the global lottery for this prized resource,
choices that could mean the difference
between allowing the pandemic to con-
tinue its deadly and tragic assault on
human life, and finally slowing it down.
At the broAdest level, the distribu-
tion question starts with how much vac-
cine each country should receive. Any
hope of benefiting from herd immunity
conferred by vaccines dissolves if not
enough of the world’s population—the
“herd”—is immunized and protected
against infection. Researchers at CUNY
Graduate School of Public Health and
Health Policy used a computer simula-
tion to calculate that if 75% of the world’s
population were immunized, the vaccines
would need to be 70% effective in protect-
ing against infection in order to control
the ongoing pandemic. If only 60% were
vaccinated, then that efficacy threshold
would jump to 80%.
And manufacturing a safe and effective
batch of vaccines, even by deeply expe-
rienced pharmaceutical companies with
a track record of producing millions of
doses of other vaccines, isn’t a slam dunk.
“In making vaccines, there is research, de-
velopment, then implementation,” says
Dr. Paul Offit, director of the vaccine-
education center at Children’s Hospital
of Philadelphia, who serves on the U.S.
Food and Drug Administration (FDA)
committee that will advise the agency’s
director on COVID-19 vaccine approv-
als. “The hardest of those three is imple-
mentation. Mass production is not trivial;
mistakes get made, and you learn as you
go.” During the U.S. polio- immunization
campaign in the 1950s, he notes, one man-
ufacturer failed to properly inactivate
the polio virus used in the vaccines and
40,000 children became infected.
The challenges to achieving such
widespread immunization aren’t just
about reaching manufacturing targets.
Dozens of nations are investing in or de-
veloping their own vaccines, and there
are nationalist arguments for funneling
the end products of these investments
back to those who financed them, which
would lock out countries with fewer
health resources from the doses they
need. Even in industrialized nations
that may produce enough vaccines, up-
take could be difficult, given anti vaccine
sentiment in general (stemming largely
from unsubstantiated links between cer-
tain vaccines and autism) and concerns
about the safety of any COVID-19 vac-
cines in particular. In a recent Ipsos poll
commissioned by the World Economic
Forum, one-third of Amer-
icans said they would not
get vaccinated if a COVID-
19 shot became available.
While some degree of
nationalism is reasonable
from a social- justice per-
spective, says Emanuel, in
a global health crisis, allow-
ing the virus to percolate
anywhere poses a threat
to people everywhere. To
stress the need for inter-
national unity, the World
Health Organization part-
nered with the vaccine-
focused public-private alli-
ance Gavi and the Coalition
for Epidemic Preparedness
Innovations, a group of
philanthropists and gov-
ernments focused on pro-
viding resources needed
to respond to infectious-
disease threats, to form the
COVAX Facility, a mecha-
nism that would allow na-
tions to purchase vaccines
at reduced prices by pool-
ing their buying power.
The initiative is helping to
fund nine vaccine candidates, and coun-
tries can sign up to make commitments to
buy the shots that end up being effective
at volume discounts.
So far, 172 countries have expressed in-
terest in joining, including 80 developed
nations and 92 lower- and middle-income
countries. The Trump Administration has
declined to join COVAX, citing ongoing
tensions with the WHO, but even with-
out the U.S., COVAX now represents 70%of the world’s population. International
experts have proposed two broad strate-
gies for deciding how much vaccine coun-
tries should receive—one that relies on a
country’s population and another that
uses the proportion of health care work-
ers as a guide—both of which Emanuel
believes will fall short of equitable alloca-
tion. “People want to be ethical but don’t
know what ethical means in this context,”
he says. In his view, it involves principles
such as reducing harm, premature death
and economic hardship, as well as limiting
community spread of disease that would
put more people in harm’s way.
Even once countries receive their
allotted doses, deciding
which people should be
immunized first raises ad-
ditional ethical and practi-
cal challenges. In the U.S.,
the National Academies of
Sciences, Engineering and
Medicine released a draft
of prioritization guidelines
in September, proposing
four tiers of vaccination
groups. The first wave of
vaccinations would be for
high-risk populations in-
cluding health care work-
ers, people with existing
health conditions such as
obesity, asthma and heart
disease, and the elderly in
group living conditions.
Next come “critical risk”
workers, teachers, older
adults, people in group
homes, and the incarcer-
ated; then young adults
and children; and finally,
the rest of the nation. A
final draft reflecting pub-
lic comments on these pro-
posals will be given to the
CDC committee responsi-
ble for making immunization recommen-
dations for COVID-19 vaccines.
In anticipation, Dr. Nancy Messon-
nier, director of the National Center for
Immunization and Respiratory Diseases
at the CDC, in early August informed the
health departments of four states (North
Dakota, Florida, California and Minne-
sota) and one city (Philadelphia) that they
would be part of a pilot program for roll-
ing out vaccines. The CDC and Operation