Globally, and especially in the least affluent countries in the world, the COVID-19 pandemic continues to push the demand for moral clarity in decision-making to ever higher standards of transparency and accountability. Within international relief and development policy and practice, ethical concerns become much more difficult to tackle when multiple demands are placed on limited resources amidst fiercely competing priorities.
On the line are life and death outcomes, at a staggering scale.
For the U.S. Agency for International Development (USAID) and its local partners abroad, the question comes down to achieving an ethically defensible balance between prioritizing the urgent reduction of the negative health impacts of the COVID-19 pandemic through prevention and treatment, while also attending to the deleterious social and economic impacts that the pandemic is having on development. International development progress already has been hugely damaged, and in many instances significantly reversed by the pandemic. In 2020, sub-Saharan Africa experienced its first recession in 25 years as regional GDP shrank by 3.7%. Over 200 million individuals globally will be pushed into extreme poverty due to the pandemic, so there is a concurrent demand placed upon USAID to support urgent humanitarian relief, rapid recovery, and development goals – all while doing so in an equitable yet urgent manner.
Public support among Americans for a global response to COVID-19 is anything but robust. To a very large extent in the United States, the media has focused almost exclusively on the domestic situation during the pandemic. This is understandable; the scale and intensity of this public health catastrophe in the United States is certainly highly newsworthy to Americans. The Center for Disease Control and Prevention and other sources report that in this country there have already been over 44 million cases of COVID-19, and 714,000 deaths. Yet, to date, around the globe there have been over 235 million reported COVID-19 cases and 4.8 million deaths. Economic impacts of the virus have also been profound, especially on low-income nations and the global poor.
Empirical evidence at this scale becomes challenging for the public to comprehend and assign meaning to; a difficulty compounded by the ongoing debate between prioritizing national interest in the context of political boundaries, and in honoring universal human dignity in the knowledge that defensible universal standards of morality have no geographic boundaries.
Not all pandemic news is grim. Good news and even some room for optimism is manifest in the recent steady decline in the latest delta variant surge of cases in the United States, and in the remarkable accomplishments in the unprecedented rapid development and production of COVID-19 vaccines. Deaths and severe illnesses are expected to continue to decline here, and America’s economic output is expected to increase as more people are vaccinated. While such optimism is heartening, the situation is less bright in lower-income countries that struggle to secure adequate COVID-19 vaccinations. The situation is especially acute across the African continent, which accounts for less than 2% of the global 5.7 billion doses administered to date.
From both an empirical and a moral perspective, the pandemic is global; the response therefore ought to be global. Our often-stated commitment to the universal nature of human dignity directly translates to a commitment to equality, everywhere. From this perspective, the goal should be to maximize lives saved, everywhere, using a science-based data-driven approach. This means that equitable global vaccine access ought to be the highest priority. USAID and its partners abroad have limited capacity to make this happen, but they do have some capacity and influence in what is a whole-of-government effort here, and within the mechanisms of international collaboration. USAID has particular assets and experience to bring to this unprecedented undertaking, for example in helping to strengthen national health systems in lower-income countries to ensure safe, equitable, and rapid administration of vaccines and in the creation of a sustainable capacity to face future pandemic and similar large scale health risks. In this context, efficient management, capable governance, inspired leadership, and adequate financial and technical support is needed at scale, and no single global institution is better positioned to play a central role than USAID.
Together with any assistance that USAID can offer, critical actions also must take place on an urgent basis involving the coordination and participation of multiple key actors and stakeholders, here and abroad. Again, most importantly, there must be a rapid scaling up of the safe, effective, equitable, and efficient production and distribution of approved COVID-19 vaccines, together with support for the infrastructure to make this possible, affordable, and accessible.
Efforts to distribute the vaccine to lower-income countries have primarily come through COVAX, a global initiative that is intended to ensure that all countries have access to vaccines within a reasonably short time, regardless of their ability to purchase them. So far, COVAX has distributed 240 million vaccine doses to over 139 countries. While that is not a negligible accomplishment, it demonstrates a global moral failure to prioritize equity. Wealthier nations have unduly prioritized distribution to their own populations; in the US over 215 million individuals have received at least one dose of the vaccine, or 66% of its over-12 population. There are morally defensible arguments for a nation-state, as the primary duty-bearer, to take action progressively within expanding concentric circles of moral obligations, in which the individual, then family, gradually extends outward to ever larger social circles including a national population, and ultimately a global population. Unfortunately, our current egregious imbalance in global vaccine distribution and treatment support makes a mockery of organically and equitably expanding the moral circles of obligation, relative to an expanding capacity to respond. With such extreme global variations in who is and who is not receiving COVID-19 prevention and treatment, it is very difficult to assert morally that human beings are human beings everywhere, no matter their passport.
Equitable vaccine distribution is necessary to address the global health crisis, but it is not sufficient. Many nations face unique challenges in the administration of vaccines, such as transportation, storage, and distribution. What is more, vaccine distribution across the Global South is not simply a problem that requires technical or logistical solutions, even though technical solutions are most often discussed. Vaccine distribution also relies on strong public trust. Such trust will easily be eroded and distorted by self-serving elite influence, other inequitable political considerations, and many non-technical factors. Within any country, the planning and administration of vaccine distribution ought to be characterized by transparency, accountability, and inclusion, and should be based primarily on medical criteria (i.e., risk of morbidity/mortality and risk of exacerbated transmission of COVID-19). Medical criteria for COVID-19 treatment places greatest emphasis on prioritizing treating those who are most likely to survive, while medical criteria for COVID-19 prevention places greatest emphasis on prioritizing those who are most likely to become severely ill or to die. These parameters are strongly defensible on moral grounds, but in practice they are seldom observable around the globe in the consistency of their application.
Technology does offer continuing grounds for hope, yet in over-focusing on technical solutions harmful effects can follow. The emergence of “expert knowledge” has long been a concern with international responses to a variety of humanitarian crises. Countries in the Global North often address complex issues in the Global South based disproportionately on expert knowledges that only a select and privileged few (mostly in the Global North) possess. This emphasis on epistemic and technical expertise mostly linked to the Global North reduces or entirely overlooks the vital contributions of local forms of knowledge that provide critical perspectives, cultural relevance, and responsiveness to other political, economic, and environmental contexts necessary to address complex localized issues.
Expertise from the Global North and other imported forms of knowledge, while essential, often overemphasize technical solutions to what can often be largely non-technical problems.The international response to the 2014-2016 Ebola outbreak in West Africa highlights the limitations of over-reliance on imported expert knowledge, while demonstrating the importance of elevating local knowledge in crisis situations. Guinea’s Ebola outbreak had been occurring for almost three months before health officials and international partners identified the presence of the Ebola virus, at which point the virus was already highly prevalent and spreading quickly, exacerbated by many social factors including some cultural beliefs and behavioral practices. For example, burials of Ebola victims performed by military personnel were safe and efficient, however, they were not always conducted in a dignified manner consistent with local practices. This failure to honor the deceased encouraged communities to continue with traditional burials that lacked critical health safeguards, thereby increasing transmission. According to Guinea’s Ministry of Health, 60% of the country’s Ebola cases were linked to traditional burial practices. To address this issue, the International Federation of the Red Cross (IFRC) worked with large networks of local volunteers who took primary responsibility to ensure burial practices were both dignified and yet also effective in safely reducing the spread of the virus. The work and expertise of local volunteers proved to be indispensable in eventually overcoming the Ebola outbreak. The importance of leveraging local knowledge and participation was a key lesson learned in tackling that Ebola outbreak.
As they demonstrated in addressing the Ebola outbreak, local actors have a vital role in preventing and, where necessary, treating victims of the current COVID-19 pandemic. Local health workers bring decades of localized experience working with a range of infectious diseases and health concerns, as well as in-depth knowledge and local relationships that most experts from Global North organizations lack regarding cultural beliefs and practices relevant to local public health needs. Such local health workers are generally better poised to earn and retain the trust and build upon relationships with affected populations.
Trust is an essential element in overcoming public health challenges. Local knowledge and participation must be leveraged in building public trust in preventative measures that rely on effective application of COVID-19 vaccinations and in pursuing optimal treatment responses to the pandemic. Vaccines are useless if they do not get to populations in need, or if people are unwilling to be vaccinated. While there are some valuable strategic and appropriate roles and resources that Global North expertise and highly specialized technical inputs that institutions such as USAID can provide, it would be irresponsible to neglect robust local participation in favor of over-reliance on imported expert knowledge and imposed technical solutions.
African nations, along with less affluent nations around the globe, remain perilously distant from the goal of achieving an adequate supply of COVID-19 vaccinations, or in achieving high standards of treatment for those who are infected with the virus. While equitable vaccine distribution and treatment must be an international priority, this must not be the sole focus. Preventing further suffering, death, and spread of COVID-19 around the globe necessitates meaningful local participation be at the forefront of the international response with a focus on incorporating local knowledge, tempered by global adherence to trusted and largely uniform medical criteria for prevention and treatment. Such criteria are ethically rigorous, but often involve triage and exceptionally challenging decisions. Medical criteria for COVID-19 treatment places greatest emphasis on prioritizing the treating of those persons who are most likely to survive. Medical criteria for COVID-19 prevention places greatest emphasis on prioritizing those who are most likely to become severely ill or to die. In both cases, moral dilemmas abound, and yet someone must be trusted, empowered, and morally supported to make decisions that can only be described as tragic.
While USAID must make the tactical decisions needed to support development and recovery in the worst affected societies and economies around the globe, it also should develop the capabilities to offer robust moral guidance and support to all staff and local partners who are providing both preventative and treatment care.
By Troy Caruana and Chloe Schwenke
Center for Values in International Development
Photo by PeopleImages
 Adegoke, Yinka. “Africa’s Diversified Economies Are Set to Rebound Quicker than Its Extractive Giants.” Quartz, https://qz.com/africa/1966850/african-economies-to-watch-in-2021-with-covid-debt-impact/. Accessed 6 Oct. 2021.
 United Nations. “COVID-19 Could See over 200 Million More Pushed into Extreme Poverty, New UN Development Report Finds.” UN News, 3 Dec. 2020, https://news.un.org/en/story/2020/12/1079152. Accessed 6 Oct. 2021.
 Cameron, C. D. 2017. Compassion collapse: Why we are numb to numbers. In E. M. Seppälä, E. Simon-Thomas, S. L. Brown, M. C. Worline, C. D. Cameron, & J. R. Doty (Eds.), The Oxford handbook of compassion science (pp. 261–271). Oxford University Press.
 NPR. 2021. “Is The Worst Over? Models Predict A Steady Decline In COVID Cases Through March.” https://www.npr.org/sections/health-shots/2021/09/22/1039272244/is-the-worst-over-modelers-predict-a-steady-decline-in-covid-cases-through-march. Accessed 6 Oct. 2021.
 Vaccine Rollouts Offer Path out of Pandemic, Hopes of 2021 Global Recovery. https://www.spglobal.com/marketintelligence/en/news-insights/latest-news-headlines/vaccine-rollouts-offer-path-out-of-pandemic-hopes-of-2021-global-recovery-62302025. Accessed 6 Oct. 2021.
 United Nations. 2021. “Only 2% of Covid-19 vaccines have been administered in Africa.”
https://news.un.org/en/story/2021/09/1099872 Accessed 6 Oct. 2021.
 American College of Physicians; “Statement on Global COVID-19 Vaccine Distribution and Allocation: On Being Ethical and Practical”; June 8, 2021
 World Health Organization. “COVAX: Working for equitable access to COVID-19 vaccines.” https://www.who.int/initiatives/act-accelerator/covax. Accessed 6 Oct. 2021.
 World Health Organization. 2021. “Joint COVAX Statement on Supply Forecast for 2021 and early 2022.” https://www.who.int/news/item/08-09-2021-joint-covax-statement-on-supply-forecast-for-2021-and-early-2022. Accessed 6 Oct. 2021.
 Center for Disease Control. 2021. “COVID-19 Vaccinations in the United States.” https://covid.cdc.gov/covid-data-tracker/#vaccinations_vacc-total-admin-rate-total. Accessed 6 Oct. 2021.
 Merelli, Annalisa. 2021. “Poor countries will have to wait for Covid-19 vaccine leftovers until 2023.” Quartz. https://qz.com/2017272/rich-countries-are-buying-up-all-the-covid-19-vaccines/. Accessed 11 Oct. 2021.
 World Health Organization. 2021. “COVAX Reaches over 100 Economies, 42 Days after First International Delivery.” https://www.who.int/news/item/08-04-2021-covax-reaches-over-100-economies-42-days-after-first-international-delivery. Accessed 6 Oct. 2021.
 Sengupta, M. 2019. Post-development. Routledge Handbook of Development Ethics, 35.
 Easterly, W. 2014. The tyranny of experts: Economists, dictators, and the forgotten rights of the poor. Basic Books.
 World Health Organization. 2015. “Factors That Contributed to Undetected Spread.” https://www.who.int/news-room/spotlight/one-year-into-the-ebola-epidemic/factors-that-contributed-to-undetected-spread-of-the-ebola-virus-and-impeded-rapid-containment. Accessed 6 Oct. 2021.
 Anoko, Julienne Ngoundoung, et al. “Community Engagement for Successful COVID-19 Pandemic Response: 10 Lessons from Ebola Outbreak Responses in Africa.” BMJ Global Health, vol. 4, no. Suppl 7, Aug. 2020.
 Bedson, Jamie, et al. “Community Engagement in Outbreak Response: Lessons from the 2014–2016 Ebola Outbreak in Sierra Leone.” BMJ Global Health, vol. 5, no. 8, Aug. 2020.