Who pick up the bill when who made who? Ain’t nobody told you?

–AC/DC

On August 18th, The New York Times ran a story on the front of its feed titled “Booster Shots ‘Make a Mockery of Vaccine Equity,’ the WHO’s Africa director says.” In case that statement sounds needlessly inflammatory and emotionally manipulative, here’s the actual quote from Dr. Matshidiso Moeti:

Moves by some countries globally to introduce booster shots threaten the promise of a brighter tomorrow for Africa. As some richer countries hoard vaccines, they make a mockery of vaccine equity.

To say that the introduction of a booster program in one nation poses a near-existential threat to a continent of 1.2 billion people is a stretch. But it’s not until you drill down to the factual details of the worldwide dynamic of COVID prevalence, vaccine production, and actual vaccination that you get a sense of how misleading and irresponsible that statement is, and how shaky is Moeti’s subsequent claim that as a consequence of boosters, more dangerous variants of COVID will arise.

To review what’s already well-established, here’s a summary in list form of the epidemiological facts of vaccination against COVID:

1. Vaccination protects the greatest number of people when it is targeted to those areas where disease prevalence is highest, and the existing vaccination rate is lowest.
2. At this time, our best information indicates that the major pharmaceutical manufacturers of COVID vaccines have a production capacity of 13 billion doses per year, or 1.08 billion doses per month. This estimate does not include the various home-grown vaccines being produced in some countries. (For more on this issue, look at the website of the Duke Global Health Innovation Center.)
3. Immunity in vaccinated individuals goes into a significant decline by 6 months after vaccination. Booster doses are demonstrated to restore immunity to levels seen after the initial vaccine series.
4. In principle, the limiting factors involved in determining the success of a global vaccination campaign include, and may seem to be determined exclusively by, the supply and finances of the nations looking to acquire vaccine. But in reality, the global vaccination campaign has been limited to a far greater extent by several other factors:

• Governmental decisions about acquiring doses independent of finances.
• Issues involving supply chain.
• Issues involving storage.
• The logistics of physical distribution from the port of entry to remote locations.
• The human resources available to achieve all three of the above plus administer, trace, track, quality-control, and dispose of waste materials related to every dose of vaccine.
• People’s willingness to receive the vaccine.

So, there’s good reason to question anyone who pushes the zero-sum narrative that a dose withheld from a soccer mom in a North Jersey suburb necessarily means a dose given to an impoverished tribesman in the Masai Mara, which is what quotes like the one above are meant to evoke. The sheer existence of a surplus of vaccinations in one location has no bearing on the administration of those very vaccinations in a remote location, especially if that remote location is governed by an incompetent or hostile government, lacks an effective supply chain, lacks storage capacity, cannot handle the logistics of transportation in an effective way, lacks the personnel to transport or distribute the vaccine, and lacks a population ready to receive precisely the amount  (or at least nearly equal to the amount) of vaccine shipped. There’s a lot more to fighting the pandemic globally than Dickensian hyperbole about “vaccine equity.”

In my medical practice in Ridgewood, New Jersey, I referred my first patient for a booster dose a few weeks ago, a middle-aged woman first vaccinated in February (i.e., the booster would ideally be administered six months after her initial dose). We just diagnosed her with pancreatic cancer. Based on our best understanding of the evidence, her cancer appears curable through a combination of initial chemotherapy and subsequent surgery. During her planned three months of chemotherapy, she’ll be continuously immuno-suppressed. She asks me four times a day when her booster will be given.

Even if there were no pandemic, my cancer patient would still be walking the line between life and death for months on end, and hoping to come out the other side intact. And even if there were no pandemic, there would still be people walking that same line in the various poor countries of the world due to malnutrition, inadequate sanitation, violence, and a host of other problems. Do we really need to parse and litigate the totality of all misfortunes in the world to fight a pandemic? If that’s what “vaccine equity” requires, then is it a legitimate concept in the first place? Feeling that we’ve done “the equitable thing” won’t control the pandemic. Vaccinating people according to sound epidemiological practices will.

With that in mind, I would argue that there is only a good case for shipping doses of vaccine currently held in the United States to some other nation if that nation meets the following four criteria:

(a) Higher prevalence of COVID-19 than the US.

(b) Lower current vaccination rate than the US.

(c) Poverty below a threshold that explains the country’s inability to secure its own vaccines.

(d) Vaccine logistics and deployment capabilities that are good enough to ensure that doses redistributed from the US do not go to waste, or at least that the rate of waste is not more than it would be if US had kept the doses.

Now, (d) may be a tall order, but it’s neither effective nor equitable to divert vaccine to a place where no one has a viable plan for what they’re going to do with it once they have it. And anyway, I thought developing such plans was the reason we have a World Health Organization. The Times article quoting Dr. Moeti is problematically silent about where we are on that project. But let’s set (d) aside for now and focus on the somewhat more objectively knowable factors related to (a), (b), and (c). 

Using the NYT’s global COVID tracker, some data from the IMF (also via Statista), a few targeted internet searches to fill in a few blanks, and an Excel spreadsheet, I compiled the following chart, which consists of all countries whose COVID cases per 100,000 matches or exceeds that of the US as of 8/18/2021, the day Dr. Moeti’s quote appeared in the online version of the Times.***

Country	Cases per 100,000	Vaccination rate	Population	Per capita GDP (PPP)**	Per capita GDP rank (of 192 nations)
Georgia	135	7%	3,720,000	$11,000	104
Dominica	108	27%	72,000	$12,000	98
Cuba*	78	27%	11,300,000	N/A	N/A
Botswana	72	7%	2,300,000	$17,000	77
Kosovo	71	12%	1,870,000	$12,000	100
Israel	69	60%	9,000,000	$39,000	35
Seychelles	69	70%	98,000	$29,000	48
Montenegro	68	27%	622,000	$19,000	68
Isle of Man	67	72%	85,000	$89,000	8
Malaysia	65	35%	32,000,000	$30,000	47
Eswatini	56	9%	1,150,000	$9,000	113
Fiji	55	24%	890,000	$10,000	108
Iran*	47	4%	82,900,000	$21,000	65
St. Lucia	47	14%	183,000	$14,000	91
United Kingdom	45	61%	66,700,000	$45,000	26
United States	42	51%	328,200,000	$60,000	13
* Homegrown and alternative-product vaccines skew these numbers.	**”PPP” refers to “Purchasing Power Parity,” the metric used by macroeconomists to control for differences in actual purchasing power of goods between the currencies of different countries.

These fifteen nations are the ones that meet criterion (a). I suppose you could argue that it makes sense to include countries with less COVID than the US as candidates for diversion of vaccine held by the US. I haven’t presented these other countries partly in the interest of simplicity. But I would say if you make the claim they should be included, the burden of proof is on you, and any argument you would make has to account for the delays created in transit when vaccine is relocated from one place to another. You would also need a working definition of “at-risk groups” that discounts the importance of disease prevalence, and a justification for discounting prevalence. Another tall order.

It’s first of all striking to note that only two African nations exceed the US in disease prevalence, Botswana and Eswatini, and those two countries have a combined population comparable to the State of Connecticut, or the City of Los Angeles. The fact is, Africa, whatever its legitimate problems and hardships, has no monopoly in the world on poor, under-vaccinated countries with high COVID prevalence. The challenges of global health are indeed global.

Of the fifteen countries captured in the chart, four have higher vaccination rates than the US (Israel, Seychelles, Isle of Man, and UK), thus failing to meet criterion (b). The Isle of Man also happens to be a richer country than the US. The other fourteen are less wealthy than the US, but not all of them are fairly described as “poor”: there is no reasonable standard by which the UK, Israel (minus the Occupied Palestinian Territories), or the Seychelles would be regarded as poor countries. Malaysia, Iran, Montenegro, and Botswana all rank in the 60^th percentile or above for per capita GDP. (The case of Iran is more complicated, because US sanctions impact its ability to transfer money, but more on the situation in Iran below.)

Finer points aside, a hard look at granular reality drives home an important point: the global landscape of the pandemic is not a simplistic dichotomy of healthy/rich/vaccinated nations vs. sick/poor/unvaccinated nations. Neither the rich nor the poor are served when public health officials paint it that way, so maybe they should stop. In reality, both in the US and abroad, factors other than national macroeconomic status and the number of vaccine doses in possession impact both caseload and vaccination rates. In this as in other things, the world is a complicated place. But let’s suppose for the sake of argument that we consider any nation with a per capita GDP below the top 50 as a candidate for our help in procuring vaccine. That would leave ten countries on our chart that justify consideration for diversion of US vaccine.

In those ten countries combined, there are 97 million unvaccinated people. In the US, there are 161 million unvaccinated people. Even that 97 million is massively skewed by two countries that, for important reasons, are in the chart with italics and an asterisk: Iran and Cuba. These two countries account for 84% of the unvaccinated 97 million, and it’s in part because both have home-grown vaccination programs, and also in many cases are giving “other” vaccines (e.g., SinoPharm) which “don’t count” as far as the NY Times tracker is concerned. According to a report in the British Medical Journal, “Cuba is likely to become the first country to immunize its entire population with its own vaccines.” If Iran’s 12 million SinoPharm doses are counted, then it actually has vaccinated 18 million people, or about 22%, rather than the 4% quoted by the Times.

I would add that, to the extent that the poor require special consideration on the global health landscape, it’s not fair simply to describe the US as a “rich country” and call it a day. One of the reasons the US is so troublesome from a public health standpoint is that it is geographically large, has a large and widely mobile population, and is plagued by an extraordinary degree of economic inequality. The US has 40 million people living in poverty. We have more people living in poverty than most African countries have people. That doesn’t make the United States a global charity case in a macroeconomic sense, but it does impact meaningfully on the proposition of diverting vaccine supplies currently in our reach in the supposed interests of “equity.”

The fact of waning immunity makes the advent of booster doses a necessity not only for Americans, but for every nation. It now makes more sense to look at COVID vaccination as a three-dose protocol, not the two-dose protocol it was originally conceived of as being. It makes no more sense to withhold the third dose than it would have made to withhold the second. A great number of Americans were (double) vaccinated in the early days of Pfizer and Moderna availability, from December 2020 through February 2021. We now know that those people don’t own immunity; they just had a 6-month lease on life that is now in the process of running out. We don’t know for sure where the next COVID variant will be bred, but it’s just disingenuous and wrong to say in defiance of all we know, that the US isn’t one of the prime breeding grounds.

If we’re having a discussion about vaccine distribution, it’s also important to go back to that number: 1.08 billion vaccine doses per month manufactured by the major suppliers (the ones who “count”). That’s 36 million doses per day. To raise all 10 countries from their current aggregate vaccination rate of 8% (again, heavily skewed by the Iran lowball) to our current vaccination rate of 51% would require about 90 million doses. For the factories, that’s only 3 days’ work. This raises the question of why people at the WHO are talking in terms of zero-sum supply scarcity when there is enough for everyone. It also raises the question of how the WHO is performing at its job.

Unfortunately, for Americans, the biggest liability remains the self-inflicted one of vaccine refusal at the individual level. If there’s one persuasive counterargument to all I’ve presented above, it’s that no one knows how to squander a good resource like Americans. If there’s a real mockery here, it’s the one we’ve made of ourselves. Ultimately, in the eyes of the world, if all we’re going to do is sit on hundreds of millions of shots while we commit genocide on ourselves, then other people, if they are ready and willing, should not have to wait on us. That said, if we can make use of shots ready to hand, maybe we should put aside vague qualms about “equity,” and do just that.

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***The data for the information in this chart exists only in very fragmented form, and is bound to be imperfect if presented in any form. I relied most heavily on The New York Times tracker and on Statista, but there were holes in their data that required a tedious series of patchwork Google searches that I haven’t cited here in full detail. One or two very small countries or territories may have fallen out of my presentation. But such issues of detail don’t affect my main point: the more imperfect the information regarding vaccination abroad, the weaker the case for re-distributing American vaccines to places about which data is imperfect. The data is imperfect in the US as well, but generally superior to that for developing countries.

(Suleman Khawaja is a hospitalist at Valley Hospital in Ridgewood, New Jersey. The views expressed here are solely those of the author in his personal capacity, and are not intended to represent the views of Valley Hospital. All formatting errors in this post are the editor’s fault, as are almost all gratuitous references to AC/DC.)