In public health policy, every choice matters. This principle is especially pertinent when individual and policy choices can determine the course of a pandemic. Currently, less than 1.5 percent of people in low-income countries have received at least one dose of the COVID-19 vaccine. This is why Wednesday’s announcement by U.S. public health officials to authorize the COVID-19 booster doses (Moderna and Pfizer) for all adults starting next month is bewildering.
While booster doses could benefit vulnerable populations — including people of advanced age, those with underlying medical conditions, or those with a compromised immune system (such as organ transplant recipients) — a broad recommendation advising this dose at this point is a reactive policy decision that doesn’t seem to be driven by available data.
The scientific evidence of a concrete benefit for such a policy is currently limited. Available COVID-19 vaccines continue to be highly protective, especially against the development of severe disease, hospitalizations and death. While emerging data suggest that antibody levels decline over time after vaccinations, that cannot definitely be construed as declining protection against the coronavirus. And if the spread of the delta variant is a concern, policymakers should note that current epidemiological modeling demonstrates that getting more people vaccinated could be a better option than adding a booster dose.
This decision to administer a booster dose should also be examined within the context of global sociopolitical dynamics since these forces are driving the pandemic. So far, less than 0.5 percent of vaccine doses have been dispensed in poor countries, creating an unimaginable deprivation of a life-saving intervention. This is also why the World Health Organization (WHO) has called for a deferral on the COVID-19 booster doses. The international public health community is struggling to understand the moral reasoning behind this policy announcement. Dr. Michael Ryan, WHO’s executive director of Health Emergencies, recently pointed out, "We're planning to hand out extra life jackets to people who already have life jackets, while we're leaving other people to drown without a single life jacket.”
Instead of booster doses, policymakers should focus on advancing global vaccine equity, so that every person has a fair chance of receiving a vaccination. This requires ramping up the production of COVID-19 vaccines, which will require enhancing the local manufacturing capabilities. This is also why “donating” vaccines, an approach pursued by rich countries is not a sustainable solution.
Unfortunately, countries with high vaccine manufacturing capabilities have engaged in “vaccine nationalism” and demonstrated hesitancy in distributing vaccines quickly or sharing manufacturing capacity with other countries. This was illustrated recently when India was undergoing an unprecedented surge in infections. Unconstrained spread of the coronavirus is one of the major reasons for the development of dangerous variants — a scenario that could have been controlled by enabling global vaccine equity.
Additionally, there is an economic argument for global vaccine equity. Recent research from the National Bureau of Economic Research (NBER) highlighted that vaccinating low- and middle-income countries will be necessary to prevent a catastrophic hit to the global economy, with losses estimated to be up to $4 trillion. The analysis underscored that the burden of these economic losses will fall disproportionately on developed nations, including the U.S.
The implementation of booster doses may be inevitable; however, it should be driven by evidence, not panic. At the time of writing this article, the Centers for Disease Control and Prevention (CDC) reports that only 51 percent of the U.S. population is fully vaccinated, which is leading to the continued spread of the dangerous delta variant. As next steps, the government should invest in designing programs to improve vaccine uptake and adoption, work with experts at the Food and Drug Administration (FDA) to examine the emerging data and promote research studies that can compare the benefits between two-dose and three-dose regimens.
Like early last year, policymakers today are confronted with an ethical predicament where they need to make consequential decisions with limited information. With mounting evidence that global vaccine equity can enable a path to normalcy, a hasty policy on booster dose without a clear prioritization of global vaccine distribution cannot be the solution. The right strategy for the ongoing pandemic is — as for many other realities in global health — international solidarity and recognition that we cannot be safe until all of us are safe.
Junaid Nabi, MD, MPH, is a health care researcher working at the intersection of health care reform and innovation. He is a senior fellow at the Aspen Institute. Twitter: @JunaidNabiMD.