Intended for healthcare professionals

Letters Covid-19: Equitable global access to vaccines

Covid-19 vaccination: the dangers of “values” imperialism

BMJ 2021; 372 doi: (Published 02 February 2021) Cite this as: BMJ 2021;372:n302
  1. Shyan Goh, orthopaedic surgeon
  1. PO Box 13, Northmead, NSW 2152, Australia
  1. sgoh{at}

In response to Schwartz on equitable global access to covid-19 vaccines,1 Lloyd-Sherlock and colleagues2 consider Indonesia’s approach to vaccination programmes as ageist. They attribute the prioritisation of working adults under 60 years over older people to age discrimination and injustice. I ask fellow readers to consider the following:

  • Trials involving the main vaccine (Sinovac) recruited volunteers under 60 years3; efficacy above this age is largely unknown. Initial focus on younger people is evidence based

  • In Indonesia (population 267 million), 9% are 60 years and older with an average life expectancy of 72 years; the UK has a population of 66 million, with 16% who are at least 60 years old, with an average life expectancy of 814

  • A significant proportion of older people in UK are socially and financially independent, whereas in Indonesia many older people are both socially and financially reliant on their children. The economic fallout from travel restrictions on unvaccinated people of working age directly impact their older dependants

  • The UK has multiple safety nets, including the NHS (worth 10% of gross domestic product (GDP)) which delivers “free at point of care” services. Indonesia’s public healthcare system (3% of GDP)5 strives to deliver affordable services but is not considered in the same class as the NHS.

When considering what is right or just for people in low and middle income countries (LMICs) like Indonesia, in contrast to countries in the Organisation for Economic Co-operation and Development, such as the UK, one should acknowledge differences in values, outlook, and available resources.

Some alternative vaccines may have safety or efficacy data for older people, but their associated high costs, difficult supply, and cold chain problems make them impractical for a tropical LMIC with a huge population scattered over many islands with numerous remote communities.

There’s more than one way to skin a cat. To shame others simply because their approach is not the same as the UK reeks of imperialism, trampling on the indigenous ethos and perspectives of those in LMICs.


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