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The role of booster in solving vaccine inequality

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LOOKING back to spring last year, many people were predicting that we wouldn’t have any vaccines available by now, and even the most optimistic didn’t predict that 6.5b doses of highly effective COVID-19 vaccines would have been administered globally. Indeed, it is truly amazing that within the next month, 50% of the world’s population will have received at least one dose of a vaccine to protect them against COVID-19, with 20-30 million more doses being given globally every day. To make and deliver so many doses in 2021 reflects astonishing global endeavours by manufacturing facility staff, those involved in the logistics of getting the vaccines to clinics, and an army of healthcare workers and vaccinators.

  But this remarkable progress is tempered by an uncomfortable moral and ethical predicament: simply put, the doses still aren’t shared fairly. That global 50% vaccinated figure hides gross inequity. More than 95% of people in low-income countries are yet to receive even their first dose, compared with over 60% in high income countries who have received at least one dose. We are protected, but they are not. To effect change in global mortality this year, it isn’t enough to promise to share doses – 1b doses in total were pledged in June by the G7 – we have to actually give the doses to those at risk of dying, and stick the needles in before they meet the virus. Tragically, a million deaths have occurred since that G7 pledge according to Our World in Data.

  Supply is constrained still, though the substantial increase in Covax distribution (340m doses so far) over the past few months is a reason for hope that the situation is improving.

  There are more donations and supply is going up. It will get better. But for many hundreds of thousands of people, it won’t be soon enough.

  To make matters worse, many countries have announced or have started booster programmes, adding to the moral jeopardy the risk that first doses will be further delayed. While the case for boosters is not yet agreed by all scientists, it is possible that boosters may bring some additional gain for some people, even though the potential benefit for most individuals is small. Most double-jabbed people are so highly protected against severe disease that a booster dose won’t improve protection much.

  But there is a much stronger case, and there is no doubt among scientists, that first doses are lifesaving for the unvaccinated. Unvaccinated people should be prioritised wherever they live. With this in mind, the director general of the World Health Organisation, Tedros Adhanom Ghebreyesus, called for a moratorium on boosters till next year as booster doses will take away from the global supply and deepen the equity problem. For equity, the case is not so focused on whether to boost, but when. It is all about timing.

  The “to boost or not to boost” moral dilemma is not in the purview of individual citizens who ponder whether to roll up their sleeve when offered a booster by a vaccine clinic this week. A dose that is in the vaccine clinic fridge (or freezer) cannot be redirected to someone else in another country, because the regulatory hurdles and shelf-life simply make redistribution of this dose not practical. Redistribution has to happen prior to the release of vaccine doses to the national health system. A protest against vaccination at individual level will be misdirected and risks wasting these precious doses. If you are asked to roll up your sleeve, then you should do so.

 The equity issues of the pandemic have brought into sharp relief the conflict between national expediency and noble foreign policy. There is no easy answer. Governments must take an uncomfortable look at the human, political and financial cost of inequity in this pandemic, and develop principles for future pandemic preparedness that embrace a set of values that include a  spotlight on moral and ethical integrity.

  There is clear evidence of a failure by governments to serve the world’s poor. But, for now, individuals must make the most of the vaccines that their healthcare systems make available to them.

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