Heath Wellman, Jonathan Wolff, Henry S Richardson


University of Pennsylvania School of Medicine material


Science abstract

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