Since SARS-COV-2, the causative agent of Coronavirus Disease 2019 (COVID-19), was first identified, reported global infections have well surpassed over one hundred and fifty million people, and millions of individuals have succumbed to the disease. To date, several COVID-19 candidate vaccines have been granted emergency use designation by multiple drug regulatory agencies and are being deployed, globally. To ensure that everyone enjoys of the highest attainable standard of health and achieves the full realization of their right to health, states are obliged to prevent and control epidemics. Mass immunization – characterized as delivering immunizations to a large number of people at one or more locations in a short interval of time – has proven to be a successful strategy for preventing the spread of many infectious diseases. Besides providing protection at the individual level, mass immunization programs also aim for vaccine-induced herd or population immunity – that is, immunizing a large proportion of the population to protect the non-vaccinated, immunologically naïve, and immunocompromised individuals by reducing the percentage of vulnerable hosts to a level below the transmission threshold. The attainment of vaccine-induced population immunity will depend on the procurement of effective vaccines and their widespread uptake. Vaccine uptake, in turn, depends on a potential vaccinee exercising their right to health and autonomously embracing vaccination. However, while voluntariness lies at the heart of autonomous decision-making, several structural factors could vitiate self-determination.
Structural factors and patient autonomy
At the broadest level, structural factors are the political, economic, social and environmental conditions and institutions at national, regional and international levels that influence the overall environment in which individuals, families and communities are situated and which shape their beliefs, decisions and behaviours. Geopolitics, conflicts, political systems, sovereignty, governance, respect for human rights, and the rule of law, count as examples of structural factors. In the field of health ethics, the principle of autonomy has been characterised as ‘self-rule that is free from both controlling interference by others and from limitations, such as inadequate understanding, that prevent meaningful choice.’ The notion of autonomy is epitomized by the argument that ‘free people must be free to make bad decisions—and to enjoy the rewards or suffer the consequences.’ The legal doctrine of informed consent upholds the principle of autonomy by requiring clinicians to inform mentally competent patients of all relevant therapeutic and prophylactic alternatives and to respect the patient’s choices in that regard. While multiple COVID-19 candidate vaccines have been granted emergency use authorization in various settings, structural factors are dictating their access at a grassroots level. As a result, patients are being denied their autonomous right to access a vaccine of their choice.
How geopolitics dictates vaccine procurement and impacts on patient autonomy
Geopolitical factors are depriving hundreds of millions of people of their right to autonomy in regard to COVID-19 vaccine choice. Hamstrung by decades of United States (US) sanctions, Cuba has strived for self-sufficiency in relation to vaccine production. Cuba has accordingly not imported any COVID-19 vaccines through bilateral deals with foreign vaccine developers, nor has the country sought COVID-19 vaccines through the COVAX facility. Instead, Cuba is developing at least four homegrown COVID-19 vaccines and trialling the vaccines domestically, and in Iran and Venezuela. However, the hardening of US sanctions during the Trump presidency has made Cuban procurement of raw ingredients necessary for vaccine production, more difficult. Venezuela is procuring Russian COVID-19 vaccines because US sanctions against the country have ruled out the procurement of certain vaccine candidates. Similarly, while Iran’s Supreme Leader has barred the importation of vaccines from the US and the United Kingdom (UK) because of mistrust of Western powers, Iranian politicians have simultaneously urged the US to lift sanctions against Iran to enable the country to import COVID-19 vaccines. While such sanctions formally exempt the importation of food, medicine, and other humanitarian supplies, Iranian health workers and sanctions experts have claimed that US sanctions are resulting in lost oil revenue for the country, and preventing the importation of pharmaceuticals and medical supplies, including raw materials and equipment needed to manufacture medicines domestically. Oil revenue losses due to sanctions has left Iran with less financial resources to effectively tackle the COVID-19 pandemic. Iran has also claimed that foreign and multilateral lending institutions have been deterred or blocked from concluding agreements with the country, including in relation to humanitarian initiatives For instance, in March 2020, during Iran’s first wave of COVID-19, the US blocked Iran’s request for an emergency $5 billion International Monetary Fund (IMF) loan aimed at helping the country respond to the COVID-19 pandemic. In December 2020, Iran reported that all methods by the country to transfer funds to secure vaccines through the COVAX facility for COVID-19 vaccines were unsuccessful because foreign assets had been frozen and monetary transfers involving Iran required permits from the Office of Foreign Assets Control of the US Treasury, by virtue of US sanctions. As a result, Iran has procured Russian, Chinese, and Indian vaccines, and is simultaneously trialling Cuban and homegrown candidate vaccines. However, notwithstanding Iran’s Supreme Leader barring the deployment of US and UK vaccines in the country, Iran is scheduled to receive more than 4 million doses of AstraZeneca vaccines through the COVAX facility.
National pride, geopolitical tensions, and mistrust are also potentially depriving people in some settings of their autonomous right to access a vaccine of their choice, including those developed by countries deemed to be ‘rivals’. While there are documented cases of drug regulators restricting or permitting access to health interventions based on domestic politics, and not on science (including in settings such as the US), global geopolitics can also dictate access to healthcare interventions. US officials are unlikely to procure and deploy state-sponsored Chinese or Russian candidate vaccines because of mistrust and transparency concerns. China and Russia are only deploying their own respective domestically-produced vaccines, despite US and European vaccines demonstrating superior efficacy. China has been accused of attempting to discredit western vaccines, and indirectly pressuring foreign expats (for example, foreign workers and students registered at Chinese institutions) to take its vaccines by announcing in mid-March 2021 that the country would facilitate the processing of visa applications if applicants had been vaccinated with Chinese vaccines.
Geopolitical factors are also dictating vaccine procurement and disbursement between countries that develop and manufacture vaccines, and those that do not. For example, Pakistan finds itself in a challenging position because of historical tensions with India. In what could be viewed as national pride trumping national interest, Pakistan has