COVID vaccine booster ethics
U.S. struggles with the rollout of a third dose
This spring, Ashima Yadava watched from the United States as the delta variant tore through India, killing tens of thousands.
“It was chaos,” she says. “I don’t know a single family member back home who has not lost somebody. It’s a really terrible thing.”
Months later, the crisis has somewhat eased, but only one in 10 Indians are fully vaccinated. The same goes for Thailand, Zimbabwe and Georgia. In Egypt, Vietnam, Nigeria and many other countries, the figure is even smaller.
It’s statistics like these that Yadava, a photographer living in the South Bay, can’t shake as the Biden administration weighs whether to roll out boosters — a third dose of the Pfizer or Moderna vaccines — to the general public.
“I’m not sure if, at this point, I want to receive a third shot because I think we need to send it out to the world,” she says. “Not getting a booster, with all that is wrong with the inequality around the world, for me, it’s an active choice.”
Ever since vaccines arrived less than a year ago, the concept of global equity has raised myriad ethical questions about a country’s obligations to its citizens versus its obligations to the world. The discussion around boosters is the latest flashpoint in that ongoing conversation.
The Biden administration
indicated last month that boosters might be available to all Americans by Sept. 20. It appears to be scaling back its plans a bit, with reports this week that the boosters would be widely available soon only for those who got their first two shots from Pfizer-BioNTech. People who have weakened immune systems due to certain conditions, such as being the recipient of an organ transplant, are already eligible for an extra shot.
But in August, just as U.S. officials were hinting at a booster rollout to the general public, Dr. Mike Ryan, the director of World Health Organization’s Health Emergencies Programme, pushed back. He compared the idea of giving healthy adults a third shot to giving “extra life jackets to people who already have life jackets, while we’re leaving other people to drown without a single life jacket.”
It’s a striking metaphor, but the ethics around boosters are more complicated, according to bioethicists.
“The question of international obligation, what are our global responsibilities around COVID is really important, given that 24% of the world’s population is fully vaccinated, but 1.3% of people in low and middle income countries have received even one shot,” says Dr. Jodi Halpern, a professor of bioethics at UC Berkeley. “So I think it’s really clear that we have an absolute moral responsibility to contribute as much as possible.”
Still, she bristled when she heard the life jacket metaphor. In the case of a sinking ship, it’s clear you only need one working life jacket, she said. “The question is are our life jackets adequate to keep us afloat? That’s the question that metaphor obscures.”
At the moment, Halpern said, “we just don’t fully know.”
That’s exactly what the Biden administration is wrestling with, as data on the highly contagious delta variant comes in: Do boosters help everyone, and if so, how much?
It’s clear that people who have had two doses can contract the virus, although with far less frequency than those who have not gotten shots. And they can transmit the virus to others — including young children, who currently are ineligible for shots — although, here again, the vaccines appear to reduce the likelihood of transmission.
Currently, the COVID-19 vaccines appear to be holding up against severe illness, hospitalization and death, says Dr. Monica Gandhi, an infectious disease specialist at UCSF. For that reason alone, she says, “I’m not sure if immunocompetent Americans need an extra booster shot.”
The calculus is different for the immunocompromised, Gandhi noted. For those individuals, it’s clear that a third dose is “definitely indicated.”
But when it comes to healthy adults, she’d rather put the focus on getting the vaccine to the unvaccinated both here and abroad. “My HIV activist heart has a difficult time accepting that young, healthy 20-year-olds in the U.S. may need a third shot prior to vulnerable health care workers and older individuals in low-income countries who have received only 2% of the global vaccine supply.”
Vaccinating the world, she says, isn’t just a moral obligation, it’s also in the best interest of the United States, given that it will reduce the chance of future variants establishing themselves.
The White House said last month that the U.S. had donated 110 million doses of the vaccines to 60 countries. It has promised hundreds of millions more doses, though that is still far short of global demand.
Ultimately, the decision to offer boosters is one that rests with national governments, says Dr. David Magnus, a professor of medicine and biomedical ethics at Stanford University — and not with individual citizens. If health officials do recommend healthy adults receive a third dose of the vaccine, “you just have to think of it the same way you thought of your first two doses, which is it’s really important to protect your community to try to increase immunity as much as you can.”
Halpern points out that many healthy young people live with and work with those who are older and, potentially, more vulnerable — so getting a booster is not just about your own health, it’s about other people’s.
“That’s the key thing about COVID, we can’t think of it so individualistically,” she said.
Passing on a booster shot when the time comes, according to Magnus, won’t do anything to help those in other countries and could, instead, make matters worse locally.
“That booster is not going to go to somebody in Nigeria who hasn’t gotten their first shot,” Magnus said. “It’s just not how allocation works. It’s going to go to the next person in line who wants a booster. And if it turns out that not enough people are getting the boosters, it’s just like having a low vaccination rate.”
Bay Area medical facilities work hard to ensure no vaccine is wasted.
At UCSF, officials keep a close eye on expiration dates. If vaccines are nearing their end, says Desi Kotis, UCSF’s chief pharmacy executive, they can place them on a statewide exchange and move them to other counties in need. So far, she said, the university has not had to throw out any doses. Moreover, as manufacturers continue to study the vaccines over time, they’ve found they have longer shelf lives than originally stated.
Similarly, Santa Clara County said it had thus far “been able to use all vaccine doses before their expiration dates.”
Even if governments — not individuals — are ultimately responsible for where the vaccine goes, the thought of getting a booster when so many people abroad have no access to shots still hangs heavily on Yadava and her friends.
Getting a booster come September, should health officials green light the Biden administration’s plans, still feels “really, really wrong to me personally,” she said.
“To me and my friends, when we talk about this, this is a no-brainer. You’ve got to vaccinate the world.”