Get vaccines to where they're really needed

A GLOBAL alliance to assure poor and moderate income countries "equitable access" to Covid-19 vaccines is shortchanging nations in desperate need, while providing vaccines to others that have comparatively few cases or lack the ability to distribute them.

Leaders of the effort, known as Covax, argue that vaccines initially should be allocated proportionally by population. But this approach is ethically wrong. Priority should be given to countries being hit hardest by Covid-19 or those likely to be hit soon and capable of distributing and administering the vaccines they receive.

Covax is important in the fight against Covid-19. That's why its distribution methodology matters. It was formed last year by the World Health Organization; Gavi, the vaccine alliance; and the Coalition for Epidemic Preparedness Innovations "to accelerate the development, production and equitable access to Covid-19 vaccines". The effort has 190 participating countries and hopes to have more than two billion doses available by the end of 2021; about 70 million doses have been distributed so far. Those two billion doses should be enough to protect high-risk and vulnerable people, as well as frontline healthcare workers, according to the organisation.

But to be fair and successful, Covax must abandon its purely population-based distribution formula, developed by WHO, which has led to precious vaccine doses being destroyed or left sitting in freezers in countries without many cases or which lack the ability to distribute them effectively. Fair distribution of vaccines must be based primarily on need.

South Sudan, for instance, recently destroyed nearly 60,000 doses it received from Covax; Malawi destroyed 20,000. Neither was able to distribute its entire allotment before the vaccines expired. The Ivory Coast similarly distributed less than a quarter of the over 500,000 doses it received in late February, raising fears that doses will expire before they are used.

On the other hand, Kenya, with more than 50 million people, was able to administer about 877,000 doses by late April with the roughly one million doses it received from Covax in early March (and an additional 100,000 donated by India), according to the country's health ministry.

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The problems are not confined to lower-income countries. More than 600,000 Covax-provided AstraZeneca vaccines sit in Canada at risk of spoilage while Canadians debate whether it is safe to use them. Vaccinations can begin to confer meaningful protection in under 14 days. Freed from freezers, these vaccines could have saved many lives in Peru, India or Brazil, where the pandemic is raging.

The Covax distribution plan calls for providing each country with enough vaccine doses for roughly 20 per cent of the population. Only after that would countries' health needs be considered.

NEEDS ARE NOT EQUALLY URGENT

True, every country needs vaccines in the pandemic. But those needs are not equally urgent. Distributing vaccines purely on the basis of population means some vaccines will fail to reach those whose actual current risk is highest.

Consider Ghana and Peru. They have roughly the same populations, 31 million versus 33 million. Ghana reported about 93,000 cases since the start of the pandemic, 630 of them in the two weeks beginning May 5, and 783 total deaths. Its hospitals are not overrun and there is no indication that morgues are overwhelmed. Peru has had about 1.9 million cases, about 80,000 of them in the same two-week period, and 67,000 cumulative deaths. Both countries probably have significant undercounts of cases. WHO estimates a two- to threefold undercount of deaths worldwide. But even if Ghana's real total is 10 times its reported number, giving it 930,000 cases and 7,830 deaths, its needs pale in comparison to Peru's.

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 ear-ache, 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 five 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 recognised 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.

As the global supply of vaccines expands, vaccine manufacturers and nations expecting to have extra doses, including the US and Britain, must decide which countries to help and how many doses to send to global organisations like Covax.

RESPONDING TO NEED

But if Covax's distribution criteria remain unresponsive to need, countries with spare doses should bypass the organisation and distribute them where they will reduce deaths the most. It would be morally indefensible to give vaccines to Covax to send to countries with few cases or that are unable to deliver vaccines, while outbreaks rage elsewhere.

We want Covax to succeed. Leaving global vaccine distribution to individual countries risks duplicated efforts and politically motivated distribution.

Even as the US and Britain recover, the pandemic is far from over worldwide. Covax has only completed a little more than 3 per cent of its planned distribution for the year. That's why it is so important that Covax prioritise countries based on need and distribution capacity, rather than population.

Doing so would be more equitable and would better steward limited vaccine supplies to protect the world's most vulnerable and save as many lives as possible. NYTIMES

• Ezekiel J Emanuel is the vice-provost of global initiatives and a professor of medical ethics and health policy at the University of Pennsylvania. Govind Persad is an assistant professor at the University of Denver Sturm College of Law, where he focuses on health law, and a Greenwall Foundation faculty scholar in bioethics.

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