The Ethics of Global Vaccine Distribution, Part Four, with Ezekiel J. Emanuel

Dec 7, 2021

As the COVID-19 pandemic continues, new questions have arisen in regards to the ethics of global vaccine distribution. In a continuation of a series started over the summer, University of Pennsylvania's Ezekiel Emanuel returns to discuss boosters and vaccine hesitancy and how that affects vaccine distribution around the world. Plus, he shares his thoughts on Biden administration policies concerning the travel ban due to the Omicron variant, domestic mandates, testing, and masking.

ALEX WOODSON: Welcome to Global Ethics Review. I'm Alex Woodson from Carnegie Council, the world's catalyst for ethical action.

In this podcast series, we'll be connecting Carnegie Council's work and current events with our senior fellows, senior staff, and friends of our organization. You'll hear from leading experts on artificial intelligence and technology, migration, public health, and U.S. foreign policy and global engagement.

In this podcast, we’ll be picking up on our series on the ethics of vaccine nationalism with Dr. Ezekiel Emanuel. He is vice provost for global initiatives and the Diane v.S. Levy and Robert M. Levy University Professor at the University of Pennsylvania.

The previous podcasts in this series, which were posted in June and July of this year, have discussed the COVID-19 pandemic and the idea that vaccine-rich nations have an ethical obligation to share doses with the rest of the world. This is discussed in great detail in the article "On the Ethics of Vaccine Nationalism: The Case for the Fair Priority for Residents Framework." This was published online on October 29, 2021, by Carnegie Council’s Ethics & International Affairs journal and Cambridge University Press.

Dr. Emanuel is the lead author on this article, which was co-authored by a group of philosophers and global health experts from around the world. For a link to this article and previous podcasts with article co-authors Cécile Fabre and Florencia Luna, please go to carnegiecouncil.org.

In our talk recorded last Friday, Dr. Emanuel and I caught up on some current issues and how they play into the fair priority for residents framework that he and his group of co-authors propose. We spoke about boosters, vaccine hesitancy, and Biden administration policies, including the travel ban on Southern Africa countries due to the new Omicron variant of COVID-19.

But first, since a lot of the conversation is focused on the fair priority for residents framework, here is Dr. Emanuel’s description of this policy from our talk in July 2021:

EZEKIEL EMANUEL: We have been trying to ask the question: How do we fairly distribute vaccines for COVID-19 among countries, and how should that distribution happen? You might say there are two broad components to it. One component is that once you have some vaccine, how do you pick which countries should get the vaccine and how much? We call that the Fair Priority model, and the Fair Priority model says basically you should distribute it on the basis of need, and then we go on to analyze what does medical need mean.

First it should encompass deaths due to COVID-19, both directly—caused by COVID-19, so someone died of COVID-19—and indirectly—because the health care system is overwhelmed, people can't get to the hospital, or people stay away with their heart attacks or their births and unfortunately die from that. Then, it should consider morbidity related to COVID-19 but also socioeconomic burdens. Obviously, the socioeconomic lockdowns are related to mortality. Once the mortality goes down, the socioeconomic lockdowns tend to ease. So that is one component. Once you have got vaccine, how do you distribute it among countries, and basically the idea is need, anticipating which countries where that vaccine is going to do the best to limit the number of deaths and socioeconomic dislocation.

There is also a question of, when a country has vaccine, when does it have to distribute the vaccine and share it, and that is a question that the Fair Priority for Residents addresses and it says at the absolute maximum you can't argue that we should vaccinate everyone in the country. You might be able to argue that we can vaccinate until we get herd immunity, but the question is: Is there a threshold below herd immunity where you should share your vaccine before giving it to your own population? And that is where this principle of the Fair Priority to Residents goes.

Yes, countries should prioritize their residents. We do not have a world government that functions, so national governments have to function and protect their own citizens, but they shouldn't hold onto vaccine once they have reduced mortality below a threshold, and that threshold we call the "flu-like" threshold, which is, when does COVID-19 cease being a pandemic and an emergency, and when does it become background risk? That is when COVID-19 is like the flu.

Just to give listeners a sense, in the United States a not-bad flu season has somewhere between 36,000 and 60,000 deaths. That is about 100 to 150 deaths a day. That gives you a sense for when. Once you have gotten COVID-19 deaths down to that level, a government really is obliged to share the vaccine with other very hard hit countries.

ALEX WOODSON: For more from this talk, and the vaccine nationalism podcasts with Cécile Fabre and Florencia Luna, please go to carnegiecouncil.org. But for now, here’s my most recent talk with Dr. Ezekiel Emanuel.

Dr. Ezekiel Emanuel, thank you so much for speaking with us today.

EZEKIEL EMANUEL: It's a great pleasure to be here.

ALEX WOODSON: We last talked in late June about the COVID-19 pandemic and all of the issues associated with that and with vaccines and vaccine nationalism versus cosmopolitanism. Since then a lot has happened. We have the Delta variant, we have had a lot of vaccine hesitancy in the United States, and we have a discussion of boosters. Your article has also been published by Cambridge University Press and Ethics & International Affairs journal.

We will get to the Omicron variant, but I am just wondering if your thinking has changed over the last few months about the Fair Priority for Residents framework and how that should be approached now that we're kind of in this new world.

EZEKIEL EMANUEL: No, I think the Fair Priority for Residents framework is probably the right one to go on and to utilize. I would say one thing, which I do think adds another ripple, is just to see the kind of vaccine nationalism by low and middle-income countries. It is not only, and I think there is a lot of attention to the United States, Canada, and the European Union, condemning their vaccine nationalism, but let's face it, India, probably linchpin to getting vaccines to developing countries, had enormous vaccine nationalism and still does, and I think there is a sort of undertone—and maybe I'm mischaracterizing it—of, "Well, that's understandable." Why is it any more understandable than vaccine nationalism in a big democracy like the United States?

It does seem to me that we have to recognize in this world that that is a natural reaction of a government and legitimate, at least in many interpretations. Democratic governments are elected to serve their citizens and to keep them healthy and safe. They gain their legitimacy from fulfilling that promise, and in the absence of a world government or an effective world order, that's the best way we know how to protect people's lives. So I think it is a kind of natural thing.

We have to limit it because governments have other obligations, but I think seeing this vaccine nationalism on lots of developing countries' parts should make us very attuned to the fact that this is in some ways I want to say a "natural"—obviously states are unnatural—reaction by a government which aims to be legitimate by its people.

ALEX WOODSON: Just to continue on that point, does vaccine nationalism look the same in India or other developing countries as it does in the United States and Canada, talking about hoarding vaccines and issues like that, or does it take a different form depending on—

EZEKIEL EMANUEL: To be honest, what is the essence of vaccine nationalism? That we should get vaccines before we share them. Now whether it is we should get boosters before we share them or we should get first or second doses before we share them, I think it is the same basic ethical issue.

That doesn't mean the analysis is the same. "We should get first doses" is very different than "We should get boosters" or that "Every adult in our population should get a booster." I think that is frankly a weaker argument for a government to make than "We should get our population first doses."

But the structure of the argument in terms of the nationalism claim is I think the same. Our primary obligation is to protect our own, which I think is valid, but that's not the only obligation, and everyone who is sophisticated recognizes that in addition to that as a primary obligation you often have to weigh obligations against each other and duties. That is part of what makes ethical dilemmas and trying to find the right answers to those ethical dilemmas.

ALEX WOODSON: You mentioned boosters, and that's one of the topics that I wanted to discuss today. I'm not sure if boosters were in mind when you were writing the paper on the Fair Priority for Residents framework. Maybe they were; maybe I'm wrong. But how do the boosters change the calculation when you're talking about sharing vaccine doses when a lot of people in the United States—I'm about to get my third dose, and a lot of people in developing nations haven't had their first one. How should we think about that?

EZEKIEL EMANUEL: We can think about it from the individual standpoint and then the governmental, national standpoint.

From the individual standpoint, Alex, if you don't get your booster and say, "I shouldn't get my booster when there are, whatever, 4 billion people around the world who haven't even gotten the first dose," that's irrelevant. Your shot is not going to Peru, South Africa, or wherever it may be, and I think from an individual standpoint you can't control, your foregoing does not get it somewhere else. It probably puts it in a refrigerator in Atlanta or something like that. So I think, go ahead and get your booster.

But from a national standpoint, how should it be prioritized, it does make a difference. We have to look at what are the risks and benefits—who is going to benefit, how much are they going to benefit, and what are the risks to you of not getting a booster? If you're under 55, for sure the booster is probably not that important. There was obviously even tension among the advisory boards in the United States as to whether all adults should get it or just the older adults and those who are at risk because of comorbidities, and there was recently an op-ed in The Washington Post I believe by the former heads of the vaccine group at the Food and Drug Administration talking about the fact that they didn't see vaccinating all adults as the right answer.

This is the way I would put it: The framework is the same. The actual calculations—and again, a good ethical framework will be sensitive to the empirical facts of the situation—are important. If we got a variant which for some reason was much more virulent among young people and the booster was really effective against it, then it would change the calculation about the booster. But the framework, the ethical reasoning, of the Fair Priority for Residents model remains the same.

ALEX WOODSON: Another issue that I wanted to discuss in relation to the Fair Priority for Residents model and just new information coming in maybe changing your thinking is vaccine hesitancy.

You have a country like the United States, which is sharing a lot of doses where there is a lot of vaccine hesitancy. I believe we have about [60] percent of people vaccinated. I am not sure if it is going to get much greater than that. People seem very entrenched in their views right now. Then you might be sharing with countries that are also vaccine-hesitant. I am not sure about the numbers in other countries, but I know there is a lot of vaccine hesitancy throughout the world.

I guess kind of a two-part question: Did you expect this much vaccine hesitancy in the United States and around the world? And now that we are here, how does that change your thinking about distributing these doses?

EZEKIEL EMANUEL: I think vaccine hesitancy is a real problem, and I think it is a conundrum that probably no one anticipated, at least to this level. First of all, the linking of vaccines, especially in COVID-19, with cultural, political, that gemish, which has now become somewhat of a cesspool—I use "cesspool" because it's a negative effect. Somehow not getting a vaccine is a cultural identity and a political—it's all mixed in together, and that's terrible.

Sixty percent of the population, give or take a few tenths of a percent, are vaccinated in the United States. That includes babies. We have plateaued. That's it. The first doses are really low. You're seeing lines now because of Omicron at pharmacies, but that's not lines of lots of people rushing to get their first dose.

I don't think all of the unvaccinated people are hesitant people. Some of them are truly hesitant, and no matter what—they would rather lose their very good jobs at hospital systems and whatever than get vaccinated. There is that group. That's probably a smallish group, around 10 percent.

Then there is a very wide swath of people—"I'm concerned about my kid, I want to delay, I want to see more data, I haven't gotten around to it, I might be concerned, it's just not a focus of my life for whatever reason" and plenty of people have lots of other burning issues. Those are the people who are persuadable by mandates in my opinion.

Let me make point two. I'm sure we'll get back to mandates because it's something I feel passionate about.

Point two is this hesitancy is again not unique to the United States. While we may have it in an extreme version and a more vocal version, you see it all over Europe, and it has slightly different but also slightly overlapping sources. Go to Switzerland and parts of Germany, and you have these very strong naturopath, alternative medicine groups, and they are just as much anti-vaxxers—low levels of vaccination in Switzerland, highly educated population, white, very rich, just a population that should be very high on the vaccine, but not very high on vaccination rates, and a lot of that is because of the naturopath views. Knowing those people and having talked to them, there are plenty of people who are like, "I have a strong body, I go mountain climbing all the time, and that's going to be much more important to protect me."

Yes, well, not really.

You see it in Africa. Everyone talks about we're not sending enough vaccine there. Well, a big problem in lots of places in Africa that actually have not been able to distribute their vaccine is hesitancy. People are connecting that back to colonialism. I'm not sure it's colonialism, and I think we are often given to facile explanations—"Oh, they've been exploited, and that's why."

You know, over the last 20, maybe even 30 years, the average life expectancy in most sub-Saharan African countries has gone way up, even including AIDS, and shockingly that's not because of avoiding Western medicine. It's exactly because we've made Western medicine available. If, in fact, they were exploited by Western medicine, then all this push for HIV drugs would have been ridiculous.

The fact is that the access to Western medicines for HIV but also for vaccines of other kinds—for nontropical diseases, for malaria—have made huge differences to the life expectancy in sub-Saharan Africa, and I am not sure that the connection is, "Oh, I'm going to be exploited by these companies." I think much more you've got just a worldwide situation of distrust which is not very well grounded but is very well fueled by social media.

ALEX WOODSON: There are a lot of points there that we will come back to, and I definitely want to talk about mandates towards the end of the conversation.

Let's move on to Southern Africa, though, as you just mentioned. I'm not sure if you saw this tweet, and this is going to tie into some domestic issues. This is from the UN Secretary-General António Guterres, on November 29, and I'm sure you've heard the sentiment if maybe you have not seen this tweet. He wrote: "I am now deeply concerned about the isolation of southern African countries to the new Covid-19 travel restrictions. The People of Africa cannot be blamed for the immorally low levels of vaccinations available & should not be penalized for sharing health information with the world."

I think you touched on a little bit of that before when you were talking about vaccine hesitancy in some of these African nations, but what do you think about his thoughts about the travel ban? Whether or not they're vaccine-hesitant, that they are in a very different situation than people in the United States and Western Europe are, and these countries in Southern Africa are bearing the brunt of this travel ban at the moment. Do you think this travel ban is warranted? If you don't want to speak specifically about this because this is still a developing situation, maybe just a thought on travel bans in general when it comes to infectious diseases and crossing borders.

EZEKIEL EMANUEL: Let's just be clear. Unless you're going to "do China," which is, "We're sealing our borders, you come into the country, your 21-day incubation"—and by the way, this doesn't apply just to foreigners; it also applies to Chinese coming back who have been overseas—travel bans are not going to keep a virus out, and we know that. If you have a travel ban like we have in the United States—"No foreigners from these countries can come in, but if you're an American citizen and you've been there or you're a permanent resident and you've been there, you can come in."

Who's the guy who brought it into San Francisco? I think that's the only one we have really well characterized. Okay, you've been there, American citizen vaccinated. Okay, you got a porous ban, and it's just not going to be that effective.

What it is going to do is slow things down a little bit. That's the best it's going to do, and we should know that.

I agree with Guterres' sentiment. We shouldn't penalize them. So how do we compensate them while trying to slow things down? There is an advantage to slowing something down, especially at this moment. We don't know enough about this virus. Is it more virulent? How effective are the current vaccines? How effective are the potential medications that might be authorized, or I guess in the Merck case have been authorized?

Getting that information would help, slowing things down would help, but we shouldn't be under any illusion that a travel ban is going to hermetically seal us, unless again we are going to do China, and no Western country has done China, and we're not going to do China as far as I can tell. So we should be very clear this buys us a few days to a few weeks at most.

ALEX WOODSON: In your position as a medical doctor, do you think about, or should people who are advising President Biden and other leaders think about the politics of this, especially coming off the Trump administration and the travel bans there and what Trump said about African countries and now President Biden is coming in, supposedly a new chapter in America, and he's banning African countries as well? Obviously I'm oversimplifying this a little bit, but you can see the argument there.

EZEKIEL EMANUEL: A lot depends upon what you mean by politics.

ALEX WOODSON: Optics maybe.

EZEKIEL EMANUEL: If you're in the policy world and you're making national policy, you have to consider effectiveness. You have to consider will the public follow you. You can make a policy and if the public doesn't follow it's not worth the paper it's written on. I can tell you, having advised many, many politicians, governors and others, about what to do, a big part of that is, "Well, can I get the public to accept this?"

That has to be balanced against is it ethical to do even if you could get the public—sometimes the public accepts things that are totally unethical, and you don't want to affirm them. Racism and lynching is one of those. We have to be able to carry the public with us.

Joe Biden is nothing if not a very astute politician with a good nose for what the middle of America will accept, and one of the things I think—my job is to try to push them to where I think they need to be. His job is to feel how fast he can go.

Sometimes politicians get it wrong. We can look at FDR, and there are a lot of things that FDR had a great nose for, but also he was probably too slow in doing certain things, certainly on racial justice, just as an example. Health care may be another example where he probably could have gotten more had he pushed it more, and you can see some of this in Harry Truman: "We're going to desegregate the Army. I don't care what the public says. I don't care what anyone says. It's the right thing to do, and we're going to do it."

A politician is always balancing these things of "Can I get the public to go along, do I have the authority, can I set the right precedent?" I think ethics is but one consideration when you're governing. Doing the right thing and no one following you does no good, so you have to marry these up, and it's hard to get everything perfect because part of what you do when you make policy is you change people's attitudes. So it's a bit of a circle which could be reinforcing positively and could be reinforcing negatively, and a good politician has to make that call.

I haven't agreed with all of Joe Biden's calls. For example, I do not agree with his call about travel mandates, which I have been pushing really hard. But I understand where he's coming from. It's too facile if you haven't been in those shoes when you're either giving advice or having to make the decision to say "I'm not paying attention to the politics." You have to pay attention to public legitimacy and public sentiment.

ALEX WOODSON: Just to continue on with the Biden administration. Something that you said in our last interview which I thought was really interesting was that the countries that effectively fought COVID-19, especially when it first started, were countries that created a "command center," I think you said. You mentioned Taiwan. Australia did a good job of that. You said that Operation Warp Speed was a good example of that in the United States.

Have you seen Biden do this? I know he just put out his winter COVID-19 plan. This will come out in a few days, but that plan just came out yesterday. What's your sense of Biden and this idea of a national command center?

EZEKIEL EMANUEL: I think that's an excellent question. When the administration came in, they had a playbook and they were executing against that playbook, and I think they did a really good job. We were at a very low—we had some vaccines—vaccination rate. We needed to get them out to different populations and multiple venues so people could access them easily. We needed to take down the pricing. We needed to make it convenient and cheap or free, educate people about it, and all that. And I think they executed incredibly well against it, and you can see it in the graphs frankly. By June we were as low as we had been since the previous March. So June 2021 compared to March 2020, I don't think we had gotten as low in terms of cases or fatalities. Then Delta hit and that threw a spanner into things.

So I think that was good. But you have to remember part of what needed to be done was not just the vaccines. You had a whole panoply of things:

Testing. We took our eye off the ball of testing, and that has never been good in this country. The latest announcement of getting free tests at pharmacies and getting the insurance companies to pay for it is good. It's really important to get it so people can get free tests or at least very, very low cost tests. I actually don't think free is probably the right price point. I think a dollar is probably the right price point unless you're on Medicaid or something. But that should have been done six months ago.

Therapeutics. Assuming the Pfizer drug Paxlovid gets approved, you have a very small window—three days—to get someone who is symptomatic or tested positive onto the drug, and I think that turns out to be a lot harder to do, and putting in an infrastructure where everyone who tests positive gets this drug is going to be hard. That is perfectly made for inequities because "I'm rich, I have a primary care doctor, I can be served." But if you don't have a primary care doctor, you don't have insurance, blah blah blah, how are you going to get that? So I think that's a serious, serious problem that we haven't actually gotten.

Two other things where I think maybe we took our eye off the ball. One is getting the vaccine right and testing therapeutics.

Air quality, having a high-efficiency particulate absorbing (HEPA) filter in every single classroom and in all public buildings is another thing where, we allocated $34 billion, $43 billion—I can't even remember now—for education upgrades and improvements. Part of that should have been, "Spend it on HEPA filters or show us that your heating and air conditioning is Minimum Efficiency Reporting Values (MERV) 13 or better," and having public buildings everywhere upgraded to that. I think that is really important.

That last area where again I think we haven't executed as well as we should is the whole mask thing. We got screwed up in May with the Centers for Disease Control and Prevention saying, "If you're vaccinated, take your mask off," and then slammed just a few weeks later with, "It's Delta, no, put your mask back on," but also the emphasis on high-quality masks.

Cotton masks just don't cut it. Having an N95 National Institute for Occupational Safety & Health (NIOSH)-approved mask—made in the United States so you don't have any false ones from China that really aren't N95 respirators—is very important, sending them out, making them easily available to people who can't afford them, whether sending them to students at school, etc. I think those are the kinds of things again I would like to see a command center execute on.

ALEX WOODSON: I want to go back to something you mentioned earlier, which is the mandates in the United States. You have been a big proponent of mandates. I'm sure you have your answer ready, so what is your answer for people who say: "Mandates take away our rights. We should be able to do what we want. This is America, freedom, and all that"—what's your answer that when it comes to vaccine mandates?

EZEKIEL EMANUEL: I don't even think any serious libertarian could possibly defend the idea that I should have a right to infect you or I should have a right to get sick and then expect you, through this thing called "health insurance," to pay for me when there is an effective therapy and it's free.

This is a non-argument. It's just grabbing at a phrase that makes you feel good. So I'll just tell a little story here. I had a prominent Republican person—not a politician but in the Republican circle—and every time we would get to policy and there was something that someone didn't like, from Texas especially, they would get up and say, "Liberty," and walk out. As if that were answer to everything. "My freedom."

"We should have reasonable gun restrictions."

"Liberty!"

"We should wear seatbelts, wear bike helmets if you're riding a motorcycle."

"Liberty!"

It's like, no. The people who defended that and gave an intellectual framework for that clearly recognized that your liberty stops at my nose, and if you're breathing and your breathing increases my risk, you don't have that right. You have to figure it out and change it.

So this is just, just nonsense. We have lots of mandates: You cannot drive a car without a license. You have to pay your taxes. We can go on and on. You can't build any house you want. There are rules. You can't have lead paint, and it's not because you're going to chew on the paint, but some kid might chew on the paint.

There are all sorts of rules of a society where we are cheek by jowl. Wearing a mask or getting a vaccination is just part of being in a society, and one of the things this liberty idea fails to take account of is that you can't be part of a society without some compromise with others and balancing of your rights and others' interests too. Individual rights don't trump everybody else. They need to be put into a context to make sure that other people's rights work.

ALEX WOODSON: So when it comes to COVID-19 what specific mandates do you think would have an effect to fight the pandemic right now?

EZEKIEL EMANUEL: Look, the biggest thing with the pandemic is quite clearly we have to get the unvaccinated vaccinated. That's way more important than getting boosters.

That's the question. What mandates are we going to put in place that get the unvaccinated vaccinated. I think this employer mandate through the Occupational Safety and Health Administration is very, very important. I wouldn't have cut it off at 100; I would have cut it off much further down. I think it's absolutely essential that that happen. The court decisions that have suspended that just make no sense at all. It's quite clear when you look at things like Tyson Foods or the 4 million retail workers who are really at the front end and heavily exposed to the public and on and on.

Domestic travel mandate for planes and trains where you have to be vaccinated and not just wear a mask because let me assure you wearing a mask—people first of all don't have high-quality masks, inconsistently, below the nose, or I'm having a sandwich or I'm having a drink, I'm going to take my mask off, well, what good is the mandate? I think those are important.

Then we know that they are effective because these people who are on the fence get tilted off the fence, and the number of people who are willing to sacrifice their job or are not willing to fly is small, just really small. Obviously, if you're going to have a mandate to fly or take a train, you need some electronic verification. Those little cards that are on paper that are easily forged don't work.

ALEX WOODSON: Final question, and this is a tough question. It's just something that I've been thinking about. It amazes me two years in how different the pandemic looks in different parts of the country. In New York City, where I am, most people wear masks on the train, we have the vaccine mandates, and the infection rate has been pretty low in New York City for a while. In rural areas obviously it's very different. Different cities have different rules when it comes to masks and when it comes to vaccines.

Again, this is not an easy question to end on, but I will just throw it out there: How do you make effective policies in this country right now when you have different regions that are just wildly different in terms of how they accept basic science and how they think about these rules that you and I might think are commonsense?

EZEKIEL EMANUEL: When you have someone like Ron DeSantis clearly running for the presidency using this as a differentiator and the fundamental basis on which he is going to attack Biden, it clearly means, I think, federalism is failing in this area. This is an interstate issue. It's not something in the states. I think we need to have a different understanding of things like public health.

But it's not only public health. The irony is that all of us are impacted by what happens within a state, and not just on infectious diseases. Lots of things. Education within a state makes a huge difference. The rate at which you tax your citizens and expect—we have lots of federal matching grants where the matching grants are related to the income level of a state. Well, state policies affect that income level. It's not an exogenous variable. It's very endogenous, that depends upon what states do, and not taxing and not investing in your citizens has a very negative effect on incomes and growth. This is a classic case of an externality, making all the rest of us pay for your policies.

I think if anything, this has shown the limits of federalism. We need states to implement and do other things because having one government for 330 million people is too remote. There are lots of legitimate critiques of it, but having states able to negate federal policies that are based on science and things where the federal government is doing a lot of the paying seems to me ought to be a nonstarter.

Anyway, that's really one of the key lessons here, and it's going to be difficult for us to really get effective public policies in infectious disease, especially once we pay so much. It's not like states are paying a lot for their public health infrastructure. That's really a federal government—we end up shoveling a lot of money to states, and I think it is going to have to come with bigger strings.

ALEX WOODSON: Dr. Ezekiel Emanuel, thank you so much for your time.

EZEKIEL EMANUEL: Thank you. Thanks for the great interview.

ALEX WOODSON: That was Dr. Ezekiel Emanuel, vice provost for global initiatives and the Diane v.S. Levy and Robert M. Levy University Professor at the University of Pennsylvania. He is also the lead author of "On the Ethics of Vaccine Nationalism: The Case for the Fair Priority for Residents Framework." This was published online on October 29, 2021, by Carnegie Council's Ethics & International Affairs journal and Cambridge University Press. For more go to carnegiecouncil.org.

Thanks for listening to Global Ethics Review. Stay safe and healthy.

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