The moral test of vaccine justice
The forces arrayed against vaccine justice—monopolies, charity, and individualism—stand in the way of a just response to other shared global problems.
People queue for Pfizer-BioNTech Comirnaty COVID-19 vaccine injections during a vaccination drive in Depok, Indonesia, 01 September 2021. The Indonesian government is speeding up its vaccination campaign as COVID-19 restrictions extended with a number of relaxations for community activities, including reopening schools, public areas and shopping malls. EFE/EPA/MAST IRHAM
While low-income countries struggle to launch vaccination programs, wealthy countries are stockpiling surplus doses and beginning to recommend additional ones. Mechanisms ostensibly established to increase vaccine equity have recently shipped more doses to vaccine-rich United Kingdom and Europe than to the entire African continent.
Calls for vaccine justice frame access to COVID-19 vaccines as a moral test: of humanity’s ability to share, of global solidarity over nationalism, of progress in ending racist exclusion from the benefits of scientific progress, and of the equal and inherent value of all human lives. Beyond an appeal to charity and benevolence—which will increase some coverage numbers—, these calls ask for structural change and redistribution that would achieve a deeper justice in access to health
An Up Close series in OGR advocated a number of “practical solutions” to vaccine inequity, some of which envision deeper change to the status quo than others. Solutions like strengthening regional cooperation to negotiate with the pharmaceutical industry, fully funding the COVAX Facility, and harmonizing regulatory approval standards would pose little challenge to the structures that undergird vaccine manufacturing, financing, and delivery.
Calls for vaccine justice frame access to COVID-19 vaccines as a moral test: of humanity’s ability to share, of global solidarity over nationalism, of progress in ending racist exclusion from the benefits of scientific progress, and of the equal and inherent value of all human lives.
In contrast, solutions like reforming and regulating the pharmaceutical industry itself, issuing blanket waivers of intellectual property protections for COVID-19 vaccines, and rethinking systems of development finance begin to imagine a world in which health is reclaimed as a public good instead of a commodity. This “transformational human rights praxis” dismantles underlying logics of hierarchy, monopoly, and charity in the service of a fundamental redistribution of power in global health.
But how sustainably do these solutions alter or redistribute the hierarchies of power that led to vaccine inequity in the first place?
In this essay, I join my public health colleagues at the Open Society Foundations in suggesting that at least three structural shifts are required to formulate a just response to vaccine inequity—one that eradicates the roots of the current inequity, so as to avoid repeating the same mistake in future pandemics.
From monopolies to shared capacity
The capacity to produce or procure vast quantities of safe and effective vaccines at an affordable price has emerged as one of the single greatest determinants of vaccine access and equity worldwide. Four countries currently dominate global COVID-19 vaccine production—China, the United States, Germany, and Belgium—creating an artificial scarcity.
Established in 2020 to help overcome vaccine inequity, the COVID-19 Vaccines Global Access (COVAX) Facility was neither intended nor designed to expand production capacity beyond a few wealthy countries. Predictably, it has failed to make a meaningful dent in vaccine inequity worldwide even after meeting its financing targets. Advocates for vaccine justice have described COVAX as doomed to fail, or worse, as one element of an elaborate smokescreen for rich countries’ and pharmaceutical companies’ reluctance to share their intellectual property.
Breaking the monopoly on global COVID-19 vaccine production capacity requires a series of steps—like constructing new manufacturing plants in countries that do not have them and sharing manufacturing technology—for which political will has thus far proved elusive. A litany of excuses for failing to act with urgency on all of these steps, such as concerns about quality control or suggestions that technology transfer is impossible outside high-income countries, obscure the simple truth that the scarcity produced by production monopolies is extremely profitable for pharmaceutical companies, who have outsized power to set policies over the sharing of production.
Pharmaceutical companies and their rich country enablers are not immune to pressure, however. While they have thus far refused to expand production, political actions such as the US support for a waiver of intellectual property on COVID-19 vaccines imply a recognition by some governments that it is insufficient to rely on rich countries to mass produce and donate surplus vaccines to the rest of the world.
From charity to shared resources
Fiscal independence represents a second and closely related factor in any country’s ability to achieve COVID-19 immunity through vaccination programs. Countries with the highest vaccination rates have typically been able to rely on their national treasuries to finance vaccine procurement, whereas those with the lowest vaccination rates remain largely reliant on bilateral aid, development banks, and surplus vaccine donations.
In October 2020, the World Bank approved $12 billion for developing countries to finance vaccine deployment—a sum that the United States alone would exceed on its own “Operation Warp Speed” by that December. Indeed, by June 2021, the IMF estimated that it would cost $50 billion to finance the equitable manufacture and distribution of vaccines and generate the trillions of dollars in returns needed to finance a global economic recovery from COVID-19.
Breaking the monopoly on global COVID-19 vaccine production capacity requires a series of steps—like constructing new manufacturing plants in countries that do not have them and sharing manufacturing technology—for which political will has thus far proved elusive.
Just like breaking production monopolies, ending financial dependency between rich and poor nations requires transformational steps for which the main obstacle has been political will. These include not only emergency debt relief, but a broader shift from aid to global public investment. In the long run, what is needed is an end to economies of extraction that perpetuate inequalities between rich and poor nations.
COVID-19 presents an opportunity and imperative to shift course. In practice, this means that national governments and regional institutions, such as the African Vaccine Acquisition Task Team and the South Asian Association for Regional Cooperation COVID-19 Emergency Fund, need to dedicate sufficient resources and investments to support vaccination, consistent with their human rights obligations. At the same time, G7 and G20 donors must commit additional financing for vaccines in addition to supporting measures to decentralize vaccine production.
From individualism to shared responsibility
A third and often neglected factor in vaccine justice is how countries approach the challenge of vaccine delivery and uptake. While much attention has been paid to generating individual demand for vaccines and overcoming vaccine “hesitancy,” equally if not more important is shaping the social, economic, and environmental determinants of whether individuals seek and receive access to vaccination programs.
Non-individualized barriers to vaccine uptake are diverse and intersect with race, poverty, migration status, and underlying health conditions. These conditions, whether poor access to public transportation or denial of paid sick leave for vaccination, are changeable with political commitment. Not unlike sharing production capacity and democratizing development financing, altering these conditions requires public policy choices that implicate everyone’s participation and sacrifice.
From an epidemiological perspective, the very premise of generating individual demand for vaccines ignores the scientific reality that any one individual’s protection from COVID-19 depends on community uptake of the vaccine. The health of vaccinated people is not solely in their hands—it is equally in the hands of those who are unvaccinated, who in turn may be facing social and environmental barriers to vaccination.
In the effort to vaccinate the world, societies face a moral choice—between emphasizing individual responsibility to accept the vaccine and protect one’s own health, or fostering shared responsibility to achieve both community immunity and the social determinants of health. The latter choice is the choice of justice. It is the choice that recognizes our interdependence, shared humanity, and responsibility to one another—giving full effect to the public health maxim that “no one is safe until we are all safe.”
Justice as sharing
COVID-19 is far from the first public health threat that has animated calls for global justice. The movement for HIV treatment justice called for a similar dismantling of pharmaceutical monopolies that artificially inflated the price of life-saving medicines. The call for reproductive justice demanded a redistribution of the racial and gender hierarchies that limit reproductive choice even where the law does not explicitly do so.
Today, the call for vaccine justice seeks similar redress for the racial and colonial roots of inequitable and profit-driven COVID-19 responses and their entrenched effects.
The forces arrayed against vaccine justice—monopolies, charity, and individualism—stand in the way of a just response to other shared global problems. Whether responding to COVID-19, climate change, or the digital divide, we would all benefit from acknowledging and sharing our mutual capacities, resources, and responsibilities, rather than hoarding them for ourselves. Perhaps this is the lesson that the COVID-19 pandemic was meant to teach us. By trapping us into thinking that we need only take care of ourselves—as individuals or as nations—COVID-19 multiplied, mutated, and prolonged our suffering. The question is whether we will ever learn.
Author’s note: The author thanks the grantee partners and staff of the Public Health Program, particularly A. Kayum Ahmed, Roxana Bonnell, Brett Davidson, Julia Greenberg, Azadeh Momenghalibaf, Rosalind McKenna, Sharmila Mhatre, and Daniel Wolfe, for their contributions to this essay.
Jonathan Cohen is a clinical professor and director of policy engagement for the Institute on Inequalities in Global Health at the University of Southern California.