Who do we vaccinate first?

As the obtaining of one or more vaccines against the coronavirus approaches, a reality emerges: there will not be for everyone, at least initially.

That raises the dilemma of how to distribute the first few doses.

It also explains the movements of many governments to seize millions of vials of the best placed candidates.

Now, a score of experts in public health ethics and philosophers warn against the emergence of a health nationalism and propose a model for a fair distribution of vaccines.

The World Health Organization (WHO) has proposed that, as long as there are no surpluses, vaccines be distributed in three phases and proportionally to the population of each country: 3% in a first wave, achieve inoculation of 20% in a second and reach 60% of the population in the third phase.

With this percentage it is estimated that group immunity would be achieved, with those vaccinated protecting those who have not yet been vaccinated.

A distribution according to the population seems fair but raises two problems.

For one thing, the most densely populated countries would get the most vaccines.

More importantly, the pandemic is not hitting the same everywhere.

While Spain, with its 47 million inhabitants, is approaching half a million cases, Poland, with 38 million, barely has 68,000, according to WHO data.

The other great proposal to distribute the first vaccines equitably proposes a more qualitative than quantitative distribution.

In these plans, the first to receive immunization should be those most exposed to the virus and those who can suffer the harshest version of the covid: health personnel who are on the defense line, those over 65 and those who have a disease or condition (comorbidity) that could aggravate the course of the disease.

It seems reasonable.

The distribution of vaccines by population does not reflect the unequal impact of the pandemic

"This is probably how countries should allocate them internally, although there are reasons to think that with [the greater availability of] personal protective equipment, it might not be necessary," says Ezekiel Emanuel, head of medical ethics and public health at the School. Perelman of Medicine of the University of Pennsylvania (USA).

"But it would be a mistake to do it between countries, as it would give less to nations with lower incomes and fewer health workers."

In addition, also in the less developed states the population over 65 years is significantly lower, as well as the incidence of some pathologies that, such as cardiac or respiratory, aggravate the course of covid.

"All this would skew the distribution in favor of the rich countries," he concludes.

Together with a score of colleagues, Emanuel has published in the journal

an article that highlights the errors that, in his opinion, contain the different models proposed so far to distribute the vaccine when it arrives.

The text, in whose writing experts in health ethics, philosophers and public health have intervened, warns of the emergence of a kind of health nationalism in which countries with sufficient science and technology to research vaccines and those that have more money to pay them threaten to monopolize production.

"This vaccine nationalism is very real," says Emanuel.

And she mentions the controversy between France and Sanofi, a French pharmacist investigating its own vaccine, for its negotiations with the US government.Examples have not ceased to emerge throughout the pandemic.

At first, with the hoarding of fans, masks and even gloves.

In the summer, the US government seized almost all the world's stock of remdesivir, a drug that appeared to work against the disease.

"Governments legitimately want to protect their citizens, but there is a greater obligation to the rest of the planet's population," he says.

In their article, Emanuel and his colleagues give a figure to limit that nationalism.

They consider it morally unacceptable to hoard more vaccines than necessary to keep the transmission rate of the disease below 1, an indicator that would lead to a reduction in the scope of the epidemic.

This group of researchers proposes their own fair model of delivering vaccines on a global scale.

According to his article, it would be supported by three pillars.

On the one hand, priority should be given to where the number of premature deaths or serious consequences of the disease can be further reduced.

But their proposal goes beyond health and introduces another variable, the social and economic impact that the pandemic is having in a certain place, so they are committed to giving priority to the most disadvantaged.

Finally, they believe that the cast should be guided by the principle of radical equality, with the same moral concern for each person.

"The point of our article is to raise awareness of the importance of making an equitable allocation and show how the countries that are in the worst conditions should be taken into account and that only by distributing to all can we return to the pre-pandemic condition" The director of the bioethics program of the Latin American Faculty of Social Sciences (FLACSO), the Argentine Florence Luna, maintains in an email.

In the 2009 influenza A pandemic, the vaccine arrived in just seven months but rich countries accounted for 90% of production

The antecedents do not blow in favor of this health internationalism.

In 2009, with the influenza A pandemic that killed almost 300,000 people, a vaccine was achieved in seven months.

But the rich countries kept all the production.

In that unleashed health nationalism, calls for solidarity made a few hoarders give up 10% of their vaccines, but only after securing enough doses to vaccinate their own.

Now, the WHO and other organizations are trying to have a binding international agreement.

"The closest we are to that agreement is COVAX," says ISGlobal's director of analysis and global development Rafael Vilasanjuan.

COVAX is a platform that seeks to develop vaccines or their centralized purchase and distribute them equitably.

It is promoted by the GAVI vaccination alliance, of whose board of directors Vilasanjuan is a member.

"We are witnessing very nationalistic behaviors," he says.

But remember that it is not known how effective some vaccines or others will be or if they will be valid for the entire population.

The Oxford one, for example, has not been tested in people over 65 years of age.

So remind health nationalists that "vaccinating yours does not mean that all your people are protected."

In this month's edition of the political magazine

is an article whose headline (translated) reads

.

And its subtitle sums up the conclusion:

.

One of its authors is Thomas J. Bollyky, director of the Global Health Program at the Council on Foreign Relations, a prestigious think tank based in Washington, USA.

Bollyky fears that vaccine delivery will be uneven and unfair, especially if the COVAX initiative fails.

“Countries that have not participated in advance purchase agreements and that do not manufacture doses at home will have to wait.

Mid-tier states will have to do even more as they don't have the resources to secure [supply] with advance purchase and are not poor enough for donor-driven initiatives to prioritize them. "

And every day counts.

Every 24 hours, more than 6,000 people die, according to the WHO.

Bollyky concludes: "already in each country, distribution can be equally unequal if governments do not adopt the principles enlightened by science for a fair distribution."

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