Written by Lisa Forsberg, Anthony Skelton, Isra Black
In Sweden, children returned to school in the middle of August. As in the UK, children under 16 will be unvaccinated, and there will be few or no protective measures, such as improved ventilation, systematic testing, isolation of confirmed cases, and masking. Like the JCVI in the UK, Sweden’s Folkhälsomyndigheten opposes vaccination against COVID-19 for the under-16s, despite Sweden’s medical regulatory authority, Läkemedelsverket, having approved the Pfizer and Moderna vaccines for children from the age of 12. The European Medicines Agency approved Pfizer and Moderna in May and July respectively, declaring that any risks of vaccine side-effects are outweighed by the benefits for this age group.
People in poorer countries deserve access to vaccines now; they should not be forced to wait until rich countries decide whether to donate a small number of doses they would otherwise have used to vaccinate children. The most efficient way of securing access would be to temporarily waive intellectual property (IP) protections for coronavirus vaccines to allow the scaling up of vaccine production. As a recent Nature editorial notes: ‘Every country should have the right to make its own vaccines during a pandemic’. The campaign for temporary waivers initiated by India and South Africa has been backed by more than 100 countries, and international organisations such as the World Health Organization and UNAIDS. The UK and Sweden are among the countries blocking the initiative. Countries like India have excellent facilities for manufacturing pharmaceutical supplies. Low- and middle-income countries are not unable to produce vaccines; rather, they are denied the opportunity to do so by rich countries (see also here). Moreover, the risks of COVID-19 infection have increased with the Delta variant, which is more transmissible, including among children (see here, here, here, here, and here). Even if only a small proportion of young people get seriously ill or die in the acute phase of the infection, high numbers of infected individuals will mean that a sizeable number of children will get seriously ill. A small proportion of a high number is a large number.
In reply to the now considerable data regarding vaccine safety and the negative effects of COVID-19 infection, opponents of vaccination have sometimes recast the insufficient evidence argument to focus on the long term. They may accept that we have sufficient data to conclude that the vaccine is safe and effective in the short term. But, they may insist, uncertainties persist about its long term effects. This argument might buttress the conclusion of this argument if the alternative to vaccination was risk free. But the alternative to vaccination against COVID-19 is not risk free – on the contrary. It involves significant risk of covid infection. We have at present no reason to believe vaccination will have long-term negative effects, while we do have good reason to believe that covid infection will carry long-term negative effects. Given what we know about COVID-19 at this point, then, the insufficient evidence argument against children’s vaccination looks increasingly disingenuous.
Proponents of the insufficient evidence argument hold that COVID-19 vaccination may not offer a favourable cost benefit ratio to children. The benefits of vaccination for COVID-19 may not outweigh the risks, because a smaller proportion of children get seriously ill or die in the acute phase of COVID-19 infection compared to adults, and vaccination can carry risks of which we know too little.
This line of argument presupposes that we have to choose between vaccinating children in high-income countries and the more vulnerable in low- and middle-income countries But it is false that we have to choose whom to vaccinate in this case. And this is our third point. We ought not accept the austerity narrative upon which the argument from global equity is based: the false claim that vaccine scarcity means choosing between vaccinating children in high income countries and vulnerable individuals in low- and middle-income countries. Vaccine scarcity is not a result of a forces outside our control; it is the result of political and policy choices made by rich countries.
The argument from global equity
One might wonder what level of uncertainty about risk would satisfy proponents of the argument from insufficient evidence. What kind of evidence would proponents of the wait and see approach like to see, before they conclude that vaccinating children is ethically defensible, or obligatory? And how many young people dead or injured from COVID-19 infection are they willing to tolerate, before they conclude that vaccination is ethically defensible, or obligatory? It would be interesting to see a risk-benefit analysis by proponents in which these questions were addressed. Neither UK’s JCVI nor Sweden’s FHM has so far produced a risk-benefit analysis supporting their decision not to recommend that adolescents get vaccinated. Other public health experts have produced such risk-benefit analyses showing the benefits of vaccines far outweigh any risks.
A core feature of our common-sense moral thinking is that we are permitted to give more weight to the interests and needs of those with whom we have close social relations and bonds (e.g., co-nationals) over those living in other (even developing) nations. It is possible that behind the decision to give priority to adults in high-income countries is commitment to this permission of partiality. This permission might justify giving vaccines to adults in the high-income countries over those in low- and middle-income countries. An appeal to this aspect of common-sense morality will not, however, help defend the claim that we ought to delay providing vaccines to eligible children. After all, the permission to give priority to adult co-nationals would also, it seems, justify giving vaccines to children co-nationals in high-income countries over more vulnerable individuals in low- and middle-income countries. We might be permitted to give priority to our children even in the case where the threat to them of COVID-19 infection is less severe than it is to adults.
As we noted previously, parents and states have obligations to protect children from various risks of death and injury, and we adopt many other measures to avoid preventable paediatric deaths. Notably, we normally do a lot to prevent paediatric deaths also from causes affecting only a small proportion of children (e.g., chicken pox). Failing to protect children from being exposed to COVID-19 with the knowledge of the risks infection carries seems to represent a serious moral failing on the part of states, societies, and individuals who let it happen, or who defend approaches allowing it.
In addition, while opponents of vaccination tend to focus on risks of serious illness or—especially—death in the acute phase only, it is now very well established that children and young adults are at risk of other adverse outcomes when they get infected with Covid. These outcomes—which are a lot more common than death and hospitalisation in the acute phase—include long covid, MIS-C, various kinds of organ damage, and—particularly worrying—cognitive and neurological problems (see also here and here).
But not only are the UK and Sweden opposing IP waivers that would allow middle- and low-income countries to manufacture vaccines to protect their populations. They are also not donating vaccines to any meaningful extent. The UK diverted 10 million doses from India at the height of their Delta variant crisis. They have been cutting foreign aid; they are donating almost nothing to the COVAX vaccine access initiative, or by other mechanisms. Sweden has so far donated small amounts.
The UK’s and Sweden’s decision conflicts with the approach taken in most other countries where vaccine supply is good. Their respective reasons for their recommendations not to vaccinate children under 16 have not been publicly articulated—Sweden’s FHM has in particular been notoriously non-transparent and unwilling to share any grounds on which they have made decisions during the pandemic, and JCVI have so far not shared the basis for their decision.
Recently, we have seen Pfizer and Moderna price gouge their covid-19 vaccines. This gouging is occurring in the middle of a pandemic which has killed many millions of people, and which kills and injures more people each day it is permitted to continue. Leaders in rich countries let them do so.
(An aside. It is important to emphasise the benefits of COVID-19 vaccination for children, as some have argued that uncertainties about its safety and efficacy undermine vaccine mandates for COVID-19. If public health experts are correct in this risk-benefit analysis, mandates are not undermined for this reason (and, in any case, uncertainty about vaccine safety and efficacy cannot undermine an in-principal argument for mandating vaccination).)
Those offering the argument from insufficient evidence often fail to compare risk profile of vaccines to the risk profile of largely uncontrolled COVID-19 infection spread. We know that vaccination offers protection against severe illness and death. We know less about whether it offers protection against long-term health effects, such as long covid. But vaccinating children means fewer infections, and therefore fewer individuals affected by long-term health complications. Conversely, not vaccinating and letting infection spread means a larger number of individuals infected, and a larger number of them developing long-term health complications. Again, a small proportion of a very large number will be a large number. So the idea that ‘only a small proportion’ get severely affected is a lot less compelling when children are infected at a large scale.
In this blog post, we examine two arguments commonly provided for the position that we ought not at present to provide vaccinations to children.
Now, of course, it is possible defenders of the claim that we ought to delay vaccinating children think we got it wrong when we gave priority to adults in high-income countries. We ought to have been more impartial in how we distributed vaccines. We should not continue to do what is wrong, the argument might continue, by giving priority to eligible children in high-income countries; instead, we should make them wait until (a sufficient number) of the more vulnerable in low- and middle-income countries are vaccinated.
In both countries, the refusal to recommend vaccination for eligible children has attracted criticism. Teacher unions have emphasised that it is not possible to ‘keep distance’ in school environments and that disease outbreaks will severely interfere with children’s education. Independent public health experts point out that we now have considerable evidence regarding the vaccines’ safety in children, and others have warned of the costs associated with adopting an approach that seems to make it overwhelmingly likely that many, or most, children will be infected with COVID-19.
In early September, children in England, Wales and Northern Ireland are set to return to school. (Scottish schoolchildren have already returned.) Most will not be vaccinated, and there will be few, if any, measures in place protecting them from COVID-19 infection. The Joint Committee on Vaccination and Immunisation (JCVI) have belatedly changed their minds about vaccinating 16- and 17-year olds against COVID-19, but they still oppose recommending vaccination for 12-15 year olds. This is despite considerable criticism from public health experts (here, here, and here), and despite the UK’s Medicines and Healthcare products Regulatory Agency (MHRA) declaring COVID-19 vaccines safe and effective for children aged 12 and up—Pfizer/BioNTech in the beginning of June, and Moderna the other week.
Second, it seems somewhat unfair to impose the burden of the demands of global equity on children, who have already shouldered great burdens for the purposes of controlling infection spread, including lost educational and social goods, many of which such goods may not easily be replaceable by other, future goods. Of course, one reason it might not be unfair to impose the burden of the demands of equity on children is that children are at much less risk from COVID-19 infection than adults. But, as we have argued above, it does not seem obvious that children are at much less risk from COVID-19 infection overall. We cannot, in any case, be certain this is the case given the potential long-term health consequences of infection from COVID-19.
Proponents of the argument from global equity argue that it is inequitable to provide vaccines to children in high-income countries over more vulnerable individuals living in low- and middle-income countries. It is unfair to provide vaccines to individuals at low risk of severe illness over those at much higher risk of severe illness who lack access to vaccines through no fault of their own (including older individuals and health care workers living in countries with low vaccination rates due to vaccine scarcity).
None of us will be truly safe until the pandemic ends. Ensuring that the world is vaccinated is both an imperative of fairness and in each of our self-interest. We should be calling for effective measures, including IP waivers, to make this happen. We should not support narratives that let leaders in rich countries pretend that their refusal to vaccinate children is motivated by concern for the wellbeing or fair treatment of people in countries they are actively denying access to vaccines.
This argument was originally premised on the number of individuals who had been enrolled in the clinical studies on COVID-19 vaccination in children. With only this evidence, the argument perhaps had some plausibility. Now, however, we need no longer need rely on these studies for evidence. Many countries have been vaccinating children for months. Millions of children have been vaccinated. Serious side-effects discovered in large-scale vaccination programmes have been extremely rare.
There are three main problems with the argument from global equity against vaccinating children against COVID-19.
First, the argument from global equity could easily have been but was not appealed to earlier in the vaccine rollout process. Many healthy adults living in wealthy countries like the UK and Sweden have been vaccinated for months. But most healthy adults in wealthy countries were much less vulnerable than many individuals living in low- and middle-income countries. So by the argument from global equity, healthy adults should not have been given priority for vaccination over the (often much) more vulnerable. The former could much more easily shield and wait for vaccines which would have produced greater benefit had they been given to the latter, vulnerable populations in low- and middle-income countries. It is therefore curious to raise claims of global equity only when considering whether to vaccinate children. Indeed, appeal to the argument only at this juncture looks rather disingenuous.
The argument from insufficient evidence
The vaccination of children in the UK and Sweden has been delayed, but there is nothing to suggest that it is being done as a necessary condition of discharging their obligation (of fairness) to provide vaccines to those living in low- and middle-income countries. Instead, rich countries are wasting excess supply, hoarding it to potentially use as booster doses for their own population in the future, or saving on buying in the first place (aiming for ‘hybrid immunity’). Children in rich countries are not being asked to wait, or being sacrificed, for some noble cause, that is, to benefit people in poorer countries.
Written by Lisa Forsberg, Anthony Skelton, Isra Black