全球疫苗分销的伦理问题，第三部分，与弗洛伦西亚-卢纳（Florencia Luna）合作

ALEX WOODSON: Welcome to Global Ethics Review. I'm Alex Woodson from Carnegie Council, the world's catalyst for ethical action.

In this podcast series, we'll be connecting Carnegie Council's work and current events with our senior fellows, senior staff, and friends of our organization. You'll hear from leading experts on artificial intelligence and technology, migration, public health, and U.S. foreign policy and global engagement.

This week’s podcast is the third in a series on the COVID-19 pandemic and the ethics of global vaccine distribution. In part one, released at the end of June, I spoke with Oxford’s Professor Cécile Fabre. And two weeks ago, we posted my talk with Dr. Ezekiel Emanuel, from the University of Pennsylvania.

Currently, in July 2021, COVID-19 is surging again in many parts of the world. In some nations, vaccines are widely available, so hospitalizations and deaths are down considerably from a year or six months ago. Other states, though, are still facing some of their worst days of the pandemic. They simply do not have the same access to vaccine doses.

In recent weeks, the Biden administration has put in motion a plan to help distribute tens of millions of doses to some of the neediest nations. Though many have applauded the move, there is less consensus as to whether it goes far enough.

Given the existing global inequities, what are the responsibilities of vaccine rich countries to the rest of the world? What ethical considerations should guide policymakers’ thinking on these issues?

To help to answer some of these questions and to understand the state of crisis in Latin America, I spoke with Dr. Florencia Luna. She is director of the Program of Bioethics at the Latin American University of Social Sciences or FLACSO and principal researcher at the National Scientific and Technological Research Council in Argentina.

One note, Dr. Luna mentions COVAX several times in this talk. COVAX is a worldwide initiative aimed at equitable access to COVID-19 vaccines. It is directed by Gavi, the Vaccine Alliance, the Coalition for Epidemic Preparedness Innovations, and the World Health Organization.

For more on COVAX, the pandemic, the vaccine, and ethics, you can go to carnegiecouncil.org. You can also find my interviews on this topic with Cécile Fabre and Ezekiel Emanuel.

But for now, here’s my talk with Dr. Florencia Luna.

Dr. Florencia Luna, thank you so much for speaking with us today.

FLORENCIA LUNA: Thanks to you for inviting me.

ALEX WOODSON: Of course. I know you are currently in Geneva, Switzerland, but we were just talking, and I know you have spent a lot of time in Buenos Aires during the pandemic. Things are very different in different parts of the world right now. How are people experiencing the pandemic in Argentina and other parts of Latin America right now?

FLORENCIA LUNA: As it is known, the pandemic is hitting quite strongly in all Latin America, so the situation is not very good there. It has been present for a long time, so it is quite complicated. Even countries that have been doing well with the vaccination process, like Chile and Uruguay, which have more than half of their populations vaccinated, still have lots of problems now, not to mention other countries like Mexico, Brazil, Peru, Ecuador, and Argentina, but also I know Paraguay and Bolivia. Really the pandemic has been hitting very strongly in Latin America.

I think it has also to do with the economic situation of these countries. Most of them are considered middle-income countries by the World Bank, but this classification I think is a bit misleading. These middle-income countries have 66.3 percent of people under the poverty line, and Latin America is also a very inequitable region, so you have these middle-income countries where you have a lot of poverty. So this idea that these countries are doing well is quite misleading because you have very rich people and very, very poor people, and with the pandemic this has increased a lot. For example, in Mexico, that had extreme poverty of 10 percent, it has grown to 18 percent, and in Argentina it is the same, so the situation is really bad.

ALEX WOODSON: Over the past month or so, President Biden has announced a plan to distribute I think up to 500 million doses of vaccine to nations that need them that might not have the access right now. I have spoken with Dr. Ezekiel Emanuel about this plan. He had some concerns about it, but overall he thinks that is the right thing to do, the ethical choice.

When you saw this announcement, what did you think? Does this go far enough? Is there more that can be done?

FLORENCIA LUNA: I think donations are welcome obviously because we need a lot more vaccines in other regions and not just in Argentina. But I think that a multilateral mechanism like COVAX is better. Though it has some problems and has been criticized, I think it is not so difficult to improve it, and I think that is the best way to go. I know Biden is going to give a lot to COVAX. I think that is the best way, but I think also we have to improve it. Maybe if you want, at the end we can come back and I can tell you how I think we can improve that.

I did a little research project for the World Health Organization (WHO) on the first phase of COVAX. I think it is the right way to go, but it is having some problems. In that sense, I think it is good to have donations. That is like second best. I think the first best would be to have a multilateral mechanism that would be fair considering mostly need and not so much the proportion of population that you have.

For example, we had that problem in Argentina. The national government, when they distributed vaccines, did it by the amount of population in each city or province. The problem is that, for example, Buenos Aires has many more health care people because we have a lot of clinics and hospitals, but it also has a much older population, so the same amount of vaccines that were given for Buenos Aires was not enough for that kind of population, and that is the problem of having this kind of proportional system of distribution, and COVAX has that kind of system built inside, and I think that should be modified, for example.

ALEX WOODSON: Dr. Emanuel was saying that as well, that distributing vaccines based on proportion of population is not the right choice.

FLORENCIA LUNA: We think similarly. I think I am more optimistic about COVAX. I think we should try to improve it because I think it is an important step.

ALEX WOODSON: Let's talk about that. Two-part question: Why do you think COVAX is the better way to distribute, and what can be done to improve it?

FLORENCIA LUNA: Okay. I think it is multilateral. In a way it has the problem that it accepts that countries can buy for themselves, and that in a way jeopardizes COVAX's system because rich nations have a better way of buying vaccines. But at the same time it avoids a lot of pressure by the richer countries inside COVAX. So it has its pros and cons.

Its focus, and it tries I think, as Emanuel said, it is not the right way to think in equity, this proportional way, but they may change and think more in need, which is what we think is better. That is one of the things.

In a way it is taking care of the poorest nations, and that is very good. I would like them to consider more, as I was saying, middle-income countries, because I think those are the countries that are suffering the most at this point. It is like low-income countries will get donations, high-income countries can buy by themselves, but as I was telling you middle-income countries have a lot of poverty and a lot of structural problems—not all, but most of them, for example, in Latin America—and they cannot compete with high-income countries and they cannot get good prices. For example, South Africa was complaining that they got the AstraZeneca vaccine at the beginning of 2021, and it was nearly double the price that the European countries bought it at because they do not have the power to negotiate as well and maybe the amount of population to do those negotiations.

Also very important, COVAX has this idea of being equitable. They did not choose the best framework. I think it has some advantages because it is simpler and less arbitrary, and it is easier to see it, but I think, as we know now, we can do quite well predictions of which countries will be worse. We know that, for example, when winter comes things get harder, so there are ways of predicting and considering need in this case.

The other thing that COVAX has is it allows all countries to be there, and it also has something that should be more exploited or worked on more, and that is this building of capacity in order to, for example, produce vaccines. I think this is very important if you can do it more regionally. They have supported a lot India and the Serum Institute, and I think they should do the same thing in Africa and in Latin America, so we have different centers. There, yes, you have to seek countries that have a certain infrastructure in science in order to build upon that. For example, in Latin America you can work with Mexico, Brazil, Argentina, and maybe Colombia. So you have three or four countries that can produce vaccines, and that was really one of the bottlenecks at the beginning of distribution of the vaccine, so I think that is very important.

In that sense, COVAX brings in different angles that are very important to tackle. One is fair distribution; another one is capacity building. Another one is funding new vaccines that might be much more interesting for developing countries, like new ways of getting the vaccines in one dose and not needing so much cold-chain.

The other thing I think is very important is having WHO helping the planning of the vaccination program. I think that is very important to have. We have in the Americas the regional part of WHO, which is PAHO, the Pan-American Health Organization, and I think it has a revolving fund for decades which has similar ideas that COVAX took of distributing vaccines in a more fair way and also with solidarity, helping the countries that are in bad shape and that cannot bargain. If you have a very small population, it is very difficult for you to get priority or a good price, so if you do it through the revolving fund that helps, and that has been done to get vaccines cheaper, but also it helps planning and thinking beforehand how the distribution will be, and I think that is very important in order to avoid losses of vaccines or expirations of vaccines, which is fundamental too. It is a very scarce resource. It is very expensive. So we have to make good use of it.

ALEX WOODSON: That brings up an issue that Dr. Fabre and Dr. Emanuel both spoke about, which is the issue of giving millions of doses of vaccines to nations that might not be prepared and might not have the infrastructure to distribute it. What do you do in that case? You have millions of people around the world that need the vaccine but just because of where they were born the government might not be able to carry that out. What do you do in that situation, and how are you thinking about that right now?

FLORENCIA LUNA: I think we have to work more, as I was saying, through these kinds of multilateral mechanisms but bring in also this capacity building for very little countries that do not have this possibility.

The other thing that happened with COVAX at the beginning and with distribution was that they were distributing to some African countries that we can say from what we call "rectificatory justice" were always forgotten, and they didn't have the possibility of having vaccines, and we can welcome that. It is very good. But at the time, where there are some other countries that are not doing really well and have thousands of deaths and millions of cases, it is a little bit unfair to lose those vaccines for countries that do not need them at that time, and that was what happened, for example, with Latin America. Peru was burning, and COVAX was giving, I don't know, to Côte d'Ivoire, to Ghana, and to other countries that were not in so much need. I think that in this sense COVAX has to rethink how to do this distribution in order to be at the point of really being equitable as they want to be. I think that is part of the issue.

ALEX WOODSON: I know you have been thinking about this and writing about this for a while along with your colleagues. What is your sense that COVAX is taking your advice and is listening to your concerns and maybe other governments' because you are talking about a lot of things that you want to improve, but we are right in the middle of this right now. What is the process like of trying to influence these huge organizations to try to make some changes?

FLORENCIA LUNA: Well, I am an academic. We try to publish in journals that may have impact. I am also—for example, our program is one of the collaborative centers of WHO, so I try to be there and I try to have an impact.

But COVAX is quite independent from WHO, so I don't know how much we can do. I know they are trying to do some changes. We will have to see what happens. I think that some of the criticisms that have been levied have impacted COVAX. So I hope they go to the right direction. For example, on all these kinds of things I think they need to have more transparency too. So I think there are two or three things that are not so difficult to improve and that they can do now.

I think it is very important because we are still in the pandemic. It is not gone. And the predictions say that there will be other pandemics, so we have to begin building some mechanism—I am calling it COVAX because it is the only one that is here; maybe we need another one—that really can address these kinds of loopholes, these problems that are so pressing.

What we see is that as things are going now, they are not going well. We are not solving the problems. It is the second summer in the Northern Hemisphere and we are seeing that people are doing more or less the same mistakes. Even rich countries cannot vaccinate all the people. I was listening to French TV, and they are quite worried. They are counseling their population not to go to Portugal or to Spain because of the new strains.

In a way we are not going to solve it that way, by not letting people move. We have to begin thinking a little bit more. It's like we are seeing just here and we don't have long sight in order to see that here we are all together, and if you leave Brazil, Argentina, or South Africa alone, they will bring these strains, and all the work you are doing in these high-income countries will be useless because you will continue to put restraints on people. That is part of the problem.

I was discussing with colleagues the situation, and they were telling me: "Well, but rich nations do not have incentives to donate or to immunize only 25 to 30 percent of populations and begin sharing." I think they do not help because they are having short sight, and they are not seeing the real problem. The real problem is that they cannot get back to normality. Even if they vaccinate their whole populations 100 percent, you will still be fearing your neighbors because the world is global, and it is impossible to restrain movement. So it is quite complicated that way.

ALEX WOODSON: It's not a good situation at all. I imagine the people in places like Argentina, Brazil, and Mexico must not be happy with the situation, and I wonder what they think when they look at places like the United States, the United Kingdom, and even France. I won't ask you to speak for everyone in Argentina, but what is your sense of how people are thinking about this right now, the fact that this country has the vaccine and this country doesn't? What do you think that means for the future?

FLORENCIA LUNA: I cannot speak for all the people. There are many people from Latin America, not only Argentina, who are going to the United States to get the vaccines, the people who have the means to do it, and there is a debate whether they should do that. Some people say they should because in that way they are leaving an extra vaccine in Argentina. Another says it's unfair, so it is a whole debate.

What I think is that even if we like it or not we have to begin thinking more globally, and we have to begin finding ways of trying to solve this in a more efficient way. What we are doing now, this nationalism of high-income countries and holding vaccines, is like shooting yourself in a way. You are not getting what you want through this. I think that is part of the problem.

ALEX WOODSON: Stepping back a little bit, as someone who has thought about bioethics for years and has worked on things like tropical diseases and vulnerable populations, did you see these issues connected with the pandemic coming? Did you predict that this was going to happen when the COVID-19 pandemic started, this nationalism, this hoarding of the vaccines? I am just wondering how you thought about this because, for a lot of people, this isn't their focus and it caught everyone by surprise, but what was your thinking as the world got into this?

FLORENCIA LUNA: I didn't see it coming. For example, there were guidelines and different proposals and essays in WHO. This idea of getting prepared for epidemics was there, so it's not that nobody saw it. It was there.

In a way, yes, I think we know that this is the way the world behaves, that rich countries or high-income countries will hoard the majority of the vaccines. For example, we have history to show us that. That is why I think COVAX is so important, because it is the first time we could build a mechanism to distribute in a fair way vaccines in less than one year, and I think that is the first time the world has been able to do that. That's why I want to build upon and to improve it, because it is not minor.

If you think, for example, in 2009 we had H1N1, which killed nearly—now it's nothing—300,000 people. In seven months there was a vaccine. Australia, the United States, Canada, and six other countries hoarded most of the vaccines. Mexico was really badly hit. They tried to make a pre-commitment, and they didn't get the vaccines. After the intervention of the WHO, 10 percent of the vaccines were released but it was too late. With that history we know—I knew at least, and I think in developing countries we know—how high-income countries behave. So that was not new for us.

That is why I try to defend the importance of COVAX because I think that is new, having a mechanism that is trying to do this distribution in a fair way. It is not achieving it, but at least it is going in the right direction, and that is why I think we have to try to reflect the need and improve it and think in the short-term possibilities that we can have. There are many other more fundamental changes that are more difficult to reach, like to have a global covenant or kind of agreement. That is much more difficult. But at least we can begin with this little mechanism.

ALEX WOODSON: That's great. For my final question: Unfortunately, this won't be the last pandemic that humanity faces. In your most optimistic view, what should we have in place for the next pandemic that we don't have now?

FLORENCIA LUNA: We should have a really equitable way of distributing, not based on the proportion of the population but based on need, which countries really need it. Or maybe we can think in a mixed way in order to be helping also countries that are not so needing but are fearing.

For example, if you have Latin America and you have Central Europe that are being hit, you have to begin working with them. That is the main priority.

You have to have more transparency. I think pharmaceutical companies have to have more transparency. That is a big issue, how pharmaceutical companies are behaving. They have done very good work regarding getting very quickly the vaccines, but I think that they are not now responding the way they should. That is one of the problems.

As I was saying before, I think that giving more regional capacity building for manufacturing vaccines is something very important. Vaccines are quite difficult to manufacture. They are not like normal drugs. That's why there are so many problems now. But there are many countries in the world that can have that leading role and that can decentralize a bit the situation and help. As I was saying, I think that in Africa you can be able to help two or three countries to have this infrastructure that can be easily put to work if we have a pandemic, and the same can go for Latin America.

Argentina has a lot of scientific infrastructure. We have had Nobel Prizes. We have a tradition in research. Most the trials that were done—for example, Pfizer—had research subjects from Argentina, and then we couldn't get the vaccines. We don't know what happened in the middle—it was the government, it was Pfizer, there was a lull in the middle.

I think we should begin building this kind of regional infrastructure in order to be more focused and have the capability to do it better, and some kind of multilateral mechanism—call it COVAX or a new one—that may help in distribution. I think it is very good that WHO be part of it because of all this planning and also because of the respect in general the WHO has in developing countries, it is very important the work they do. I think in that sense it is important to have that expertise inside.

So those are some of the things—and, if possible, begin building more of an institutional infrastructure for these kinds of things. So maybe countries can buy vaccines but up to a certain point, and you cannot buy nine times your population or eight times your population. There is some rationality in that, but that is a problem of coordination, a very hard one, but you have to do it in a global way where you have to get these countries to have limits to what they want. It is a very, very tough and difficult situation. I think it will take more time, but we have to begin thinking about different models.

We have, for example, in the world decreased [smoking tobacco]. This was done after years and years of working and laws in most of the countries against smoking of air, and we could do it. We should think in different and innovative ways of trying to build these kinds of minds. We have to also educate people in these kinds of things so they are aware and more conscious. We have to ask also the governments to behave correctly.

ALEX WOODSON: Dr. Florencia Luna, thank you so much.

FLORENCIA LUNA: Thanks to you.