Coronavirus

The Bioethics Of COVID Boosters When 2% Of Africa Is Vaccinated

Affluent countries have begun offering COVID-19 boosters to already fully vaccinated citizens. Meanwhile in some low-income countries, access to doses is virtually non-existent.

The Bioethics Of COVID Boosters When 2% Of Africa Is Vaccinated

People queuing to get the COVID-10 vaccine in Nairobi, Kenya

Nancy S. Jecker

Should countries that can afford COVID-19 booster vaccines offer them to residents if scientists recommend them?

The director-general of the World Health Organization, Tedros Adhanom Ghebreyesus, has made his position clear, calling for countries to impose a moratorium on boosters until 10% of people in every country are vaccinated. His plea comes amid mounting concerns about the slow progress getting COVID-19 vaccines to people in low-income countries.

Like the WHO, some ethicists, including me, have argued that the world must stand together in solidarity to end the pandemic.

Yet as of Sept. 14, of the 5.76 billion doses of vaccine that have been administered globally, only 1.9% went to people in low-income countries.

Meanwhile, many wealthy countries have begun offering COVID-19 boosters to fully vaccinated, healthy adults.

Early evidence on the benefit of COVID-19 boosters to protect against severe disease and death cuts both ways. Some experts tout their benefits, while others argue against them for now.

As a philosopher who studies justice and global bioethics, I believe everyone needs to wrestle with another question: the ethics of whether to offer boosters while people in poor countries go without.

A dangerous gap

The WHO's call for a moratorium on boosters is an appeal to fairness: the idea that it's unfair for richer countries to use up more of the global vaccine supply while 58% of people in the world have not received their first shots.

In some countries, such as Tanzania, Chad and Haiti, fewer than 1% of people have received a vaccine. Meanwhile, in wealthy nations, most citizens are fully vaccinated – 79% of people in the United Arab Emirates, 76% in Spain, 65% in the U.K., and 53% in the U.S.

Even if boosters save lives and prevent severe disease, they benefit people far less than first shots.

In the U.S., the Centers for Disease Control and Prevention has recommended boosters for moderately to severely immunocompromised people. President Biden has publicly endorsed offering boosters to all Americans eight months after they complete their second shots, pending Food and Drug Administration approval. Yet on Sept. 17, the FDA's advisory panel recommended against a third dose of the Pfizer vaccine for most Americans, though they did endorse boosters for people over age 65 or at higher risk.

On Aug. 11, before the CDC had authorized boosters for anyone – including immunocompromised people – it estimated that 1 million Americans had decided not to wait and got a third vaccine. It is unclear whether some of them were advised by doctors to seek a booster shot based on, for example, age or compromised immunity. Some healthy Americans have reportedly lied to gain access to unauthorized shots, telling pharmacists – falsely – that this is their first shot.

In addition to raising concerns about fairness, gross disparities between vaccine haves and have-nots violate an ethical principle of health equity. This principle holds that the world ought to help those who are most in need – people in low-income countries who cannot access a single dose.

China's Sinovac COVID-19 vaccine arriving in Cambodia – Photo: Phearum/Xinhua via ZUMA Press

There's also a purely utilitarian case to be made for delaying boosters. Even if boosters save lives and prevent severe disease, they benefit people far less than first shots, a notion known as diminishing marginal utility.

For example, the original laboratory studies of the Pfizer vaccine showed more than 90% protection for most people against severe disease and death after the primary, two-dose series. Booster shots, even if they boost immunity, give much less protection: perhaps less than 10% protection, according to a preliminary study.

As a recent article in a leading medical journal, The Lancet, points out, “Even if boosting were eventually shown to decrease the medium-term risk of serious disease, current vaccine supplies could save more lives if used in previously unvaccinated populations than if used as boosters in vaccinated populations."

Moreover, when scarce vaccines are used as boosters, rather than as first shots for the unvaccinated, that allows the virus to replicate and mutate, potentially creating variants of concern that undercut vaccine protection.

One could argue that since rich countries have bought millions of doses, they are the rightful owners of those vaccines and are ethically free to do as they wish.

Buy it, use it?

While the ethical argument for delaying boosters is strong, critics think it is not strong enough to override every nation's duty to protect its own people. According to one interpretation of this view, countries should adopt an “influenza standard." In other words, governments are justified in prioritizing their own residents until the risks of COVID-19 are similar to the flu season's. At that point, governments should send vaccine supplies to countries with greater needs.

One could argue that since rich countries have bought millions of doses, they are the rightful owners of those vaccines and are ethically free to do as they wish.

Yet critics argue that vaccines are not owned by anyone, even by the pharmaceutical companies that develop them. Instead, they represent the final part of product development that is years in the making and the result of many people's labors. Moreover, most COVID-19 vaccines were publicly funded, principally by governments using taxpayer dollars.

Since 1995, the World Trade Organization has required its member states to enforce intellectual property rights, including patents for vaccines. Currently, however, the trade organization's members are debating proposals to temporarily waive patents on COVID-19-related products during the pandemic.

Some commentators suggest that the whole debate over boosters is overblown and not really about ethics at all. They propose simply calling boosters something else: “final doses."

But regardless of what we call boosters, the ethical question the WHO's director-general raised remains: Is giving these shots a fair and equitable way to distribute a lifesaving vaccine?The Conversation

Nancy S. Jecker, Professor of Bioethics and Humanities, School of Medicine, University of Washington

This article is republished from The Conversation under a Creative Commons license. Read the original article.

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Coronavirus

Where Lockdowns For LGBTQ Meant Moving Back In With Homophobic Relatives

The confinement experience could turn brutal for those forced to live with relatives who would not tolerate a member of the family living their sexual orientation openly as a young adult. Here are stories from urban and rural India.

At a Rainbow pride walk in Kolkata, India

Sreemanti Sengupta

Abhijith had been working as a radio jockey in the southern Indian city of Thiruvananthapuram when the COVID-19 pandemic hit in March, 2020. When the government imposed a nationwide lockdown, Abhijith returned to the rural Pathanamthitta district , where his parents live with an extended family, including uncles, cousins and grandparents.

Eighteen months later, he recalled that the experience was "unbearable" because he had to live with homophobic relatives. "Apart from the frequent reference to my sexual 'abnormality', they took me to a guruji to 'cure' me," Abhijith recalled. "He gave me something to eat, which made me throw up. The guru assured me that I was throwing up whatever 'demon' was possessing me and 'making' me gay."


Early in 2021, Abhijith travelled back to Thiruvananthapuram, where he found support from the members of the queer collective.

Inspired by their work, he also decided to work towards uplifting the queer community. "I wish no one else goes through the mental trauma I have endured," said Abhijit.

Abhijith's story of mental distress arising from family abuse turns out to be all too common among members of India's LGBTQ+ community, many of whom were trapped in their homes and removed from peer support groups during the pandemic.

Oppressive home situations

As India continues to reel from a pandemic that has claimed more lives (235,524) in three months of the second wave (April-June 2021) than in the one year before that (162,960 deaths in March 2020-March 2021), the LGBTQ community has faced myriad problems. Sexual minorities have historically suffered from mainstream prejudice and the pandemic has aggravated socio-economic inequalities, instigated family and institutionalized abuse, apart from limiting access to essential care. This has resulted in acute mental distress which has overwhelmed queer support infrastructure across the country.

Speaking to queer collective representatives across India, I learned that the heightened levels of distress in the community was due to longstanding factors that were triggered under lockdown conditions. Family members who are intolerant of marginalized sexual identities, often tagging their orientation as a "disorder" or "just a phase", have always featured among the main perpetrators of subtle and overt forms of violence towards queer, trans and homosexual people.

Calls from lesbians and trans men to prevent forced marriages during lockdowns.

Sappho For Equality, a Kolkata-based feminist organization that works for the rights of sexually marginalized women and trans men, recorded a similar trend. Early in the first wave, the organization realized that the existing helpline number was getting overwhelmed with distress calls. It added a second helpline number. The comparative figures indicate a 13-fold jump in numbers: from 290 calls in April 2019-March 20 to 3,940 calls in April 2020-May 2021.

"Most of the calls we have been getting from lesbians and trans men are urgent appeals to prevent forced marriages during lockdowns," said Shreosi, a Sappho member and peer support provider. "If they happen to resist, they are either evicted or forced to flee home. But where to house them? There aren't so many shelters, and ours is at full capacity."

Shreosi says that the nature of distress calls has also changed. "Earlier people would call in for long-term help, such as professional mental health support. But during the pandemic, it has changed to immediate requests to rescue from oppressive home situations. Often, they will speak in whispers so that the parents can't hear."

Lack of spaces

Like many of his fellow queer community members, life for Sumit P., a 30-year-old gay man from Mumbai, has taken a turn for the worse. The lockdown has led to the loss of safe spaces and prolonged residence at home.

"It has been a really difficult time since the beginning of the lockdown. I am suffering from a lot of mental stress since I cannot freely express myself at home. Even while making a call, I have to check my surroundings to see if anybody is there. If I try to go out, my family demands an explanation. I feel suffocated," he said.

The pandemic has forced some queer people to come out

Sumit is also dealing with a risk that has hit the community harder than others – unemployment and income shortage. He's opened a cafe with two other queer friends, which is now running into losses. For others, pandemic-induced job losses have forced queer persons from all over the country to return to their home states and move in with their families who've turned abusive during this long period of confinement.

Lockdowns force coming out

According to Kolkata-based physician, filmmaker and gay rights activist Tirthankar Guha Thakurata, the pandemic has forced some queer people to come out, succumbing to rising discomfort and pressure exerted by homophobic families.

"In most cases, family relations sour when a person reveals their identity. But many do not flee home. They find a breathing space or 'space out' in their workspaces. In the absence of these spaces, mental problems rose significantly," he said.

Not being able to express themselves freely in front of parents who are hostile, intolerant and often address transgender persons by their deadname or misgender them has created situations of severe distress, suicidal thoughts and self-harm.

Psychiatrist and queer feminist activist Ranjita Biswas (she/they) cites an incident. A gender-nonconforming person died under suspicious circumstances just days after leaving their peer group and going home to their birth parents. The final rites were performed with them dressed in bangles and a saree.

"When a member of our community asked their mother why she chose a saree for someone who had worn androgynous clothes all their life, she plainly said it was natural because after all, the deceased 'was her daughter,'" Biswas recalls.

The Indian queer mental health support infrastructure, already compromised with historical prejudice, is now struggling

David Talukdar/ZUMA

"Correctional" therapy

In India, queer people's access to professional mental healthcare has been "very limited," according to community members such as Ankan Biswas, India's first transgender lawyer who has been working with the Human Rights Law Network in West Bengal.

"A large majority of the psychiatrists still consider homosexuality as a disorder and practice 'correctional therapy'. It's only around the big cities that some queer-friendly psychiatrists can be found," Biswas said. "The pandemic has further widened the inequalities in access to mental health support for India's LGBTQ community."

Biswas is spending anxious days fielding an overwhelming amount of calls and rescue requests from queer members trapped in their homes, undergoing mental, verbal and even physical torture. "We don't have the space, I just tell them to wait and bear it a little longer," he said.

Medical care is dismal

Anuradha Krishnan's story, though not involving birth family, outlines how the lack of physical support spaces have affected India's queer population. Abandoned by her birth family when she came out to them as a trans woman in 2017, Anuradha Krishnan (she/they), founder of Queerythm in Kerala who is studying dentistry, had to move into an accommodation with four other persons.

Isolation triggered my depression

"I am used to talking and hanging around with friends. Isolation triggered my depression and I had to seek psychiatric help." Living in cramped quarters did not help with quarantine requirements and all of them tested positive during the first wave.

What is deeply worrying is that the Indian queer mental health support infrastructure, already compromised with historical prejudice, is now struggling, placing more and more pressure on queer collectives and peer support groups whose resources are wearing thin.

During the 10 months of the first wave of the pandemic in India in 2020, Y'all, a queer collective based in Manipur, received about 1,000 distress calls on their helpline number from LGBTQ+ individuals. In May 2021 alone, they received 450 such calls (including texts and WhatsApp messages) indicating a telling escalation in the number of queer people seeking help during the second wave.

As India's queer-friendly mental health support infrastructure continues to be tested, Y'all founder, Sadam Hanjabam, a gay man, says, "Honestly, we are struggling to handle such a large number of calls, it is so overwhelming. We are also dealing with our own anxieties. We are burning out."

Sreemanti Sengupta is a freelance writer, poet, and media studies lecturer based in Kolkata.

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