Illustrative vial of coronavirus vaccine
As we grapple with Covid-19, the world waits with bated breath for a vaccine to allow society to return to the days of old and the U.S. presidential debate has validated the importance of this therapeutic tool. Massive efforts are underway to accelerate the process of vaccine development including the U.S. government’s Operation Warp Speed initiative, which has pledged $10 billion with an aim to deliver 300 million doses of a safe and efficacious vaccine by January 2021. With its broader mandate, The World Health Organization is eyeing the prospect of delivering two billion doses by the end of 2021, and we are making incremental but substantial progress, with Russia having approved a vaccine and vaccine candidates produced by Chinese companies Sinovac Biotech and Sinopharm.
We need to think about how we will distribute the vaccine
Considering the ubiquitous demand for a vaccine, it may take months before sufficient doses are produced and demand will surely exceed the cumulative capacity of manufacturer supply. Custodians of global health including the WHO, worldwide political leaders and vaccine producers face the challenge of determining optimal distribution. Many agree to the pursuit of fair vaccine distribution, however the concept of what this looks like is highly subjective. As we slowly inch towards the mark of successful vaccine development, we must deeply reflect on the logistics of its distribution and ensure that we harness the power of this effective transformative tool with intention, equity and pragmatism.
How to we know where the vaccine should go?
Different models have been proposed to inform optimal vaccine allocation
Though no consensus has been attained in the dialogue around global Covid-19 vaccine distribution, several approaches have been proposed by experts. Some propose a model that seeks to minimize cumulative mortality, suggesting that high-risk populations should be given priority, while others seek to minimize the rate of spread. In the former, health professionals are prioritized given their expectedly frequent point-of-contact with infectious risk, and on whom the health of the larger population is dependent. This model also includes individuals above the age of 65 years, who face an outsized risk of death and morbidity from infection. In the latter model, supported by experts including the WHO, a population-parity-based system is suggested, wherein allotment is determined in proportion with the population of that country.
Risk-based approaches are useful but present lines of ambiguity
Risk-based methods of allocation involve identifying vulnerable or high-risk groups in the population, such as those who are immunocompromised and individuals with chronic illnesses. This approach is supported by several experts in medical ethics, including Professor Lydia Dugdale from Columbia University, who has voiced her interest in seeing ‘the population being protected through vaccinating the high risk population’. This model solves for reducing overall mortality, and compliments the vaccination of healthcare workers, who can also unwittingly serve as vectors of disease given their prolonged, repeated and high-risk profiles of exposure.
The question remains, however, as to what dictates whether an individual is ‘high-risk’, and if this definition extends beyond the boundaries of clinical observations. Though clinical data will show that individuals with certain diseases are biologically susceptible, sociological data will illustrate that certain social groups, such as black people and others of color, have disproportionately negative outcomes. Do we prioritize such groups as well? Suggestions of vaccine distribution by way of ‘social determinants of risk’, including race, have been gaining greater volume in global dialogue, including a recent position by Melinda Gates that black people should be given priority access to the vaccine. It is unclear, however, whether these sociobiological observations justify this approach. Furthermore, this approach opens Pandora’s box of questions around the determination of racial lines, legal consequences of race-guided selection, and mistrust by minority communities given the long and ugly history of exploitative scientific experimentation.
Digital generated image of multi-ethnic arms raised in the air
A cross-sectional distribution model does not solve for equity
Another strategy proposed is ‘a cross-sectional distribution’ model, including models endorsed by the WHO, wherein countries receive vaccine doses in proportion to their population. Although this seems, on first blush, a reasonable means of ensuring equal allocation, it fails to meet the primary purpose of the vaccine, which is to ultimately prevent cumulative global mortality and morbidity. Given equal populations of approximately 6 million people, can we justify giving the same vaccine allocation to El Salvador and Turkmenistan, the former having over 26,000 cases and the latter with zero? If not, should we deprive the latter of the immunological protection and social freedoms therein offered by this tool? This approach fails to acknowledge that countries of the same population sizes may have vastly different health and economic needs. Simply put, it fails to promote health equity.
A hybrid model has been proposed that seeks to solve for risk and distribution
Given the challenges with vaccine distribution using isolated risk-based or population-based approaches, a team of global experts have proposed a new model, known as the ‘fair-priority model’. Led by Ezekiel J. Emanuel, distinguished medical ethicist at the University of Pennsylvania, this model seeks to promote distribution based on a combination of clinical, socioeconomic and political considerations. Proponents of this new approach have suggested three primary considerations when distributing the vaccine: it should have maximum benefits with minimum harm, it should prioritize countries already disadvantaged by poverty or low life expectancy, and it should be constructed around reduced chances of discrimination.
The first phase of the fair-priority model focuses on preventing Covid-19-related premature death, which is the passing of an individual before his standard expected years of life, captured in a health metric known as the standard expected years of life lost (SEYLL). The second phase of the model addresses minimizing the economic and social consequences of the Covid-19, through allocation informed by non-clinical metrics. The final phase seeks to prioritize countries with high transmission rates, ultimately ensuring all countries receive sufficient doses to halt community transmission. Ultimately, this blended approach seeks to solve for clinical risk, socioeconomic status and community spread using a single tool, and has great promise in serving as the line of best fit between clinical considerations, ethics and practicality.
A group of doctors with face masks talking about the bioethics of the corona virus
The pandemic will force us to make hard decisions
In addition to driving innovation in global health, this pandemic has forced us to think deeply about an oft-forgotten arm of healthcare: bioethics. Whilst we can afford to wait while we decide our approach to designer babies, we simply do not have the luxury of time in deciding how we will optimally allocate life-saving vaccines, and the decision-making matrices of today will inform the bioethical mandates of the future. As we seek to untie the Gordian knot of optimal vaccine distribution, we can only hope that, in the days to come, humanity will ultimately take the best shot.
