Third Time’s a Charm? Not Really – Yet.

“Though the conduct of nations in dealing with one another has commonly been determined at all times by selfish and short-sighted considerations, the conscious, deliberate adoption of this standard at an age when the intercourse of nations and their interdependence for all essentials of human life grow ever closer is a retrograde step fraught with grave perils to the cause of civilization.” - J.A Hobson, 1902.

“Though the conduct of nations in dealing with one another has commonly been determined at all times by selfish and short-sighted considerations, the conscious, deliberate adoption of this standard at an age when the intercourse of nations and their interdependence for all essentials of human life grow ever closer is a retrograde step fraught with grave perils to the cause of civilization.” – J.A Hobson, 1902.

As updates of the Omicron Covid-19 variant dominate the news this week, I can’t help but think back to a conversation I had last week. Simply put, the question raised in my English class was whether one should take a third Covid-19 vaccine or not? While the majority of my classmates had already discussed this topic in their economics class, I was new to the conversation. Nevertheless, I formed an opinion almost instinctively – no, I would not take a booster shot. This stance, given the premises of the conversation, seemed most logical to me, and indeed I thought most of my friends would agree. To my surprise, however, only three of thirteen students (myself included) publicly opposed taking a booster shot. Admittedly, one of the three was not even a student in my English class, but rather an advocate for our stance in the original economics class, bringing the percentage in my English class down to 15% against a third inoculation.

Allow me to clarify that advocating against the booster shot was not defended under the premise of vaccine hesitancy; we agreed during the discussion that a third shot is scientifically recommended to maintain people’s level of immunity. Instead, we focused on the ethics of abstaining from receiving a third dose so that vaccines may be distributed to poorer countries, particularly those in the Global South. Nevertheless, something I think is relevant to mention now but was left unsaid in the classroom discussion is that except for Moderna, the booster shots are the same formulation as existing vaccines, thus the distribution of vaccines is safe. 

Underlying the divergence in opinion are fundamental differences in how people see the magnitude of the impact of their actions. Despite this though, there are deep ethical questions that ought to be at the forefront of this discussion. Most prominently, is it fair to perpetuate a system based on self-interest at the expense of others’ well-being? While some countries, such as Tanzania, Chad and Haiti, have fewer than 1% of people who have received a single vaccine, wealthy nations such as the United Arab Emirates, Spain, U.K. and U.S. have most citizens fully vaccinated – 79%, 76%, 65%, and 53%, respectively. The obvious effect of having ten countries (Brazil included) administering approximately 75% of all vaccine doses is the perpetuation of inequality. Fully vaccinated people can already safely return to normal without risking severe disease or death, especially if masked and practicing proper health measures. We ought to bring everyone to this level of safety and ‘normality’ before securing further protection above this level for fully vaccinated people. 

The principle of utility most plainly states that actions are right when they promote the greatest happiness for the greatest number and wrong when they produce unhappiness for the majority. Underlying this principle is the idea that there is equal consideration to everyone’s interests affected by a distributive policy, regardless of things like where they live or their level of wealth. In trade-off situations, when resources are scarce, utilitarian reasoning supports providing vaccines first to those who are unvaccinated because they gain greater benefits than those receiving a third shot. The opportunity cost, that is, the second best option that you give up when you chose the first option, is greater when a dose is used as a booster than as an initial shot. As an initial shot, we lose solidifying people’s immune system against COVID. As a booster shot, however, we widen the gap between the have and have-nots by allowing populations to remain unprotected and significantly more vulnerable to serious health issues. As Benjamin Schreiber, the deputy chief of UNICEF’s global immunization program said, “vaccine equity is not charity; it is an epidemiological necessity.” Taking this a step further, diminishing marginal utility refers to the phenomenon that each additional unit of gain leads to an ever-smaller increase in subjective value. In terms of vaccines, taking a third vaccine may mean you don’t experience fatigue but taking a first shot may mean you don’t die. Since Wednesday’s report that Pfizer booster shots offer significant protection against Omicron, one might be more inclined to take a third dose. However, two doses still protect you against severe diseases, so while you might get a fever, you likely won’t end up in the ICU. We are collectively better off having non-fatal spreads everywhere (as facilitated by egalitarian access to two doses), rather than no spread somewhere and fatal spread elsewhere (which is happening as some have three shots while others have zero). What is the point of everyone in, for example, Brazil having mild symptoms of the current variant – and who’s to say there won’t be a next one – while people in, say, Rwanda are dying? Current vaccine supplies could save more lives if used in previously unvaccinated populations than if used as boosters in vaccinated populations. We are seeing the effects of this right now; because scarce vaccines are being used as booster shots rather than first-time vaccines, mutations facilitate by spreading through unvaccinated populations, and fast-forwarding this observation from three months ago to today, the Omicron variant is our new hurdle. 

Admittedly, there is also a demand-side issue in countries like Liberia, which has administered only 55% of the vaccines they have. Although this discrepancy between the supply and demand of vaccines may be due to misinformation, distrust of one’s own government, or uncertainty over the vaccines’ origins, what is most relevant in the Global South is the lack of infrastructure. Without the proper means to reach the most outskirt communities efficiently, it becomes increasingly hard to vaccinate individuals. Yet even if they do manage to utilize all the supply, the lack of available shots is still prominent – as is the case with Guinea-Bisseau, which has used 96% of the doses available to them but has only 1% of their population fully vaccinated. 

Nevertheless, some may argue the short-term benefit of redistributing vaccines would be outweighed by the long-term cost of failing to prevent variants given vaccines are not being employed as booster shots. Still, with a constrained global vaccine supply, it is unethical to provide booster vaccines as long as the existing two-dose regimen continues to effectively protect against variants. Moreover, the locations of where vaccines are lacking are relevant. With low standards of living where safety and sanitary measures to decrease the transmission of the virus heightens the risk of illness. It is worthy to note I am not discussing the comparative benefit of a third vaccine dose in relation to immunocompromised people – clearly in that case, a third dose would indeed have a utilitarian benefit that is relevant to the discussion of when and who should get a third dose. My focus is on broad-based booster campaigns like the one in São Paulo. In this context, it is better to have everyone fully vaccinated with the two current doses – which are still highly protective against infection, hospitalization, and death – before we go around jabbing for a third time. With this, let me make myself clear: I am not saying we should never take a third COVID vaccine. I am saying we should not take a third dose yet, only until enough people around the world have actually had the opportunity to take their first two shots. We can always take a third dose tomorrow, but most don’t even have their first dose today.

It’s simplistic to say that every time a Brazilian abstains from taking a third dose, that third dose will be sent to Africa. Still, we must remember that our governments have the responsibility to be ethical, and as citizens, we must hold our leaders accountable. We cannot possibly look at countries like Canada, which purchased nearly nine times as many vaccines as its population of 37 million people, and not place any responsibility on their shoulders. Only collective action can catalyze change, so I am optimistic that if enough people (which historically speaking is around 3.5% of a population) were to publicly voice their opposition to the Brazilian government’s offering of a third dose, real change could be made. And likely in the long-term, leaders would understand that when another health crisis arises, we cannot take only our self-interests into account. 

Though from a nationalist perspective, the government is required to exclusively prioritize the interests of their people, a cosmopolitan would say borders are arbitrary and where people are born is wholly out of their control, therefore, it should not affect their access to lifesaving interventions. The latter is impractical as there is presently no political will to follow a single global platform that could fairly distribute vaccines without regard for national borders (though this is exactly what COVAX is attempting). As a solution, bioethicists have brought forth a middle ground: an ‘influenza standard’. Countries would be ethically permitted to prioritize their own residents as long as measures stop Covid-19 from being an emergency. When Covid-19 becomes similar to a bad influenza season, then there is no longer an ethical justification for retaining vaccine doses for country residents. At this time, countries should donate their excess vaccines to foreign countries who are lacking single and second doses. As Brazil’s death counts continue decreasing yet our leaders advocate for a third dose, this ethical standard developed by experts in the field seems to be more and more relevant to us at Graded.

Ultimately, I stand by my instinctive response. A temporary moratorium on booster shots, as advocated by the World Health Organization since August, would enable 10% of people in every country to be vaccinated. Even 10% of every country is not a lot, but it’s logical – and more importantly, ethical and empathetic – to distribute vaccines away from those who are already protected by two doses (and do not urgently require a third one) into the hands of those who have nothing. I mentioned collective action earlier, and while I believe that it is through the joint efforts of millions of people that change can happen, collective action is the sum of individual actions. You and me not taking a booster shot may not mean our doses will get sent to Africa, but if enough of us decline a third vaccine, then we can begin to voice change for our leaders to listen, or at least go to bed knowing we’ve made the most ethical choice.