The Third Dose Debate


As of the beginning of September, 27% of the world was fully vaccinated against COVID-19, but the distribution of those vaccines has not been at all equal. Only 1.9% of the 5.76 billion doses that have been given out internationally were in low-income countries — Tanzania, Chad, and Haiti, for example, have vaccinated less than 1% of their populations, while richer nations like the U.S. have vaccinated at least half of theirs. In recent months, the concept of “booster” vaccines, a third dose to increase waning immunity administered about eight months after the second dose, has gained popularity in the U.S.  But considering the wildly uneven distribution of vaccinations across the globe, is it ethical for people in wealthy countries who are already enjoying the considerable protection of two vaccine doses to get a third before many people in other countries have a chance to get their first shot?

According to multiple leaders at the United Nations’ World Health Organization, it isn’t entirely ethical. The general-director of the organization, for example, has called for an international moratorium on COVID boosters until 10% of every country has been vaccinated, and the director of WHO’s Health Emergencies Programme compared booster vaccines to giving “extra life jackets to people who already have [multiple], while we’re leaving other people to drown without a single [one].”  This metaphor isn’t perfect, as Dr. Jodi Halpern, a professor of bioethics at UC Berkeley, points out: it neglects to consider the fact that we don’t know if those vaccine “life jackets” are “adequate to keep us afloat” in this particular situation. But the current consensus, at least in the U.S., seems to be that boosters aren’t really necessary for everyone.

Right now, the CDC has only granted booster vaccine eligibility to seniors, people with underlying medical conditions, or those that live or work in “high-risk settings, with the additional constraint of having gotten the Pfizer vaccine as their first and second doses. However, before the third dose was being offered to any group of Americans, an estimated 1 million people had already gotten it, some even lying that they hadn’t had their first dose yet in order to justify themselves to those administering the vaccine. This, at least, seems a clear violation of the principle of health equity: we should help the people who need it most first (in this case, those in low-income countries who still haven’t had the opportunity for even a first dose). Additionally, giving out vaccines as third doses instead of first or second doses can be said to violate the utilitarian principle of doing the greatest amount of good for the greatest number of people; while the combination of the first and second dose of the Pfizer and Moderna COVID vaccines offer at least 90% effectiveness, one early study has found that the booster only increases total efficacy by 10%. That would mean potential third doses could be used much more efficiently (and do the greatest amount of good) as first doses for people who have yet to receive the vaccine.

Proponents of COVID boosters have a different view of the situation, though. Some believe that every country’s primary duty is to protect its own people; specifically, they have floated the idea of an “influenza standard,” meaning that countries should prioritize the health of their own citizens at least until the risk and impact of COVID is no more than a normal flu season. And in the U.S., while our cases counts are no longer spiking the way they were a few weeks ago, we are well above “flu season” levels, and still make up a large fraction of the world’s cases (almost 20%, at latest count). In the mind of Matt Koci, a virologist at North Carolina State University, we have a responsibility to get our country’s part of the pandemic under control so we don’t end up being the ones responsible for more deadly variants. Ideally, we should vaccinate everyone, but since that doesn’t seem to be possible, he thinks booster vaccines could help limit breakthrough infections, at least.

However, it’s important to consider the larger picture: the longer the rest of the world, not just the United States, goes unvaccinated, the more chance of variants cropping up and spreading. As we are all now well aware, COVID doesn’t care about borders between nations, so it’s in every country’s best interest to help others vaccinate their citizens. The U.S. government seems aware of this, since so far it has donated 110 million vaccine doses to 60 other countries and promised to donate many hundreds of millions more. That is a massive amount, but worldwide demand is in the billions, and the sheer logistical nightmare of transporting the mRNA vaccines, which have to be kept at extremely cold temperatures and expire soon after being thawed, along with the complicated legal agreements between countries required for sharing vaccines makes the demand difficult to satisfy. Countries producing their own vaccines would eliminate those complications, but even if current intellectual property protections that prevent the broad manufacture of COVID vaccines were lifted, many countries (especially the aforementioned low-income ones that need vaccines the most) lack the infrastructure and expertise to make the vaccines themselves. Matt Koci argues that we need to help other countries produce their own vaccines “based on what works for them and their infrastructure — not what works best in the U.S.,” which would mean non-mRNA vaccines that are easier for countries with less specialized infrastructure to mass produce. This line of thought is somewhat reminiscent of the “each country for itself” mindset in the long run: if every nation can manufacture its own vaccines, then perhaps it should be able to use them to vaccinate its own people in whatever way it sees fit.

So, in essence, the booster vaccine debate is about the obligations countries have to their citizens versus to each other: is it ethically sound to prioritize the possibly less extreme needs of a country’s own population over the needs of those in other, less fortunate nations? Or, given the deeply international reality of the pandemic, should countries be willing to help each other at the potential cost of the health of their own citizens?