Vaccine Nationalism: Striking the balance

Written by Owen Schaefer and Julian Savulescu

This is an updated cross-post of an article published in MediCine

On 2 February 2021, the Director-General of the World Health Organization, Dr Tedros Adhanom Ghebreyesus, issues a broadside against COVID-19 vaccine nationalism, calling it “morally indefensible” and “tantamount to medical malpractice at a global scale.” Rich countries representing 16% of the global population have snapped up 60% of the global supply of COVID-19 vaccines. [1] Meanwhile, India, which has only vaccinated 10% of its population, is facing a catastrophic COVID-19 surge.[2] And the COVAX facility – an international effort to get COVID-19 vaccines equitably distributed around the world – currently only projects capacity to offer vaccines amounting to about 3% of participating countries’ populations by mid-year.[3]

COVID-19 vaccine nationalism is not the exception to normal practice. In almost all matters, countries spend the vast majority of budgets on local needs, and only a small fraction of that foreign aid, even when the latter represents much greater need. But the fact that this is normal or expected does not amount to a moral defense.

Here, we explore a question of practical ethics: what is the appropriate extent to which a country can prioritize its own people over those in other countries in the securing of vaccines for COVID-19?

Moderating nationalism

There are two extreme positions that could be taken in regards to vaccine allocation: pure cosmopolitanism and pure nationalism.

According to pure cosmopolitanism, which country a person lives in is morally irrelevant to what they are owed. So, countries should fund and supply vaccines (to the extent practicable) to the global population irrespective of nationality.[4] Certain ‘impartial’ ethical frameworks might be used to determine which particular countries receive how much vaccine. For example, a utilitarian frame would suggest vaccines should go to countries where it will benefit the local population the most. A more egalitarian frame might instead spread vaccines more evenly across the global population, giving each population similar levels of protection against the virus. The latter is roughly the current approach of COVAX, which at this point distributes vaccines in proportion to a country’s population, not their need.[5]

Another extreme is pure nationalism, according to which countries may strictly prioritise the interests of their own people over those of others. This may be justified on a variety of grounds: it is most conducive to promoting human rights and interests for countries to primarily promote the interests of their own citizens; countries owe reciprocal duties to its people, who are subject to its laws and taxation; and co-nationals possess associative ties that create special obligations to each other the country can enforce through national priority.[6] Importantly, in practice there will be a connection between democratic legitimacy and nationalism: if the will of the people is to protect themselves first (as it typically is), governments must to a certain extent be responsive to this. The precise role of responsiveness in democratic legitimacy is a long-standing dispute in political theory,[7] but more deferential approaches to popular opinion may in practice favor nationalism.

Actual best practice is likely a compromise between the two extremes of nationalism and cosmopolitanism. Pure cosmopolitanism ignores the morally salient features of nationhood, while pure nationalism ignores the moral interests of those outside a country’s own borders. Democratic nationalism also obscures the further question of what citizens should demand of their governments vis-à-vis meeting the needs of the international community. A position of ‘moderate’ nationalism (or perhaps ‘moderate’ cosmopolitanism) would allow countries (or, propose citizens should demand of their governments) to prioritise the interests of their own people to some degree, while also requiring them to provide meaningful support to the global population.[8]

Models of balancing

Even accepting moderate nationalism, the question remains of what exactly is the appropriate balance. In practice, a number of models have been proposed and carried out. We survey four, and discuss the ethical balance underpinning each.

Cash support

While the US, under the new Biden administration, has pledged to fund COVAX to the tune of billions of dollars, it has also stated that it will not send any actual vaccines abroad until the US is fully vaccinated.[9] This is an important distinction, because while funding goes some way towards securing vaccines in the future, wealthy countries have secured priority access to current production through advance market commitments. In other words, this approach keeps a country’s own people at the ‘front of the queue’ while offering a degree of financial assistance for other countries.

In present context, this approach leans heavily in favor of national priority, because the world faces an absolute scarcity of vaccines; one country securing a given supply of vaccine means another country will not receive that supply. Much of the current global production has already been secured through advance market commitments. While cash assistance to COVAX now will help contain the pandemic in the future, it still comes too late to reverse the worst near-term effects of vaccine nationalism.

Concurrent distribution

French President Emanuel Macron has proposed countries to reserve 3-5% of their purchased vaccine supply to redistribute to countries most in need.[10] This allocation of vaccines, rather than cash, is more sensitive to the current scarcity of vaccines and so more cosmopolitan than the US’s current policy.

Still, this proposal would allocate only a small fraction of vaccines to meet global need, leaning still heavily towards national priority – just not as much as with only offering cash support. By design, richer countries would keep twenty times as many vaccines for themselves as compared with that made available to others. Other countries might supplement that donated supply with their own bilateral deals, but many low and middle income countries will still have to wait months if not years to reach the same level of coverage as wealthier countries.

India’s vaccine approach is substantially more generous: of 193 million doses manufactured there, over a third have been exported, a mixture of donations to individual countries, donations to COVAX and direct sales.[11] Indeed, much of COVAX’s ability to begin to deliver vaccines to dozens of under-served countries around the world is due to those exports. This approach, though, has come at substantial national cost, given that India now grapples with one of the worst surges of COVID-19 in the world since the pandemic began.[12]

Vulnerable only

Risks of COVID-19 are not distributed evenly within a population. The elderly and individuals with certain co-morbidities are at particular risk of getting sick and dying of COVID-19, while healthcare workers are at especial risk of exposure. One proposal is to draw a line: a country can strictly prioritise vaccinating its own population until such a time as healthcare workers, the elderly and vulnerable are vaccinated. At that point, a country should be able to open up safely while donating their vaccine supply to international efforts to ensure such vulnerable populations around the world are protected.[13]

This framework somewhat more evenly balances cosmopolitan demands with obligations to prioritise one’s own people. It is in this way analogous to a form of rescue ethics that would permit an individual to save the lives of their family members before those of (perhaps more) strangers, but once their family is saved, obligate them to save the strangers before tending to the injuries of their family. However, it focuses primarily on demographic measures rather than actual outcomes, potentially excusing some countries from donating abroad when their need is very limited, while requiring others to donate abroad when many are still dying locally of COVID-19.

Eliminating excess mortality

An alternative is for countries to focus first on eliminating excess mortality through vaccines. Excess mortality refers to the unusually high number of deaths experienced as a result of the pandemic. This will include deaths directly from COVID-19, as well as indirect deaths caused by, for example, lack of access to essential services due to lockdown disruptions. On this model, countries can vaccinate their population until such a time as they have brought down excess mortality to a tolerable and non-emergency level, perhaps the level experienced during a somewhat bad year of a seasonal flu outbreak.[14]

This model balances cosmopolitanism with nationalism by identifying a point at which the interests of other countries in receiving vaccine can reasonably trump that of domestic need. Eliminating excess mortality will come at different points for different countries, so is more sensitive to local contextual factors than a purely demographic-based approach like the preceding. It also appeals more directly to what matters most during a pandemic: saving lives, whether directly or indirectly threatened by the virus. It will, however, be challenging to operationalize real-time metrics of excess mortality, and requires more willingness than is currently evident on the part of countries to trade off the interests of their own people compared with the much more pressing needs of those abroad.

The approach also runs the risk of leaving a country that has well contained COVID-19 vulnerable to a later surge. This appears to be the case in India, which as of January 2021 had comparatively few cases and deaths, as a proportion of population.[15] Around this period, the country was manufacturing and export large quantities of vaccine to protect the world. However, recently the Indian government has justifiably limited vaccine exports in order to address its massive crisis at home.[16] Other models of national priority would have justified more stringent export limits sooner, which might have to some extent mitigated the magnitude of the current crisis – though at the expense of exposing other countries to greater harm if they have their own surges.

 

Weighing up

There is not space here to offer a proper defense of these options over the other. Each espouses a somewhat different balance between national priority and global need, and so which is preferable will depend on how heavily a country weighs those competing interests. Notably, even the more nationalistic approaches like Macron’s 3-5% proposal are substantially greater than the normal aid distribution. By comparison, France in 2019 spent 0.44% of its Gross National Income on foreign development aid.[17] In addition, recent polling suggests that even in countries like the US often perceived as highly nationalistic, there is widespread support for prioritizing global over domestic need.[18]

This exceptional level of international support might be reflective of the more pragmatic concern that it is in countries’ national interests to ensure the pandemic is controlled globally. Yet this does not mean that vaccine cosmopolitanism and nationalism collapse into each other – shared interest in global pandemic control will only go so far in terms of justifying support of international distribution of vaccines. Ethical concerns like those espoused in this article should generally push countries and their citizens to be more generous than they otherwise would be to ensure globally equitable access to COVID-19 vaccines.

However, ultimately, democratic governments are responsible to the people who elect them. Whatever policy they believe it is best to pursue, they must persuade their citizens in a democracy that that policy is the one which should be adopted. This requires not propaganda, but sound argument and evidence. In short, we require ethics first to identify the best or most justifiable policy and practical ethics to rationally persuade the people that this is the policy they should support.

[1] https://foreignpolicy.com/2021/02/02/vaccine-nationalism-harms-everyone-and-protects-no-one/

[2] https://www.theatlantic.com/international/archive/2021/04/india-covid-19-crisis/618691/

[3] https://www.who.int/docs/default-source/coronaviruse/act-accelerator/covax/covax-interim-distribution-forecast.pdf?sfvrsn=7889475d_5

[4] https://gh.bmj.com/content/bmjgh/6/2/e004812.full.pdf

[5] https://www.who.int/publications/m/item/fair-allocation-mechanism-for-covid-19-vaccines-through-the-covax-facility

[6] https://link.springer.com/article/10.1007/s10677-021-10160-0

[7] https://www.cambridge.org/core/journals/perspectives-on-politics/article/abs/two-cultures-of-democratic-theory-responsiveness-democratic-quality-and-the-empiricalnormative-divide/0A9BF5D8453C4488001FD55B1B8B40C0

[8] https://jme.bmj.com/content/early/2021/02/16/medethics-2020-107036

[9] https://www.politico.com/news/2021/02/18/us-share-vaccine-americans-world-469886

[10]  https://www.euronews.com/2021/02/18/coronavirus-vaccines-macron-proposes-sending-3-5-of-supplies-to-africa

[11] https://thewire.in/health/how-the-modi-government-overestimated-indias-capacity-to-make-covid-vaccines

[12] https://www.reuters.com/world/india/india-reports-record-352991-new-covid-19-cases-2021-04-26/

[13] https://theconversation.com/the-uk-should-share-the-vaccine-with-the-other-countries-but-only-after-all-the-vulnerable-have-been-vaccinated-154351

[14] https://www.foreignaffairs.com/articles/world/2021-03-09/how-many-vaccine-doses-can-nations-ethically-hoard

[15] https://www.straitstimes.com/asia/south-asia/india-says-it-contains-spread-of-covid-19-no-new-cases-in-fifth-of-country

[16] https://qz.com/india/1992029/india-curbs-covid-19-vaccine-exports-opens-up-for-those-over-45/

[17]https://donortracker.org/country/france#:~:text=France%20is%20the%20fifth%2Dlargest,0.55%25%20of%20GNI%20by%202022.

[18] https://www.one.org/us/press/onecampaignpoll/

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2 Responses to Vaccine Nationalism: Striking the balance

  • David Horacek says:

    We can’t forget that if we rich countries allow COVID to burn through places like India, we increase the risk that a far nastier mutation will arise there and boomerang back on us. COVID-19 is here to stay. Its ultimate form and virulence depends much on how the world handles itself in 2021. Containing third world outbreaks also protects first-world citizens.

  • Amy Scanlon says:

    To me it’s a pretty non-negotiable proposition that India MUST be rescued for both moral and practical reasons.

    On the moral side it’s important to consider India is the home of The Serum Institute and the world’s largest vaccine mfg. They’ve expressed a willngness to help vaccinate the world so I believe that those countries that can help out should help out in their time of need. India was expected (and willing) to be a major Covvax contributor even though there own country was going to be challenging and deserve some reciprocity.

    Also India has a lot of potential for scary new variants to develop in Covid-19 is allowed to circulate there.

    What I think Biden out to do is this (and the Cabinet is debating this): Since the Oxford Vaccine has not been approved in the US and some argue just having three vaccines for now would be better, the nation should ship any Astrazeneca-Oxford doses produced in the US, that have not already been promised to another country straight to India-not for the duration of the pandemic certainly, but for weeks to months.

    Also the US is facing a “glut problem” the vaccines produced is starting to outstrip the ability of the country to get vaccines into arms both due to hesitancy but also due to a shift in the campaign from very large vaccination sites to smaller sites, local pharmacies, GPs, community clinics and mobile units. Most of the largest mass vaccine sites have decreased their hours and starting to take “walk-ins”. One site in Philadelphia ended up hunting for people to take 4,000 vaccines in two days so they wouldn’t go bad.

    State governments are somewhat empowered to enforce vaccine mandates (ei fines) but this will take time, and the other half of the problem is frankly logistical.

    So waiting for every America to have a shot before sending vaccine abroad makes no sense. It is necessary to eitehr slow down manufacture or send a large fraction of the vaccine (maybe over half soon) it produces abroad to prevent the waste of millions of doses.

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