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Covax must go beyond proportional allocation of covid vaccines to ensure fair and equitable access

BMJ 2021; 372 doi: (Published 05 January 2021) Cite this as: BMJ 2021;372:m4853

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Re: Covax must go beyond proportional allocation of covid vaccines to ensure fair and equitable access

Dear Editor,

Herzog et al highlights an important ethical dilemma in COVAX vaccine distribution. The proportional allocation approach currently planned by the COVAX initiative threatens to fail the most vulnerable populations, among them Palestinian refugees.

Palestinians have been left out of regional vaccination efforts. As of February 12, Israel has vaccinated nearly 72% of its population, achieving the largest vaccine distribution per capita [1,2]. However, the story of those Israel occupies, the Palestinians, tells of a starkly different reality that demands international attention [3].

The West Bank (including East Jerusalem) and Gaza Strip are referred to as the Occupied Palestinian Territories (OPT). While the West Bank is under direct military occupation by Israel, the Gaza Strip has been under a strict air, land, and sea blockade by Israel and Egypt since 2007. The blockade prohibits everything from fresh produce to medications from entering the Gaza Strip [1]. Such a reality has resulted in a humanitarian crisis, which has been exacerbated during the COVID-19 pandemic [1].

As of February 12, over 175,000 Palestinians have tested positive for SARS-CoV-2 infection, with strong evidence for underreporting due to the limited access to testing facilities [4]. The health infrastructure in the OPT was under-resourced prior to the pandemic [1]: there are estimated to be only 375 ICU beds for a population of nearly 5 million people [5]. The Palestinian governing bodies do not have the finances needed for purchase of the vaccine. Under international human rights law and the Geneva Accords, as an occupying power Israel is required to provide vaccines to Palestinians [3]. However, Israeli officials do not have any plans to do so [3,6].

Among the low-to-middle-income countries, Palestinians are uniquely vulnerable. Under the COVAX proportionality approach referenced by Herzog et al, Palestinians would receive enough vaccinations to cover only 20% of the population [3,6]. This is simply not enough.

The U.N. has called the OPT an “unlivable situation” [7]. Rather than an approach that focuses on proportionality, COVAX should account for such disparities. Additionally, the WHO should advocate for a lift on barriers to healthcare created by the occupation. Finally, health professionals must be at the forefront of advocating for Palestinian refugees.

To completely ignore the desperate situation of the Palestinians is discrimination [3]. We must act now or risk a moral failure that will be borne by the most vulnerable human lives-- a catastrophe that the medical community has the power to still prevent.

1 Alser O, AlWaheidi S, Elessi K, et al. COVID-19 in Gaza: a pandemic spreading in a place already under protracted lockdown. East Mediterr Health J Rev Sante Mediterr Orient Al-Majallah Al-Sihhiyah Li-Sharq Al-Mutawassit 2020;26:762–3. doi:10.26719/emhj.20.089
2 University of Oxford. Coronavirus (COVID-19) Vaccinations - Statistics and Research. Our World Data. (accessed 14 Jan 2021).
3 Amnesty International. Denying COVID-19 vaccines to Palestinians exposes Israel’s institutionalized discrimination. (accessed 12 Jan 2021).
4 World Health Organization. Coronavirus disease 2019 (COVID-19) in the occupied Palestinian territory. (accessed 24 Jan 2021).
5 Palestinian Ministry of Health. Palestine’s COVID-19 Response Plan.'s-COVID-19-Response-Plan (accessed 14 Jan 2021).
6 Hincks J. Israel Is Leading the World in COVID-19 Vaccination. But Palestinians Aren’t on the List. Time. (accessed 19 Jan 2021).
7 Heaney C. Gaza ‘Unliveable’, UN Special Rapporteur for the Situation of Human Rights in the OPT Tells Third Committee - Press Release (Excerpts). Quest. Palest. (accessed 24 Jan 2021).

Competing interests: No competing interests

14 February 2021
Nadine K. Jawad
Stanford Medical Student
Nicole L. Khamis (Harvard Law School), Osaid Alser (Harvard Medical School), Alice Rothchild (Jewish Voice for Peace Health Advisory Council), Alan Myers (Jewish Voice for Peace Health Advisory Council), Bill Slaughter (Harvard Medical School)
Stanford School of Medicine, Stanford CA