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

July 14, 2021

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. 

This week’s podcast is the second in a series on the COVID-19 pandemic and the ethics of global vaccine distribution. In part one, released at the end of last month, I spoke with Oxford’s Professor Cécile Fabre.

Currently, in July 2021, some nations, like the United States or the United Kingdom, are seeing vaccination rates of around 50 percent, effectively ending the imminent threat of mass hospitalization or death due to COVID-19. Other nations—including many in Latin America and Southern Africa at the time of this recording—are still facing public health emergencies. These states simply do not have the same access to vaccine doses.

In recent weeks, the Biden administration has put in motion a plan to help distribute tens of millions of doses to some of the neediest nations. Though many have applauded the move, there is less consensus as to whether it goes far enough.

Given the existing global inequities, what are the responsibilities of vaccine rich countries to the rest of the world? What ethical considerations should guide policymakers’ thinking on these issues?

To help to answer some of these questions and to understand the thinking behind some of the policy choices we are seeing play out, I spoke 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. Dr. Emanuel also served on President Biden’s COVID-19 advisory board during the transition after the 2020 election.

One note, Dr. Emanuel mentions COVAX several times in this talk. COVAX is a worldwide initiative aimed at equitable access to COVID-19 vaccines. It is directed by Gavi, the Vaccine Alliance, the Coalition for Epidemic Preparedness Innovations, and the World Health Organization.

For more on COVAX, the pandemic, the vaccine, and ethics, you can go to carnegiecouncil.org. You can also find my interview on this topic with Cécile Fabre.

I’ll back in the coming weeks with more, but for now, here’s my talk with Dr. Ezekiel Emanuel.

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

EZEKIEL EMANUEL: It's my pleasure. Thank you for having me.

ALEX WOODSON: You and your colleagues have put together something called the Fair Priority for Residents framework for handling global vaccine distribution. I spoke a couple of weeks ago with one of your colleagues, philosopher Cécile Fabre, about this, but for our listeners who might not have heard part one, could you briefly outline for us what this framework is?

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. At the moment those are probably countries like in Latin America, Southern Africa, and Mongolia that are being very hard hit.

Does that help?

ALEX WOODSON: That's great, yes. You were a member of President Biden's COVID-19 Advisory Board during the transition. Was the Fair Priority for Residents framework something you discussed with the president and his team during those months, and if so, were they receptive to this idea?

EZEKIEL EMANUEL: No, we did not discuss this in particular, but we did discuss the issue of sharing, and certainly we discussed the issue of sharing vaccines. One of the reasons is you have to remember that the transition was between mid-November and January 20, Inauguration Day. We were not getting any vaccines out. We were doing a horrible job of distributing vaccines, and the president legitimately set a goal of 100 million doses of vaccines in people in 100 days, and then it became 200 million, which was achieved round about July 1. Once you get a big pool of the American public vaccinated, then you can turn your attention to sharing vaccines. But in the transition we were not thinking about sharing because we had almost no Americans vaccinated, so the focus was: How do we get shots in arms in the United States? That the intention.

But as things evolved and as our position evolved, I did advocate—you can see when President Biden announced the sharing of vaccines overseas, the 500 million doses, part of it went to COVAX, but 25 percent he reserved to be distributed to hard-hit countries, which is consistent with our Fair Priority model approach.

ALEX WOODSON: I want to talk about where we are today. When Biden announced his plan last month, you tweeted that that was "fantastic news." You also had some concerns. I was hoping you could describe those concerns and discuss whether maybe some of them have been alleviated in the past month.

EZEKIEL EMANUEL: First of all, I do think we were probably a bit slow in sharing vaccine. We had about 60 or 70 million doses sitting in states unused, and we could see that the number of people vaccinated was dropping, dropping, dropping. We hit the maximum I think April 13 with 3.34 million Americans vaccinated, and then it has just gone down pretty consistently. We went down to below 800,000. We are now back at about a million a day. We are producing something like 10 million—I haven't checked recently—doses. We have more than enough to share with the world, and I think we were a little slow in sharing, so that was one concern I had.

The second concern, as the Fair Priority model makes clear, is that we should not be distributing it on the basis of population. We should not be distributing vaccine—and I made this argument in The New York Times, saying, Ghana in west Africa and Peru in Latin America, two countries with roughly 32 million people, COVAX says, "Look, they should get an equal amount of vaccine," and Zeke Emanuel says, "No, more should go to Peru because Peru has almost 80 times more cases and deaths than Ghana has, and you should send it to places that are really suffering based upon the need because of COVID-19 and not places that so far have escaped."

Now it's true, Ghana could blow up. Then we have to look and try to anticipate and send vaccine there, but when we have lots of countries that have high need they have a stronger claim to vaccines. I made this analogy, and I think this analogy holds, which is, the emergency room doctor doesn't say, "All right, all you seven people waiting, I'm going to give each of you five minutes regardless of why you came to the emergency room." It just makes no sense. Someone who is seriously ill and can recover, they get the attention. The same thing holds in the distribution of vaccines that can save people.

It makes no sense to say equal, and I have no idea why COVAX decided that except for political reasons, not ethical reasons. They wrapped themselves in, "We're distributing the vaccine for equity," but it's clear that if there is a justification for distributing on the basis of population it is to get as many people to say, "Look, you'll get some if you join COVAX." That's a political consideration. That's practical. It's not ethical, and ethics, I think, strongly argues against that.

I know that some members of the COVAX facility have argued that we are being idealistic. That's fine, but don't justify what you're doing by ethics. Call it what it is: "It's unethical, but we're doing it for pragmatic reasons."

ALEX WOODSON: It's interesting that you bring up politics and foreign policy. This is something we think a lot about at Carnegie Council. I just wonder when you are advocating for something like this with the Biden administration or any other health care policy that you are thinking about, how do you balance foreign policy and politics when it comes to these concerns? Are you just focused on saving the most lives, or does something like some country's human rights record or their relationship with the United States enter into your thinking when you are helping people make these decisions?

EZEKIEL EMANUEL: Distributing COVID-19 vaccines is a kind of soft power. Part of what soft power means is that you are trying to win hearts and minds and persuade people that you are doing the right thing, that you are a noble, ethical country, and you are doing good for them in the world. And if you are doing something which is blatantly not good for them in the world, it is going to be hard to win hearts and minds and actually hard to make this an element of soft power. So I think you have to have a situation where the ethics goes along with what's best. I think our position is both ethical and most effective.

It's funny. I just got off a call with people I had been having conversations with, and they were saying: "We've got to distribute the vaccine equitably, and everyone has to get it. Now that Africa has got a lot of COVID-19 you've got to send the vaccine to Africa. We should be at the top of the priority list."

That's an inconsistent position. The consistent position is that we send the vaccine to places that have real need because of their situation with COVID-19, and that is going to change, empirically as we've seen. India was nowhere on the map for 15 months, and then suddenly it had a huge surge; Latin America has had such a consistent surge that they should get priority.

When we distributed in the President's Emergency Plan for AIDS Relief (PEPFAR) HIV antiretrovirals and all the other things that went along with PEPFAR to combat HIV, we didn't say, "We're going to distribute them equally among countries. We looked at the most severely affected countries, and they got priority. PEPFAR, by the way, was a huge soft power win for the United States, and I think we need to do the same in the COVID-19 situation.

ALEX WOODSON: What about countries that might not be set up to distribute the vaccine effectively, that don't have the infrastructure? A country desperately needs the vaccine because its people are dying, but it doesn't have the infrastructure. What do you do in that situation? How do you think about that?

EZEKIEL EMANUEL: You cannot waste an absolutely scarce resource. There are more than enough people who need vaccines. If a country gets a vaccine and can't distribute it or administer it or it doesn't have the cold chain storage, you have to help them get the cold chain storage, but you don't send vaccine before they've got the infrastructure. Otherwise, you're just wasting this incredibly valuable resource, and that is unethical if anything is unethical. If you don't put a shot in an arm and you end up just flushing it down the toilet, that's the worst, it seems to me. No one is benefited by that, and we have seen that happen—South Sudan wasted, ended up couldn't administer; some other countries have had problems, I think the Congo. It's just unacceptable. Unacceptable.

ALEX WOODSON: Speaking about soft power, the United States is not the only country that is distributing vaccines. China and Russia have also launched their own efforts.

EZEKIEL EMANUEL: And failed. I had some discussions with the Russians early on, just when Sputnik was being developed, and I told them you have got to run a big clinical trial to international standards and then release the data so people have—if you really think your vaccine is going to work—and by the way, there are many good reasons to think their vaccine certainly is as effective as Johnson & Johnson (J&J) and AstraZeneca, but they obviously didn't. I haven't studied the issue enough. I linked them up with a very good research organization that could have done the pristine, Food and Drug Administration-level study, and they failed to do it. That was their mistake, I think. Just ridiculous.

And China, obviously. It is an interesting case where they were pooh-poohing the mRNA vaccines and went for a traditional inactivated-by-risk vaccine, and it is not clear that their vaccine, despite the World Health Organization certification, is worth anything given the situation in Chile, the Seychelles, and other places.

If given a choice, I don't know anyone in the world who wouldn't take a Pfizer or Moderna mRNA vaccine ahead of the Chinese vaccine or a J&J vaccine ahead of the Chinese vaccine. It's unclear that it is efficacious at all. The Chinese never acknowledge anything, but they did acknowledge that the efficaciousness is not all that it should be. When you talk to people who are in the know in China they say: "We know that our vaccine effort is 1.0 and Pfizer is version 5.0. We're just not there."

ALEX WOODSON: There is another big player in these conversations. You have mentioned a lot of pharmaceutical companies and a lot of drug companies—Pfizer, Moderna, AstraZeneca, and some others. What have you seen from them when it comes to these questions of ethics and when it comes to vaccine distribution? Are they thinking about these questions ethically, or are they more focused on their profit? What has been your impression of the pharmaceutical companies and how they have handled this vaccine distribution?

EZEKIEL EMANUEL: I would say that there are pluses and minuses. They are very interested in what we have done. As a matter of fact, the group that you are referring to, we talked to Pfizer about their thinking about the distribution and how what we develop might be influential. I would say they have been pushing COVAX to distribute the vaccine on the basis of need. I know that is a concern.

They have other concerns, as you mention. One of them is liability. A major issue in the distribution is that they want liability protection, which is not an insane request. It is part of the fact that if we had prepared better for a pandemic the world would have a way of trying to put in liability protection so companies wouldn't worry: "Well, we're going to be taken to the cleaners if something goes wrong in some country where we either sell at cost or we donate. That doesn't seem fair."

They also have negotiated with some middle-income countries not fairly and jacked up the price or charged a higher price to them. I can't explain why. It seems to me counterproductive, but that would suggest putting profits above their reputation.

But I do know that at least the ethics isn't absent from their discussion. I can't say that it is controlling, but I know that it's not absent from their discussion. I think what we outlined in the Fair Priority model had some influence in their thinking.

I know that when they negotiated with COVAX, one of the things that they were concerned about is that they did not want to have the vaccines that they were either selling at cost or donating go to rich countries that were part of COVAX. It just didn't seem consistent with their notion of selling it at cost so that Switzerland or some other country that is part of COVAX and can easily afford it at a reasonable price.

Some people are outraged: "They're making $15 billion." I'm scratching my head: "One, they're saving the world, let's be clear. We're all benefiting, and you want that vaccine too. Two, the world has lost $20 trillion of economic damage. Fifteen billion is less than 0.1 percent. Doesn't that seem like the right payment?" I want them to stay in the game of making vaccines and making them as good as this mRNA vaccine, and if that costs $15 billion across the whole globe, that doesn't seem to me like the wrong kind of price.

ALEX WOODSON: I definitely agree with that.

I want to step back a little bit and talk about some of the stuff leading up to where we are today.

President Trump took a lot of criticism during the pandemic from many different people for how he handled it, but I wonder what your thoughts are about Operation Warp Speed. That was one of his big initiatives. We have these vaccines that work. We have a high vaccination rate in the United States, and we are in this position where the United States can help distribute millions of vaccine doses.

I am just wondering how you see Operation Warp Speed. Was there something uniquely Trumpian about it? Would any president have done the same thing, and did that lead to where we are today with the situation in the United States, where we are able to get close to 70 percent of our citizens vaccinated?

EZEKIEL EMANUEL: In my soon-to-be-released paperback version of Which Country Has the World's Best Health Care? I rewrote the coda, which takes a look at COVID-19 and what it says about health care systems. One of the conclusions I draw is that countries that created a command center to manage the whole thing and bring the different groups together did a much better job. Taiwan immediately created a COVID-19 command center, Australia built on something it had, and Warp Speed was kind of like that. Now the rest of management of COVID-19 was a total disaster, in part because the president saw how much attention those daily briefings were having and went to the daily briefings and issued contradictory statements and ridiculous statements.

But Warp Speed basically took the Department of Health and Human Services and the Defense Department, the logistics people, people who knew how to do contracting very rapidly, and the people who knew how to manage research, and put them together with a guy who had a lot of experience. Now he has been disgraced because of sexual harassment issues, but had the actual skill in the management of a process to develop a vaccine and understood what you had to do to get the pharmaceutical companies to play the game because he had been part of the pharmaceutical companies. It's like the old line about Joe Kennedy at the Securities and Exchange Commission: You put someone who knows the crooked ways of Wall Street in control of Wall Street to regulate it.

Anyway, I think Warp Speed was a success. There were multiple bets made either by research or by advanced purchase commitments so that people knew that they would get rewarded, and it was not a single bet. It was on multiple platforms, and I think that was great.

Now if you look at the other things, we have yet to have a single highly successful study of a therapeutic. Maybe remdezivir, maybe a few of the monocolonals, but it has been awful, and those monocolonals are the worst approach to this kind of pandemic, something that is labor intensive to deliver, you can't produce in high quantity, and the production competes with the production of the vaccine. It's like, "What were you guys thinking when you prioritized this?" But we were Nowheresville in terms of clinical research and development of therapeutics. On the other hand, vaccines, very effective and fantastic.

Could you speed up the research, development, manufacturing, and Emergency Use Authorization from what we currently have? Maybe you could shave a month off, six weeks off, but you're not going to shave much more. It was—I think Tony Fauci used this phrase—a "land speed record."  It was a record, and it's going to be the model for every future development in this area. So I think, yes, Warp Speed did work, maybe in spite of Trump, but you can't take it away from him that that did work.

ALEX WOODSON: A lot of the discussions that we look at at Carnegie Council are nationalism versus cosmopolitanism. Was Operation Warp Speed a case of nationalism working? The term has a very bad connotation in Europe, but does nationalism work in this sense in the United States to get us these vaccines?

EZEKIEL EMANUEL: Cosmopolitanism and nationalism are at two poles, and as our Fair Priority for Residents says there is a middle ground where some prioritizing of your own fellow citizens is legitimate, but you have to remember you are part of a world community and you have to share. By the way, we criticize people who with ease could save the life of someone else or reduce the suffering of someone else and they don't do it. Similarly, if we had lots of excess vaccine and we didn't share it with the world, we would be open to criticism. 

And Warp Speed was a necessary precondition of getting enough vaccine, not just for the United States but for the world. Fine-tuning the production process now to maximize production is critical to helping the world. It may be part of nationalism that got us going, but it wasn't limited to nationalism. Again, the place we have come out in the Fair Priority model is that in the absence of a world government, in the absence of an effective way for the whole world to come together, this kind of limited nationalism is justifiable and I think you could say the only way to go in the current world situation. In the non-ideal world is there an alternative to limited nationalism? I don't think so.

The bad kind of nationalism—"America First and screw the rest of the world, we're not part of that community"—everyone who is reasonable repudiates that because it is totally unethical.

ALEX WOODSON: Just a couple more questions. I want to focus a bit on your own thinking about the pandemic as we finish the talk.

As someone who has thought about things like vaccine distribution and public health for years, when this pandemic hit over the past year and a half was there anything that really surprised you, or did it kind of play out how you thought it might?

EZEKIEL EMANUEL: The thing that has to surprise everyone is the fact that we had technologies that had never been used for vaccines successfully were successfully used for vaccines, and technologies that had been used successfully for vaccines didn't prove to be too efficacious.

One lesson that I think is certainly true on the biomedical response side is that none of these solutions that we have had—the vaccines, coming up with dexamethasone—occurred de novo. They all occurred within systems where you had preexisting large investments and ecosystems of biotech companies, academic researchers, venture capitalists, all of it working already, so the seed necessary had very fertile ground. That is true for the vaccines.

By the way, in Britain, which has done the best of the clinical research on therapeutics, it was true too. They have a 35-year history of large simple randomized trials to get a simple answer fast, and they did a great job, and you can see, they have continued to do some great jobs in terms of mixing and matching of the vaccines and things like that. So I think one of the things this affirms for me is that preexisting ecosystems are really important to have a rapid response.

I have already mentioned one of the other lessons, which is making an effective command-and-control system really important. I think one of the unfortunate facts is that the COVID-19 pandemic suggested that the Centers for Disease Control and Prevention (CDC) is not performing as well as it should be. Immediately prior to the COVID-19 pandemic some body—I forget which international body—evaluated public health capacity in different countries, and the United States was number one, and if anything was shown by COVID-19, it is that we are not number one.

The CDC had multiple, multiple errors, and I am not sure that they fully acknowledged those errors. They got the COVID-19 test wrong. They sent out the wrong kits. They got all the information about masking wrong, and it took them a long time to actually get it right. I listened to them once I looked at the data myself, and it was like: "Of course masking works."  We have actually a lot of data on this, and I came out and urged masking several weeks ahead of the CDC.

They got aerosol-versus-droplet wrong. Their genetic surveillance was bad, and they couldn't coordinate, and still a too small number of genetic surveillance sequencing of vaccines to understand which variants are dominant and how fast they are becoming dominant and finding new variants.

So I think the CDC really needs an overhaul. These aren't just a few personnel changes. This is pretty structural, and I think their response was—and it wasn't all political. Because of the politics by Trump, the CDC didn't get the criticism it might otherwise have, but I do think that there has to be a lot of serious reorganization at the CDC.

ALEX WOODSON: It definitely sounds like a lot out there to talk about.

Just for the final question—and thank you for your time today—is part of the thinking behind the Fair Priority for Residents framework that this could be used for future pandemics as well? Is this something that can be used when we have new pandemics and new vaccines to distribute? Is that part of the thinking when you put something like this together?

EZEKIEL EMANUEL: Absolutely. The reason I put it together—one of the things that the COVID-19 pandemic has made clear is that the ethics of allocation is central to almost every discussion during the pandemic—distribution of personal protective equipment, distribution of test kits, and distribution of other diagnostics. There just wasn't enough for the world, and we had to allocate it.

Who better to think about allocation than frankly philosophers, public health people, and others, so I put together basically a group of all-stars from the world and not just the United States—Canada, Australia, Singapore, Latin America, and Africa—to really think hard about it and to come up with a framework that was both ethically defensible and practical. And we had several people, not just myself, who have done work in global health and with government so that we understood the practicality and the concerns of policymakers. So I do think this is a generalizable framework. I think the values we articulated, how we weighed those values, and the framework we came up with is probably generalizable.

It is also generalizable in another sense. We made clear that data and epidemiology matter to how you come to judgments; who is suffering and whether death is the most serious consequence or whether it is socioeconomic dislocation matters; and being able to anticipate where the vaccine is going to do the most good matters to how you distribute it.

So I think it will have a good longevity and influence policy going forward.

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

EZEKIEL EMANUEL: This has been a pleasure. Thank you, Alex.

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