1. Introduction
In November 2020, the world received the good news that some vaccine candidates, such as Pfizer and Moderna, were highly effective at preventing COVID-19. This came around the second wave of the pandemic, a time when the global infection rate was soaring. Canadian Prime Minister Justin Trudeau described Pfizer and BioNTech's efficacious vaccine as the “light at the end of the tunnel” (Ljunggren & Scherer, Reference Ljunggren and Scherer2020). Vaccines presented a way for Canada and other countries alike to build herd immunity and see the eventual return to ‘normal,’ i.e., how things were before the pandemic.
Soon after these vaccines were approved for use by the Food and Drug Administration (FDA) in the U.S., and by the Medicines and Healthcare products Regulatory Agency (MHRA) in the U.K., they became readily available to their citizens. While this was encouraging, the “light at the end of the tunnel” remained far off for those in other countries. The demand for COVID-19 vaccines within the global free market led to the large procurement of vaccines by countries that possess the economic resources to attain them. Wealthy nations received large vaccine shipments, while low- and middle-income countries (LMICs) were forced to wait.
These high-income countries have largely taken a ‘my people first’ approach to vaccine procurement. This has commonly been described as vaccine nationalism, an approach that prioritizes the needs of their own populations before the needs of others (Eaton, Reference Eaton2021). The seemingly paradoxical consequences of vaccine nationalism are that many LMICs who desperately need COVID-19 vaccines, given their high infection rates and limited health infrastructure, will be last to receive them. Although assistance has and continues to come from COVAX, which aims to ensure equitable access to COVID-19 vaccines for LMICs, the problem persists. High-income countries have received first and unrestricted access to vaccines.
Even as more vaccines were granted approval around the world, including the Oxford AstraZeneca and Johnson & Johnson vaccines, the circumstances for LMICs remained dire. In view of the new COVID-19 variants of concern, particularly the Delta variant, high-income countries have even sought to implement booster shots. As a response, the World Health Organization's Director-General, Tedros Adhanom, has called for a moratorium on booster shots (Mackintosh, Reference Mackintosh2021). The likelihood of high-incomes countries adhering to this prohibition, however, remains low.
While most people would acknowledge that these events are unfortunate, others may suggest that it is difficult to attribute any moral blame. Pharmaceutical and biotech companies are exactly that: companies. They develop, produce, and eventually market medical treatments for commercial purposes. Companies negotiating with countries that are wealthy is just ‘business as usual.’ Additionally, elected government leaders may only be procuring large vaccine supplies because they have a duty to protect their own citizens. They may be simply ‘putting on their own oxygen masks’ before assisting others.
While identifying a direct culprit and attributing moral blame remains a difficult task, my goal in this article is to show that although our vaccine procurement approach adheres to the parameters set out in global business and global politics, it nonetheless has moral deficiencies. After considering our vaccine procurement strategies, I present some moral arguments, based on the principles of fairness and non-maleficence that identify these moral deficiencies.
2. Global Procurement Strategies
Excessive vaccine procurement is not a new phenomenon. During the H1NI pandemic in 2009, wealthy nations bought most of the initial vaccine supply (Liu et al., Reference Liu, Salwi and Drolet2020). Australia prevented its producer of H1N1 vaccines from exporting to other countries before its own citizens were immunized, while the U.S. failed to fulfill its promise to donate a portion of its vaccine supply to other countries (Liu et al., Reference Liu, Salwi and Drolet2020). So, it comes as no surprise that we are witnessing something similar with COVID-19 vaccines.
The harsh reality is that the way we procure vaccines does not have global fairness as its foremost objective. Jason Nickerson and Matthew Herder suggest that “the way the vaccine research and development system is currently constructed is not optimized to develop, manufacture, and equitably distribute vaccines on a global scale” (Nickerson & Herder, Reference Nickerson, Herder, Flood, MacDonnell, Philpott, Thériault and Venkatapuram2020, p. 591). Instead, it is designed in such a way that allows nations to enter a competitive market and negotiate contracts to secure part of the vaccine supply.
Take Canada, for example. As it stands, Canada has procured up to 409 million doses of COVID-19 vaccines with a variety of pharmaceutical companies for a population close to 38 million (Government of Canada, 2021). Canada has also secured 35 million doses for 2022, 30 million for 2023, and an optional 30 million for 2024 with Pfizer (Government of Canada, 2021). Furthermore, each year between 2022–2024, Canada has options to add an additional 30 million doses.
The rationale for such a high procurement strategy, it is commonly suggested, is due either to the uncertainty surrounding vaccine approval, the two-dose requirement that many vaccines possess, and for a potential supply of booster shots. Yet, despite these reasons, 409 million doses is excessive, especially if Canada would only need close to 76 million doses to inoculate its entire population (assuming each resident requires two doses). Perhaps procuring a few extra million doses may have been a prudent decision, given the uncertainties surrounding vaccine approval, but 409 million — and counting — seems very unreasonable.
In December 2020, Anita Anand, the Minister of Public Services and Procurement and the Receiver General for Canada, said the following regarding Canada's vaccine procurement strategy:
We have ensured that Canadians have access to the supplies and vaccines needed in a hypercompetitive global marketplace marked by uncertainty, volatile supply chains, and shortages of raw materials. It is because of this reality that we continue to pursue an aggressive procurement strategy with a diverse portfolio of suppliers, whether in the area of PPE or vaccines. (Prime Minister of Canada, 2020)
Anand's words clearly show the unfavourable climate that countries are in and the way they are forced to compete. Other wealthy nations, including the U.S. and the U.K., have also procured large quantities of vaccines for their population. Yet, amid all this, LMICs are struggling to keep their heads above water.
Take Ethiopia, for example. As Africa's second largest country, with a population close to 114 million, Ethiopia is counting on COVAX to secure enough vaccines for only 20% of its total population, without the ability to secure more (Duke Global Health Institute, 2020). Reports suggest that some LMICs, like Ethiopia, will have to wait until 2023 or 2024 before they have enough vaccines for their populations (Padma, Reference Padma2021). All the while, countries like Canada are aiming to inoculate their entire populations before the end of 2021.
3. Neoliberalism and National Governance
One parameter that has led to over-procurement is business within the global free market. Take Pfizer, for example — a company that has co-produced a very effective COVID-19 vaccine. Pfizer was founded in 1849 and is one of the largest pharmaceutical companies in the world. They are “dedicated to discovering, developing, manufacturing, and marketing prescription medications for both humans and animals” (Nolen, Reference Nolen2016). Pfizer's shareholder company operates in 180 different countries, employs 96,000 employees, and had a total 2019 revenue of $51.8 billion USD (Llamas, Reference Llamasn.d.).
It is unsurprising that Pfizer, along with BioNTech and similar companies, would wish to sell their COVID-19 vaccine and make a profit — it is what they have been doing for years. Hence, negotiating contracts with wealthy nations is to be expected. For companies like Pfizer to do otherwise would be to go against their operations as a company. The Global Justice Now campaign, however, has suggested that normal company operations during a pandemic is morally concerning; calling for the suspension of the patent on Pfizer and BioNTech's vaccine, they say:
If we continue to leave everything to the market, it will artificially restrict the number of doses the world can produce. As it stands, Pfizer and BioNTech can only produce 50 million doses for 2020 and 1.3bn for 2021 … nowhere near enough to meet global demand … Pfizer and BioNTech need to share this vaccine with the world, not hoard it for profit. That should mean putting it into the WHO's global pool so that the technological know-how and patent rights are shared to enable multiple manufacturers to produce it as fast as possible. (Global Justice Now, 2020)
While suspending the vaccine patent would certainly provide a rapid way for the world to overcome COVID-19, it is extremely unlikely that this will happen. Pfizer's Chief Executive Officer, Albert Bourla, has opposed suggestions to waive patent rights (Breuninger, Reference Breuninger2021). The contention, it seems, is whether Pfizer and BioNTech have an obligation to suspend their intellectual property. Under global business parameters, perhaps they are not required to do so, given these patent rights and their responsibility to their shareholders. Yet, from a moral perspective, perhaps they do have an obligation to suspend these rights if a substantial amount of harm can be avoided. Their position is complex, given these competing obligations.
Such negotiation tactics are not only limited to Pfizer and BioNTech. The same is true for other pharmaceutical companies around the world, including Moderna and Johnson & Johnson. Pfizer and BioNTech is used here only as example rather than as the only pharmaceutical company that is noteworthy and relevant. The same could be said of the national governments that procure large vaccine supplies. While the Canadian government is the primary focus here, these procurement strategies are also identifiable in other high-income countries as well.
Aside from global business, there is also national governance. Government leaders, at least in most countries, are elected by their citizens. Citizens, in turn, rely on their leaders to represent their best interests and do what is right for them and their country. When this duty is mixed with the hypercompetitive global free market in which we live, the procurement strategies we are seeing are not only predictable but expected. It is not surprising that leaders have attempted to procure as many vaccine doses as possible for their own populations.
Unless one adopts a highly cosmopolitan view, it seems reasonable and understandable that government leaders are first and foremost responsible for their own citizens before the citizens of other countries. This is not to suggest that countries do not have any duty towards those in other countries. Rather, it suggests that a country's primary duty should be to its citizens. Canadian leaders should primarily look out for Canadians, American leaders for Americans, Peruvian leaders for Peruvians, and so on. Hence, government leaders, along with pharmaceutical companies, may not only be doing what is expected of them but also what they believe they have an obligation to do. It thus becomes difficult to assign blame here.
4. Moral Deficiencies
Although these expectations and obligations motivate pharmaceutical companies and wealthy nations to negotiate and procure large quantities of vaccines, this approach is nonetheless morally deficient. These obligations, it seems, possess reasonable limits, as they not only leave LMICs in dire circumstances, but also violate basic moral principles, including fairness and non-maleficence. I will consider each in turn.
Fairness
The countries that have procured the most vaccine doses are the wealthiest countries in the world. This is no mere coincidence. Clearly, it is primarily through a country's economic resources it can secure large quantities of vaccine doses. Conversely, a country's lack of economic resources makes that country less capable of procuring vaccines.
This criterion of deciding which countries get access to a lifesaving vaccine is unfair. COVID-19 has negatively impacted the entire world and each country has been on the receiving end of economic disruption, social restrictions, and most importantly, the death of many precious lives. Suggesting that a country's ability to access a vaccine solely based on economic resources does not give everyone an equal chance of overcoming COVID-19. Wealthy nations will inevitably go first simply because they are wealthy.
Furthermore, while there is no consensus regarding why some countries are disproportionately wealthier than others, it is undeniable that colonial conquest, theft, along with uncontrollable factors related to a country's geography and resource richness, have caused global economic inequality (Satz, Reference Satz and LaFollette2010, p. 622). Countries being ‘low and middle income’ is not something that they have fully brought on themselves. Given this, it is untenable to suggest that each country is given an equal chance to access a COVID-19 vaccine based on its ability to pay. What we are seeing here seems to violate the principle of fairness.
There are other criteria that can make our global procurement strategy fairer. As is commonly suggested, perhaps prioritizing countries based on necessity (i.e., the hardest hit). Alternatively, perhaps it wold be fairer to prioritize the most vulnerable citizens of each country, such as the elderly and front-line healthcare workers. These strategies would equip all countries, not just wealthy ones, to combat COVID-19 more effectively.
Non-maleficence
The principle of non-maleficence can be defined as the “obligation not to inflict harm on others” (Jahn, Reference Jahn2011, p. 225). Harm can be intentional or unintentional, direct or collateral. When wealthy nations procure a large amount of vaccine doses, they are harming other countries by way of hoarding (Winning, Reference Winning2021). They are accumulating an excessively large portion of the vaccine supply, while depriving other countries of the ability to access their fair share. Although Canada may be looking out for Canadians by procuring over 400 million doses, it is nonetheless causing harm by making the accessibility of vaccines to LMICs untenable.
These actions inevitably leave a limited and insufficient number of COVID-19 vaccines for the rest of world. As it stands, in 70 poor countries, only one in 10 people will be able to get vaccinated in 2021 (Amnesty International, 2020). Conversely, as we have seen, many wealthy countries will be able to vaccinate their entire populations by the end of 2021. Additionally, as of July 2021, 80% of the vaccines administered were in high-income and upper-middle-income countries, while only 1% of residents in LMICs have been given ‘at least one dose’ (Padma, Reference Padma2021).
Some may suggest that, despite our procurement strategies, many wealthy countries, including Canada, have generously given money to COVAX to distribute vaccines to LMICs. This gives LMICs a chance to get some vaccines. Yet, despite the positive outcomes that have and will continue to come out of COVAX, wealthy countries can still choose to negotiate large contracts with pharmaceutical companies. Canada has generously supported COVAX with financial aid, but it has still procured an excessive amount of vaccine doses and has even taken vaccines from the COVAX pool for Canadians (Major & Cullen, Reference Major and Cullen2021). This, of course, undermines the whole process, and, in turn, does not solve the issue. It is very difficult, if not impossible, for COVAX to distribute vaccines to LMICs when the entire supply is virtually gone.
5. Conclusion
The way we procure vaccines on a global scale is at odds with the moral principles of fairness and non-maleficence. Of course, the circumstances in which we find ourselves are complex. Companies and governments each have their competing interests and obligations. However, that does not excuse the moral deficiencies of our global procurement strategies.
We need a shift towards an approach that seeks to treat countries fairly, tries to limit harm, and acts in the best interest of all. Some authors have proposed different ways to make this possible, including the idea of conceptualizing vaccines as global public goods (Nickerson & Herder, Reference Nickerson, Herder, Flood, MacDonnell, Philpott, Thériault and Venkatapuram2020, p. 591–600). On this view, vaccines would not be viewed solely as marketable items, but rather as essential goods that should be made available to everyone, regardless of who they are and where they live, based on need.
Other suggestions — that vary in degree of contentiousness — include limiting countries and pharmaceutical companies from excessive procurement via an accountability mechanism. Perhaps an initiative like COVAX can regulate or even stop excessive procurement. Additionally, common suggestions include significantly increasing vaccine production capacity. While this would not solve the problem entirely, it would help to reduce the time it takes between wealthy nations and LMICs getting their vaccine doses. Or ensuring that vaccines are not wasted and are instead used by or donated to other countries. Beyond these suggestions, we should recognize that while our global vaccine procurement approach abides by the parameters set in global business and global politics, it nonetheless has moral deficiencies that we should seek to change.
Acknowledgements
I would like to thank Serena DeJong and the audiences at the Canadian Philosophical Association Conference (2021), the Canadian Bioethics Society Conference (2021), and University of Missouri-St. Louis's 15th Gateway Graduate Conference for their encouragement and helpful suggestions on this article.
