I'm not an ethicist but would love to get a public health ethicist's take on something that has been troubling me ( @prof_goldberg?)

Some middle-income nations (e.g. Mongolia, Vietnam, Thailand) have done superbly at suppressing viral transmission ('elimination countries') 1/n

They did so by urgently & aggressively adopting proven, science-based, public health measures (e.g. test/trace/isolate/support). They listened to @who's clear guidance. A model for how all nations could have acted.

But now they're at the back of the queue to get vaccinations 2/n

The initial idea behind COVAX (disclosure: I was consulted during the design phase) was that all nations would get enough doses to vaccinate 15% of their population by end of 2021 (2B doses given, 2 per person) - health workers & high risk citizens in ALL nations. 3/n

But obviously rich nations bypassed COVAX, opting instead for a 'me first, me only' approach (through direct bilateral deals with vaccine companies). Low- & middle-income nations won't probably get many doses until 2022-2023.

Here's where I have an ethical question...4/n

I totally understand that there's a need to urgently vaccinate people in countries with massively uncontrolled transmission (e.g. US, UK). I'm obviously thrilled to see citizens in these nations getting doses (including my parents in London!). 5/n

The original COVAX design absolutely recognized that there should be a "reserve" of perhaps 5-10% of all available doses that would be directed to places where the pandemic is worst. In other words, these extra doses would indeed have been directed to places like the US/UK. 6/n

What I'm struggling with, ethically, is this:

Some middle income nations have reached 'zero COVID' because they followed the science. Now they are being penalized; they won't get the benefits of vaccines until 2022-2023

Can an ethicist help me grasp how we think about this? 7/n

Again, I'm overjoyed that rich nations are now rolling out vaccines, which prevent severe illness & death. This is astounding & I'm thrilled

But these nations could ALSO be adopting the same strategies as, say, Vietnam and Thailand (and NZ and Australia) to get to zero COVID 8/n

Couldn't there be a kind of ethical global compact in which nations of any income level agree to drive down viral transmission through a RANGE of health interventions (including vaccines?) 9/n

I fear we're saying: "only rich nations deserve the benefit of vaccines and all other nations must use non-pharmaceutical interventions [NPIs], even though many rich nations failed to adopt such NPIs & are now relying only on vaccines to get them out the of the mess." END