Science and Need—Not Wealth or Nationality—Should Guide Vaccine Allocation and Prioritization

Ensuring COVID-19 vaccine access for refugee and displaced populations, and addressing health inequities, is vital for an effective pandemic response. Yet, vaccine allocation and distribution has been neither equitable nor inclusive, despite that global leaders have stressed this as a critical aspect to globally overcoming the pandemic, according to a paper by Columbia University Mailman School of Public Health researchers. The article is published in the journal Nature Medicine. 

As of April 1, high and upper-middle-income countries received 86 percent of the vaccine doses delivered worldwide, while only 0.1 percent of doses have been delivered in low-income countries. Worldwide, over 80 percent of refugees and nearly all internally displaced persons are hosted by low and middle-income countries—nations at the end of the line for COVID-19 vaccine doses.

“As the world grapples with supply challenges and inequitable vaccine access on local and global scales, marginalized groups, particularly refugees, internally displaced persons and stateless persons, face a double burden of access, even within countries that are themselves marginalized on the global stage,” said Monette Zard, Allan Rosenfield Associate Professor of Forced Migration and Health and director of the Program on Forced Migration and Health. “Legal status should have no place in decisions about vaccine access, and relying on regularization as a route to vaccination will unacceptably delay the protective effects for migrants and refugees, particularly in higher-risk groups.”

In fragile settings with weak governance, competition for scarce COVID-19 vaccines may heighten tensions and exacerbate conflict, while unequal access raises the prospect of populations moving in an effort to access vaccines that are not available in their country or region, according to the authors.

The COVAX facility allocates around 5 percent of total available vaccine doses for humanitarian use, including vaccinating refugees, yet the total 2 billion vaccine doses targeted by the end of 2021 will only cover 20 percent of participating countries’ populations, at most. Poorer countries may not be able to widely vaccinate their populations until 2023

To create an equitable and inclusive COVID-19 vaccination strategy, Zard and co-authors believe lessons can also be drawn from experience managing conditions such as HIV and TB among mobile populations, as well as previous large-scale vaccination campaigns in humanitarian settings. They point out how the global community approaches COVID-19 vaccinations may further entrench the inequities and distrust experienced by refugees and displaced populations around the world or is a chance to build stronger, fairer health systems that are better prepared to respond to COVID-19 and future health emergencies. “Engage, listen, and mobilize trusted community and religious leaders—involving the community, including displaced populations, in vaccine activities is vital,” noted Zard.

“Policymakers need to seize the opportunity of the pandemic to strengthen health systems more broadly and sustainably, to better respond to the challenges of COVID-19, while addressing the comprehensive health needs of refugees and host populations,” observes S. Patrick Kachur, MD, co-author and professor of Population and Family Health at Columbia Mailman School. “As the world confronts one of the most formidable public health challenges in recent history, how we respond today will not only determine the course of this pandemic, but also who benefits from public health advances for years to come.”

Co-authors include Ling San Lau, Goleen Samari, Rachel Moresky, Mhd Nour Audi, and Claire Greene, Program on Forced and Migration and Health, Columbia Mailman School; Diana M. Bowser and Donald Shepard, Brandeis University; Fouad M. Fouad, American University of Beirut; Diego Lucumí and Arturo Harker, Universidad de los Andes; and Wu Zeng, Georgetown University.