1. Introduction

This article takes as its basis for analysis the International Monetary Fund’s Plan for dealing with the SARS-CoV-2 pandemic. It sets out a global strategy with a twofold objective: on the one hand, to achieve vaccine equity and, on the other, to make progress in defeating the pandemic. This plan is aligned with the objectives of the World Health Organization and is presented in line with the COVID-19 Accelerator initiative (Accelerator act) and its global vaccine access program (COVAX), as well as with the work of, among others, the World Bank Group ⁽¹⁾. Against this background, this paper problematizes, from a global justice perspective, some aspects of this strategy related to vaccine distribution and prioritization.

There is abundant literature on the contemporary issues addressed in the global justice debate ⁽²⁾. In this debate, recurrent reference is made to the issue of poverty, human rights, or other alternative proposals linked to certain struggles championed by social movements on a global scale. From a theoretical point of view, these issues face the challenge of specifying, in Fraser’s words, the normative framework in which they must fight the battle for justice, in relation to the who and the how of global justice ⁽³⁾; and, on the other hand, to specify the articulation of the what of justice. Indeed, according to Palacio ⁽⁴⁾, the debate on global justice is fundamentally centered on two issues:

Based on these two axes, this article highlights some of Fraser’s key ideas ⁽⁵⁾ on the need for a global distributive justice that places the axis of analysis in the dynamics of exclusion that this structure reproduces under the dynamics of capital and the difficulties that this implies for the development of an idea of social justice in this global context ⁽⁶⁾. This problematization is intended to address the key question of our analysis: What does this global justice approach bring to the critical analysis of the distribution and prioritization criteria that are being taken into account for the COVID19 vaccination strategy at the global level?

This article proposes a development around this question from a critical questioning of the criteria of justice ⁽⁷⁾ of the COVID-19 global vaccination strategy. From the perspective of global justice, the problem of vaccine distribution has become a geopolitical problem with unprecedented global repercussions. One of the challenges it faces is to respond efficiently to a demand for universal vaccine coverage; something that requires, as is becoming apparent, difficult trade-offs between multilevel institutional governance and global markets. All agencies, at different scales, recognize that vaccines are and will continue to be available in different waves and in a changing scenario, governed, in any case, by market logic. All this is not only conditioning the vaccination schedule established in each country, but also, as de Bolle warns, access to the vaccine at a global level ⁽⁸⁾.

The vaccination strategy should not only focus on the distribution of consignments at the national level, but, within the framework of global justice, should also consider the mapping of distribution at the supranational level. The limited availability of vaccines in some contexts calls for specifying how to distribute vaccines equitably between countries and according to what criteria. Both questions are addressed in the first three sections of this paper. Finally, the article closes with a last section in which a brief approach to the scope of this strategy for women is discussed.

2. Nancy Fraser’s approach to global distributive justice

Nancy Fraser’s proposal is an indisputable reference in critical thinking and has contributed to generate one of the most controversial debates on justice in the framework of what she calls the «post-socialist era» ⁽⁵⁾. Its aim is to provide concrete solutions to solve the pressing problems of social justice of our time, but placing her reflections in a global framework. Her contributions on the dilemma that arises from the challenge of reconciling economic redistribution measures with the demands for recognition that are more persistently present in contemporary societies are well known. This is precisely the context of some of the debates she has held with thinkers such as Honnet or Butler, to mention at least the most cited, on issues such as redistribution and/or recognition ⁽⁶⁾ and which, in any case, are part of a broader framework of reflection on global justice in which, in addition to her own, the contributions of Pogge ⁽⁹⁾ and Young ⁽¹⁰⁾ stand out for the subject that concerns us. Fraser has highlighted the controversial paradox that arises when policies for the recognition of diversity come to occupy a preferential place in the framework of concerns for justice, to the detriment of redistribution policies, hence his interest in delving into the consequences that this has at the normative level.

Fraser’s defense of justice is based on the need for equal treatment of the different people who make up a society. It does not emphasize the defense of justice in a transformative framework. It mainly advocates clarifying how differences that produce negative discrimination need to be managed in order to alleviate their effects. It places more emphasis on the effectiveness of measures than on the transformative processes required to make decisions about them. In any case, and synthesizing his contributions, Fraser defends the idea that injustices in contemporary societies cannot be explained in a univocal way: either as inequalities that are solely the result of inadequate and unfair economic redistribution; or as the sole consequence of biases, stereotypes resulting from discriminatory cultural patterns that are detrimental to certain people ⁽⁶⁾. Both redistribution and recognition should be seen as two overlapping lenses that integrate both recognition and distribution demands. Both interact in the different axes of subordination and from this interaction they are able to account for the complexity of inequalities. Fraser insists on the need for a change of approach that can make this necessary interaction possible at all levels.

Specifically and synthetically, Fraser proposes the elaboration of a politics of framing that will make it possible to concretize the normative frameworks required, also at the transnational level, to integrate all the dimensions of justice (recognition, redistribution and representation), understanding them at the same time as autonomous, though interrelated categories ⁽⁶⁾.

Her proposal at the transnational level consists in adopting measures that will make it possible to know how to articulate «communities of affected people» to face their demands in the global order. Her analyses on food sovereignty or the agricultural question at the global level serve as a reference to make visible the functioning of this measure in transnational civil society. A measure that ultimately requires normative mechanisms that allow us to determine and evaluate the scope that the basic structure of society has on subjects and collectives. To see who deserves moral consideration -she writes- we must determine who is jointly subject to a set⁽⁶⁾. The framework that, according to her, allows us to define the way in which injustices are generated and reproduced lies in the social structure.

I share with Palacio ⁽⁴⁾ her analysis of the importance of linking the demands of justice with the idea of the structure of justice and the need to analyze this interaction between the different dimensions of justice in the way in which they affect the conditions of a dignified life for the subjects of justice and societies in any part of the world. In this sense, it would be necessary to analyze the way in which the dynamism of capital itself affects as a mechanism for the reproduction of structural injustices. This element constitutes, in the words of Palacio, a suitable approach to thematize the degrees of interweaving of different dimensions of justice, as well as in different scales of interaction in order to be able to define the degrees and types of responsibility that can be demanded and assumed by virtue of the social position we occupy in these structures⁽⁴⁾. Not only that, this approach also makes it possible to situate the debate on social justice beyond the merely economic. Indeed, it is not just a question of inequality, unemployment or poor distribution (however serious these realities may be). Beyond focusing this debate on the question of how wealth is distributed, the problem lies in how this wealth is understood and how it is produced. This is what is required to speak of justice in the context of globalized capitalism.

From these reflections, some of the data provided by the evolution of the COVID-19 vaccination strategy at the global level, where the global scope of the community of affected people mentioned by Fraser has become evident, take on special significance. How to articulate this strategy for a community whose scale is planetary, and affects us all equally, based on criteria subject to the struggle for the monopoly of patents of the large pharmaceutical companies?

A first consequence of the limitations of the development of this strategy within the framework of the rules of globalized capitalism has not been long in coming. On the one hand, it has been possible to launch the largest vaccination campaign in the history of mankind. The challenge of distributing billions of vaccines to stop the spread of COVID-19 is progressing at a pace that seemed technically and logistically unaffordable a few months ago. However, from the standpoint of justice, the strategy offers a mapping whose results were very predictable. By June 2021, according to data collected by Bloomberg ⁽¹¹⁾, more than 2.42 billion doses have been administered in 180 countries, at a rate of approximately 35.1 million doses per day ⁽¹¹⁾. By June 2021, doses have been administered to vaccinate 15.8% of the world’s population. However, the distribution has been very uneven among countries. In fact, countries and regions with higher incomes are being vaccinated more than 30 times faster than those with lower incomes ⁽¹¹⁾.

Since the start of the global vaccination campaign, countries have experienced unequal access to vaccines and varying degrees of effectiveness in vaccine delivery and access. By March 2021, few African countries had received a single shipment of vaccine, whereas in the United States, 93.9 doses per 100 people had been administered by then. Moreover, as de Bolle ⁽⁸⁾ points out, although much has been said about the lack of vaccines in many African countries, these countries are not currently experiencing the extremely aggressive outbreaks seen in India, Nepal, Brazil and many other Latin American countries, which requires analyzing the features of these different levels and scales of inequality from other prisms.

3. Vaccine distribution from the perspective of global justice

Considered a global public good, an equitable distribution criterion should allow all countries to have equal access to the vaccine, regardless of their participation in its scientific development or financing, and even beyond the economic resources of each of them. The entire world population, regardless of the country in which it resides, should have equal access to the vaccine. Its distribution cannot be conditioned by the dynamics of a global market or by social, economic or political circumstances derived from the situation of the country of residence.

There are precedents that suggest that it will be difficult to apply these principles of global justice. The global management of the 2009 influenza A epidemic left the precedent of the purchase by high-income countries of the doses needed to meet the mass vaccination forecast in the event of contagion of the population. The sharing with other countries was only carried out once the necessary national stocks of influenza A-H1N1 vaccines had been covered in each country. The most impoverished countries were not reached until well after the end of the crisis. The forecasts that the same will happen with the COVID-19 vaccines seem to point to the same scenario of inequality. In fact, based on the first vaccine distribution data ⁽¹¹⁾, similar limitations are confirmed in the COVID19 pandemic scenario.

To address them, the who has launched the covax platform ⁽¹²⁾, which aims to achieve equitable distribution of vaccines, especially in low-income countries. After several proposals to articulate criteria for fair distribution (e.g., based on the proportional distribution of the population of each country, which has been the option of the European Union, or an allocation of vaccines according to the needs of each country), a model called by Ezekiel et al. «fair priority» of vaccine distribution between countries ⁽¹³⁾, which aims to reconcile the interests of vaccine manufacturers, supranational institutions and national governments on the basis of a series of ethical criteria, including the principles of effectiveness and rationalization required for the distribution of scarce goods.

This proposal argues that fair criteria for the distribution of vaccines among countries should be considered as those aimed at: i) benefiting people and limiting harm to them; ii) giving priority to those who are in the worst conditions to cope with the situation, and iii) avoiding discrimination based on ethically irrelevant differences ⁽¹³⁾. Furthermore, the Ezekiel et al. model rightly advocates differentiating different dimensions of the harm suffered by the pandemic, distinguishing between different types of harm:

This proposal has gained some notoriety in the debate on criteria for distribution and prioritization of the vaccine among the 172 countries that support the initiative promoted by the covax platform ⁽¹²⁾. There has also been no shortage of critical voices warning of the limitations of this «fair priority» model ⁽¹³⁾. Most notably, those who insist that the model would unfairly disadvantage countries that have managed to significantly reduce community transmission without vaccines, and reward those that have responded ineffectively ⁽⁸⁾. The issue is undoubtedly complex.

However, reality prevails. In the first weeks of distribution, alarms have already been raised due to the monopolization of doses by high-income countries. The distribution companies, moreover, seem to be giving priority to bilateral agreements with these countries, which is not only producing inequalities in distribution, but is also causing vaccine prices to fluctuate upwards, with the astronomical profits that all this brings with it ⁽¹⁴⁾.

Another criterion that is being claimed with a certain degree of argumentative solvency from the health sector is the one that calls for prioritizing the distribution of the vaccine among the countries in such a way that in all of them the transmission rate can be kept at least below one. In this case also, the scenario of benefiting in the distribution to those who need it most because they have been (or could have been) less effective in controlling the spread of the pandemic in their territory is reproduced. It eliminates the criterion, proposed by the European Union, of establishing a criterion based on a percentage of distribution according to the population of each country. This criterion grants the same recognition to the right of access to the vaccine to all persons, but leaves aside the particularities and different needs that each country may have or the differences in the health benefits that exist between them. In fact, as de Bolle concludes, the shortcomings of the distribution of vaccines based on a population-based criterion do not allow for capturing the seriousness of the underlying public health problems faced by different countries ⁽⁸⁾.

In addition to outlining very briefly some of the challenges posed in terms of global justice by vaccine distribution, another axis of analysis also opens a heated debate on the criteria that, at both supranational and national levels, should be established to establish an order of prioritization in the process of vaccinating the population.

4. Vaccine prioritization: who counts first?

The issue of vaccine prioritization also has a global impact in terms of justice, in this case from the perspective of who counts first, on the basis of what criteria, and how and by whom the order of priority is decided. Following WHO guidelines, countries have established a specific order of prioritization for vaccinating the resident population in each country. However, taking into account that, at this time, the entire world population is in need of the vaccine, it is especially relevant to consider the way in which a specific order is established for access to the vaccine.

The criterion of prioritizing the most vulnerable has been applied individually, identifying high-risk population groups in each country. A global criterion on this issue has been to try to maintain similar criteria among countries to determine priority population groups for vaccination. However, it has not been possible to prioritize, following the «higher risk» criterion, access to the vaccine for these same groups, health personnel and the elderly, in low-income countries. Or even to prioritize within these groups those who are at a higher risk of infection.

In any case, this individual criterion has not taken into account the different particularities that may occur in each of the prioritized groups: Who do we prioritize? All healthcare personnel or those most exposed to infection? In high-income countries, for example, health services have greater resources for individual protection in the health professional field, resources that are not available or are scarcer in lower-income countries. However, in these countries, healthcare workers are proportionally much younger than those in higher income countries and, therefore, according to statistics, they belong to a group that, because of their age, is at lower risk. What should be prioritized: age or weak healthcare systems?

Is it possible to establish universally applicable criteria without taking into account the characteristics of their application? A similar reading, for example, can be made of the criteria for prioritization among the elderly: Who to prioritize? Those living in nursing homes or those in a more vulnerable socioeconomic situation? From what age onwards?

The need for prioritization highlights the interrelationship between the different spheres of interaction, both at the supranational and national levels, and the consequences and difficulties involved in managing them at both levels.

The global perspective shows that distribution is hardly possible based on criteria of equity, taking into account the tensions faced by the actors involved. It tends, for the most part, to be detrimental to the most impoverished countries or those with lower incomes or lower capacities for scientific or technological innovation. The rhetoric calling for the establishment of criteria based on the principles of solidarity or reciprocity is common in institutional declarations but very ineffective in practice. At the end of January 2021, coinciding with the start of the global vaccination campaign, of the 39 million doses that had been administered by that time globally, less than 1% had been applied to patients in poor countries, data that contrast with the vaccination numbers at the same date in the United States (12 million); China (10 million); the United Kingdom (4.3 million); and Israel (2.4 million: a quarter of its total population) ⁽¹¹⁾. In the light of the data, it can be affirmed that the altruism criterion for global distribution claimed by Van Parijs ⁽¹⁵⁾ has clearly been called into question. In June 2021, this unequal trend not only continues, but has become even more pronounced ⁽¹¹⁾.

In general, the criterion of vulnerability and debt to the elderly has prevailed. At least, this has been the case in the countries of the European Union and those that are in the same orbit of prioritization. This criterion, based on a logic of accountability towards the most vulnerable in the context of the COVID-19 pandemic, seeks to reconcile equal treatment of the most disadvantaged groups without having to give up maximizing results. It therefore combines utilitarian criteria with others closer to social justice. However, even so, and without being able to enter into a more exhaustive assessment of what this entails, it must be recognized that in any case the protection of the individual good of the vaccine is being prioritized over its potential to benefit the population as a whole.

5. Criteria for the prioritization of groups in the vaccination strategy: which ones and why?

The pressure on health services, including, in this case, those related to the need for vaccination of the population as a whole, necessarily requires prioritization: That is, choosing which individuals will benefit from certain scarce resources before others. This implies that a scarce resource (vaccine) must be distributed. The criterion consists of determining which and why certain groups of the population benefit from it before other groups. From the utilitarian criterion, for example, priority should be given to those who maximize the net benefit of society. Rawls, on the other hand, considers that the important thing is to consider the position of those who are worse off ⁽¹⁶⁾. This is precisely what is recognized in the principle of difference that he introduces in his theory of justice. Under this principle, people who are in a more vulnerable socioeconomic situation should have priority when it comes to receiving social and health care. But do they only need one vaccine in the current context?

Amartya Sen’s capabilities theory also considers precarious socio-labor conditions as a prioritization criterion ⁽¹⁷⁾. This theory, moreover, does not fetishize low income or resources as the only information to be taken into account to establish prioritization criteria. The capabilities theory argues that what justice should seek is to equalize the capabilities we need to achieve our possibilities of development. This perspective presents as a factor of enormous value the possibility of decentralizing the strategy against COVID19 beyond the vaccination process, and moving towards a social protection system that generates capacities and care networks also necessary to face the consequences of the pandemic, beyond, without excluding, the resource that is the vaccine itself.

In any case, the priority established in the COVID-19 vaccination strategy establishes a priority that has as an immediate consequence unequal access to scarce resources. When and why is this differentiation in the equal treatment of people legitimate? As is well known, ideally, access to the vaccine should be equal; that is, everyone should have access to it. The problem is precisely that this is not possible. The question, therefore, is to clarify what type of inequality best respects the principle of equality between people. What inequality is legitimate for access to a resource such as the vaccine which, at the moment, is scarce? Who are the unequal ones in the vaccination strategy and why are they legitimately so?

In Spain, for example, the vaccination strategy has distributed the whole population into 15 groups according to a combination of different criteria: equal need, equity, protection of the disabled and minors, social benefit, reciprocity and solidarity. Seen from a general perspective, these groups respond to differences in age, chronic illness, disability, professional performance (prioritizing the provision of some essential goods, mainly in the health and social-health fields, in their early stages) and certain situations of vulnerability to the pandemic.

The prioritization of healthcare personnel seems more than justified from the point of view of justice: not only is the instrumental value of the essential service they provide to society in a pandemic context recognized, but it is also necessary that this group, in the front line of healthcare, be immunized so that they themselves do not become a focus in the chain of contagion. Social recognition of their work and the need to protect the social good they provide to society as a whole have also been taken into account. Beyond this, and the moral debt to the elderly that has been taken into account to protect this group in the first instance, the rest of the criteria are ambiguous and unclear. As we will try to show in the following section, this is especially significant in the treatment of gender issues in this strategy.

6. Incidence of the COVID-19 vaccination strategy in females

Indeed, one of the most striking issues about the COVID-19 vaccination strategy is the absence of a reading of its possible unequal scope for men and women. In fact, the entire argumentation on the prioritization criteria incorporated to justify the strategy opts for gender neutrality in the groups prioritized at each stage without taking into account the different impact it may have on men and women. The ethical framework established in this strategy takes into account the principle of equal respect, with the aim of ensuring that health service delivery systems give equal consideration to men and women in each of the priority groups. The group is prioritized, but no distinction is made within the group on the basis of gender.

However, the COVID-19 pandemic has refocused attention on many health inequalities, including those related to gender. Worldwide, men and women are believed to be infected with COVID-19 in roughly equal numbers. The data, however, do not support the extent of this principle when they explain (they have remarked since the beginning of the crisis) that the risk of developing more severe medical conditions and deaths from COVID-19 is higher in men than in women, very significantly also in older population groups. Overall, men are 40% more likely than women to die from COVID-19 and almost three times more likely to require admission to an intensive care unit ⁽¹⁸⁾. Women are therefore considered to be part of a group at lower risk of infection. The data also do not take into account, for example, the feminization of many of the high-risk care jobs in the health, social-health and domestic spheres. This bias recognizes the lower incidence of the virus in women, without taking into account that it is mostly women who assume, from a professional and/or occupational point of view, the responsibility of caring for a highly vulnerable population, and who are therefore more exposed and at higher risk ⁽¹⁹⁾.

Nor does it take into account the disadvantage and inequalities in access to health benefits that women have in some contexts, this being a priority concern of the World Health Organization that has been diluted in the implementation of the COVID-19 Vaccination Strategy in different countries. In general, there is no specific reference to this issue, nor does it take into account gender as a criterion to identify the need to prioritize women in some groups to access the vaccine ⁽¹⁹⁾.

Nor does it consider the disadvantage or inequality of women in the socioeconomic and cultural spheres, which prevents an assessment of their subordinate status in some contexts ⁽²⁰⁾. The structural resistance that exists or may exist in their own communities is ignored. All this reduces their personal autonomy in the area of decisions related to the management of their own health. Giving priority to men over women in a vaccination strategy could have a negative impact on the chronification of these structural inequalities. Or even be a consequence of them.

Pregnant women are a group that has been systematically disadvantaged in vaccination strategies in previous pandemics. This is still the case with COVID-19 vaccine despite studies showing that pregnant women are at increased risk of adverse complications during pregnancy and childbirth. It is argued that there is still little data on the risks posed by COVID-19 to pregnant women and their children ⁽²¹⁾.

Currently, in the prioritization strategy, pregnant women are incorporated as a prioritized group in the intermediate phases of vaccination, not in the priority phases. The criterion has been, therefore, to wait for more evidence on the risks for pregnant women to justify their vaccination within the priority groups. However, it is expected that there will be little data on the safety and efficacy of COVID-19 vaccines in the group of pregnant women, which makes it difficult to effectively prioritize them as such in the early stages of vaccination.

It seems necessary to insist on the need to generate pregnancy specific data to assess the safety and immunogenicity of vaccines among pregnant women.

This circumstance is similar to that of lactating women. They have also not been considered as a priority group in vaccine development and response in pandemics prior to COVID-19. Nor has there been accumulating evidence to conclude that lactating women and their infants are at such risk that they need to be prioritized for COVID-19 vaccination. There are also no data on possible infectious risks for infants ⁽²²⁾. So far, vaccine manufacturers are not considering this as a risk factor.

7. Conclusions

This article has drawn attention to the limitations of the COVID-19 global vaccination strategy. The restriction of its criteria, with respect to distribution and prioritization, has highlighted the difficulties for its access at a global level. It is a strategy that is mainly based on the covax initiative. Without detracting from its value, it should be noted that the impetus given to vaccine production on a global scale has not had an equitable or effective correlate in terms of distribution and availability. The COVID-19 vaccination strategy is also failing to address one of the consequences that has become visible after its implementation and which highlights the serious shortcomings and, at the same time, urgent public health emergencies in the world to cope with a mass vaccination campaign for the entire population. The strategy requires clearly defining strategies of cooperation and global justice that will allow the distribution and accessibility of the vaccine to become not only effective but also truly equitable.