The Shaky Ethics of the Booster

A wave of guilt came over me as I felt the prick of my first vaccine dose this March. I had cut the line, using my status as a first-year medical student to receive the vaccine alongside elderly veterans at the local VA hospital. I suppose I had succumbed to peer pressure; I didn’t want to be the last student to receive their vaccination. Yet, I knew my risk of serious illness from COVID-19 was essentially zero, and I hadn’t seen an actual patient in a professional capacity. Thankfully, the vaccine became available to the general population only a couple of weeks later, and the guilt quickly faded. I was vaccinated, with freedom I hadn’t felt in over a year.

In the US, the COVID-19 pandemic is the pandemic of the unvaccinated. We have seen a return to normalcy, as more and more people return to work fully vaccinated. Epidemiologists are hopeful that the ‘delta’ wave will mark the last ‘deadly’ wave of the pandemic in the United States. The vast majority of elderly and immunocompromised people are now immune. The United States hit 100 million vaccine doses administered on March 19th of 2021, and today, anyone who wants a vaccine in the US can walk into their local CVS and receive one.

Yet, outside our country’s borders, the global pandemic rages on. Less than half of the world’s population is fully vaccinated, and global life expectancy continues to drop since the World Health Organization declared a public health emergency of international concern on January 30th of 2020. Moreover, vaccination distribution reveals massive inequalities for people born in different parts of the world. For example, only .25% of people in Haiti, an impoverished and politically unstable country of 11 million people, are fully vaccinated. In Ethiopia, a country of 115 million people currently in the midst of civil war, only .85% of people are fully vaccinated. Overall, only approximately 3% of people in developing countries have received one vaccine dose.

Enter COVAX. This initiative is spearheaded by the World Health Organization and the Bill Gates Foundation, and its goal is to provide equitable access to COVID-19 vaccines worldwide. It has seen some success, as the United States and other Western countries have agreed to donate millions of dollars to fund the vaccine effort in poorer countries. Yet, vaccine distribution continues to be swayed by economics. Vaccine manufacturers are much more willing to sell vaccines to richer countries, paying more per dose. As a result, the United States, which paid more per dose for many COVID-19 vaccines than the European Union, was able to distribute these vaccines much earlier in the pandemic. This is an overarching theme that continues to play out worldwide. There is no economic incentive for vaccine manufacturers to distribute vaccines to poorer countries over wealthier countries, which often can pay more than twice as much per dose.

This brings me to the third dose—the booster. The science supporting the booster shot remains controversial. While many vaccine efficacies appear to wane in the long term, they remain effective in preventing severe disease (for now). Furthermore, President Biden has shown a willingness to get ahead of the science, as he has made it clear that booster shots will soon be available to the general population despite objections from Centers of Disease Control (CDC) and Food and Drug Administration (FDA) scientists who state the science isn’t clear yet. Every dose that goes towards a booster shot here in the US could be someone’s first dose in another country. I remain conflicted.

In a perfect world, we would all be vaccinated. We would administer booster shots to ensure a continued immunological response and a decreased transmission rate of Sars-CoV-2. Yet, we don’t live in a perfect world. I can justify a booster shot for the immunocompromised and healthcare workers, but I fear an early authorization will perpetuate worldwide healthcare inequalities. We should fight against these inequalities, not endorse them.

The pandemic rages on. Perhaps the booster shots can wait.