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Third Dose vs. Third World Countries: Halakhah Approaches COVID-19 Vaccine Allocation

Kislev 5782 | November 2021
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This article originally appeared on the lehrhaus.com website

To boost or not to boost?

This question is one that wealthy countries that have vaccinated most of their adult population must answer. As the Delta variant tears across the world and growing evidence indicates that COVID-19 vaccine effectiveness wanes with time, public health officials are debating whether to administer booster shots to fully vaccinated adults or divert these doses to the five billion unvaccinated in poor countries. This article explores how Halakhah helps to resolve this debate. To answer this question we must begin with the scientific background.

Scientific Background

Data from Israel indicate that COVID-19 vaccine effectiveness wanes with time. Those vaccinated in January 2021 were 2.26 times as likely to develop breakthrough infections between June 1 and July 27, 2021 as those vaccinated in April of that same year.[1] The vaccine was 16% effective at preventing symptomatic infections in those vaccinated in January; this was not statistically significantly different from zero, compared to an efficacy of 79% among those vaccinated in April.[2] Vaccine efficacy diminished across all age groups.[3] The CDC released three studies showing similar results;[4],[5],[6] two of these studies indicated that the vaccine continues to prevent severe disease.[7],[8] On the other hand, data from Israel suggest that even a 12-point decrease in vaccine effectiveness could translate into a five-fold increase in severe cases.[9] Further, most of the recent data from Israel indicates that for those aged 60 and older who were vaccinated in the first round of vaccinations, the vaccine’s ability to prevent severe disease was less than 60%, while for those vaccinated later it reached more than 80%.[10] Vaccine effectiveness against severe disease also decreased among those aged 50-59 and 40-49. However, Israel has insufficient data regarding vaccine efficacy among people aged 16-39, probably because this cohort was vaccinated more recently.[11] Francis Collins, Director of the National Institute of Health, has stated that the US is beginning to see similar trends.[12] Kaiser Permanente reported that the vaccine’s effectiveness for people who received two doses dropped to 47% after five months. Additional studies have shown that while vaccine efficacy against symptomatic disease stood at 96% one week after vaccination, it dropped to 84% at five months.[13]

With 78% of its eligible population vaccinated against COVID-19 as of August 31[14] Israel has one of the highest vaccination rates of any country in the world. Yet, a few weeks ago the country was facing one of the highest rates of COVID-19 infection; half of these recent infections have occurred in fully vaccinated citizens. As of August 15, 2021, 514 Israelis were hospitalized with severe or critical COVID-19, a 31% increase from four days earlier. Fifty-nine percent of those hospitalized with severe disease were fully vaccinated. Among the vaccinated hospitalized with severe COVID-19, 87% were 60 or older.[15] Three weeks into the month of August, Israel reported 350 deaths due to COVID-19 compared to seven COVID deaths in the month of June.[16] This latest surge has severely burdened the Israeli health care system, pushing it near to collapse. The situation was so dire that Professor Salman Zarka, Israel’s coronavirus commissioner told a parliamentary committee, “I believe we are at war.”[17]

In an effort to stem this latest wave of infection, Israel began administering booster shots to the immunocompromised and those over age 60. It then extended its booster campaign to those over age 50, and is now offering them to everyone over age 12.[18] Although Pfizer has reported that boosters increase antibodies up to ten-fold,[19] data from Israel show that those who received the booster were 11.3 times less likely to develop infection and 19.5 times less likely to develop severe illness, compared to those who were fully vaccinated and had not received a booster.[20] These results translate into 95% vaccine efficacy against COVID-19 in the presence of the Delta variant, which is comparable to the effectiveness of the initial vaccine rollout when the Alpha variant predominated. In addition, over three million Israelis have received the booster, the majority of them over age 60, with no new adverse events and side effects similar to those that appeared after the first and second doses.

The world has watched the re-emergence of COVID-19 in Israel, a highly vaccinated population, with great concern. Some have interpreted it as a warning about what can happen when COVID-19 vaccine efficacy wanes in the face of the Delta variant. UK, France, Germany, Sweden, and the UAE, following Israel, have decided to offer boosters.[21]

In the United States, the debate over boosters has intensified. Some healthcare policy makers believe that the US is a few months behind Israel, which vaccinated a greater percentage of its population earlier. They believe that the two-dose vaccine continues to offer protection against severe infections, but acknowledge that the vaccine’s effectiveness against severe disease, hospitalization, and death is likely to wane over the next few months.[22] US President Joe Biden announced that beginning on September 20, 2021, the US government will offer boosters to anyone over age 18, with healthcare workers, the elderly, and nursing home and long-term care residents getting priority.[23]

The FDA advisory committee unanimously approved the booster for high risk populations including immunocompromised individuals, those aged 65 and older, healthcare workers, and teachers.[24] The committee has not categorically approved the booster for all those over age 16. These recommendations will likely change as more data emerge.[25]

COVID-19 Vaccine Inequity

The introduction of the COVID-19 vaccine has led to profound international vaccine inequity. As of August, ten countries (China, India, US, Brazil, Germany, UK, Japan, France, Turkey, and Italy) have administered nearly 75% of the world’s doses, although they represent only 50% of the world population.[26] Poor countries have limited access to the COVID-19 vaccine. For example, with under 2.5% of its population fully vaccinated, Nepal suspended vaccination in April due to inadequate supply.[27] Vaccine inequity leads to high COVID-19 mortality. Of the ten countries with the greatest number of COVID-19 deaths as of the week ending August 10, six had vaccinated less than 10% of their population. In Africa, as of July, when many high-income countries had over 50% of their population vaccinated, less than 2% of the African population had been fully vaccinated and COVID-19 fatalities had surged.[28] Haiti has only vaccinated 0.3% of its population.[29]

The World Health Organization has denounced efforts to offer boosters to the vaccinated. It believes the world is on the “brink of a catastrophic moral failure by not giving enough vaccines to poorer countries. It is not right that younger, healthier adults in rich countries are vaccinated before health workers and older people in poorer countries.”[30] The WHO argues that the case for COVID-19 vaccine boosters at this point is weak, as two vaccines still protect against severe disease, and there is no evidence that the boosters will decrease transmission. While there might be a need for boosters in the future, the WHO maintains that there is currently little justification for using doses to protect the already-protected. A small dent in the efficacy of the vaccine does not justify a third dose when others have not had a single dose. The WHO compares boosters to fighting friendly fire and “handing out extra life jackets to people who already have life jackets… leaving other people to drown.”[31],[32],[33]

Francis Collins takes issue with the life-jacket analogy. He points out that if the vaccines are life-jackets, they are “leaving people to drown with a jacket that is not quite working anymore.[34]

Several healthcare policy makers offer an intermediary position that limits boosters to the immunocompromised and those at high risk, and focuses resources on vaccinating the unvaccinated in wealthy countries, while allocating doses to poor countries. They would only implement mass administration of boosters if a new resistant variant arises or efficacy drops even more dramatically.[35]

While ethicists acknowledge that governments have a special obligation to protect their citizens over those in other countries, they believe there are moral limits to this obligation. At some point, the needs of those in other countries trump those of one’s citizens. They use the influenza standard as a yardstick for this threshold. This means that countries may prioritize the needs of their citizens as long as COVID-19 continues to be an emergency. When this risk drops to a background-level health risk – one that does not warrant significant public health measures such as lockdowns and limitations on travel, and the mortality rate is similar to the background level health risk of influenza – governments may no longer hold onto vaccine doses and must send them to countries in greater need. Although COVID-19 has not reached this point, these ethicists believe that wealthy countries should nevertheless send their boosters to poor, unvaccinated countries, because 99% of deaths have occurred in the unvaccinated; they believe that boosters will not have an impact on COVID mortality. Ultimately, they argue, diverting booster doses to poor, unvaccinated countries will protect citizens of wealthy countries by preventing the development of variants. They believe that governments may use available doses to boost their citizens only when there is no longer a shortage of vaccines, or when the vaccine no longer provides protection against variants or severe disease.[36],[37]

A Halakhic Perspective

Two gemarot, Gittin 45a and Nedarim 80b, offer guidance regarding the allocation of limited resources and suggest that Halakhah rules differently for communities and individuals. The mishnah on Gittin 45a says that we do not redeem captives for more than their monetary value “for the betterment of the world.” The gemara offers two explanations for why we do not do so; redeeming captives for more than their monetary value will either impoverish the community or incentivize and encourage future kidnappings. While the first explanation emphasizes the financial danger to the community and the second explanation addresses the existential threat, both explanations suggest that the needs of the community trump those of the individual and that ultimately policy decisions must consider the larger good of the community. Ultimately, the gemara does not reject either explanation and leaves open the possibility that both explanations inform this policy. Although Rambam Matanot Aniyim 8:10-11 teaches that there is no greater mitzvah than redeeming captives, the needs of the community nonetheless override it.

At first glance, Gittin 45a might seem irrelevant to a discussion regarding allocation of COVID-19 vaccines, as sending vaccines to poor countries will certainly not impoverish wealthy countries, although it will deplete them of a limited resource. However, the gemara’s broad justifications for refusing to redeem captives for more than their monetary value suggest that we are not merely concerned with the impact of redeeming captives on the financial status of the community, but also with its effect on the broader welfare of the community. Diverting vaccines affects the broader welfare of the community because taking such action could compromise the safety of the community, placing it at greater risk of a life-threatening disease. If vaccinated individuals in wealthy countries do not receive boosters and boosters are instead diverted to poor countries, the vaccinated may become infected. Infection of the vaccinated will increase transmission, perpetuate the pandemic, and contribute to the development of variants potentially resistant to the vaccine. Ultimately, mortality in wealthy countries will rise. Thus, Gittin 45a can inform a discussion regarding reappropriation of COVID-19 vaccines to poor countries, since this policy can potentially endanger the community.

Does Gittin 45a definitively argue for one side of the debate about allocation of COVID-19 vaccines? On the one hand, this gemara might argue in favor of wealthy governments retaining boosters for vaccinated adults and vaccines for children because diverting these doses to poor countries might bankrupt the community of doses and compromise its safety. It is noteworthy that Gittin 45a rules in favor of the community even though the captive is one of its members. Presumably if the captives did not belong to the community, the community would have even less obligation to redeem them. In the current COVID-19 vaccine situation, wealthy governments might have even less obligation to poor countries since those in the greatest danger are not members of the wealthy community.   Alternatively, in a world of globalization where countries have fluid borders and variants which develop in one country quickly spread across the world, one could argue that the world is one large community.  As such, wealthy countries have an obligation to the citizens of poor countries.

On the other hand, one might understand Gittin 45a as simply a numbers game: One may not redeem an individual captive and endanger the many other present and future citizens of the town. This is the position of Rabbi Ephraim Oshry in Shut Mi-Ma’amakim 5:1. During the Holocaust, community leaders turned to him asking whether they could agree to deport some Jews in order to save the rest of the community. Rabbi Oshry ruled that they must save the greatest number of lives possible and could agree to the deportation, consigning the deported to certain death, because doing so would save the rest of the town. Rav Shlomo Zalman Auerbach similarly suggests that Halakhah prioritizes saving the greatest number of lives possible.[38] Rabbi Kook disagrees. He argues that one may not place an individual in danger to save the many. In Mishpat Cohen 142, he writes, “the worth of a person is hidden beneath the eye, there are people worth more than 600,000, and if not, maybe one of his descendants might be worth that much.” In wartime, however, this principle might not apply; in that same teshuvah, Rabbi Kook echoes this admonition to save as many lives as possible during war.

How would these principles apply during a pandemic? In his article “Rationing During a Pandemic Flu,” written under the guidance of Professor Shimon Glick, Dr. Aryeh Dienstag suggests that Rabbi Oshry would likely rule that during a pandemic, one must save as many lives as possible at all costs.[39] This could be interpreted as diverting vaccines to poor countries where they could have the greatest impact. With five billion unvaccinated individuals worldwide at substantially greater risk of COVID-19 than the 190,000,000 fully vaccinated Americans who would benefit from a booster, it is possible that more lives will be saved by diverting the vaccine, and therefore perhaps the community may bankrupt itself for the unvaccinated.

Nedarim 80b

Nedarim 80b describes two adjacent towns, one of which owns a spring. If both cities need the water, the city that owns it takes precedence. The same holds if both cities need the water to launder clothing. What if the city that owns the water needs it to launder clothing and the city that does not own the water needs it to live? In such a situation, the Tanna Kamma holds that the city that does not possess the water takes precedence, since its need is stronger.

However, Rabbi Yosi disagrees with the Tanna Kamma, stating that the city with the spring may use the water for their clothing even though the residents of the adjacent city might die without it, because unlaundered clothing can cause suffering and endanger lives. The Sheiltot Rav Ahai Gaon Parshat Re’eh 147 explains that failure to launder clothing will lead to tza’ar – suffering – and surprisingly, concludes that Halakhah rules in accordance with the opinion of Rabbi Yosi that we allow the residents of the city to launder their clothing. Shut Maharsham 2:210 believes that Rambam also rules in accordance with Rabbi Yosi.

At first glance, Rabbi Yosi’s position is difficult to understand. How can the city with water absolve itself of its obligation to save the lives of its neighbors and allow them to die of thirst? While not doing laundry can cause blindness, madness, and boils, these sufferings will arise over the course of several months, and seemingly should not take precedence over the greater and more immediate need of the neighboring town! For this reason, Ahiezer 2:232 believes that the Halakhah adheres to Tanna Kamma’s position. He explains that under Rabbi Yosi’s ruling, laundry would only take priority over the lives in the adjacent city when that city has already received enough food and water from another source to survive. Had it faced true danger of death, Rabbi Yosi would not have prioritized laundry over survival.

In contrast, Ran believes that this scenario is in fact a case where the adjacent town does not have enough water to survive, and explains that the other community may nevertheless use the water to launder clothing. This is because failure to launder causes “physical suffering,” a broad phrase that might refer to physical discomfort or danger to life. Rav Moshe Feinstein explicitly states that failure to launder will lead to physical discomfort and ultimately pikuah nefesh.[40] Professor Avraham Steinberg and Rabbi Moshe Tendler clarify that failure to launder clothing will lead to disease. They view the town’s decision to launder clothing as a public health measure to prevent potential widespread disease.[41] Ran views the position of Rabbi Yosi as consistent with the opinion of Rabbi Akiva in Bava Metzia 62b regarding two individuals who are lost in the desert with a jug of water. Ben Petura rules that they should both drink although both might die; Rabbi Akiva argues that the one who owns the jug should drink since ve-hai ahikha imakh, hayekha kodmin – your life takes precedence. The owner of the jug may not endanger himself even though his friend will certainly die. Rabbi Yosi rules that the needs of the city that owns the spring take precedence over those of the adjacent city because hayekha kodmin.

Netziv in Ha-amek She’elah on Sheiltot Rav Ahai Gaon 4 explains that Rabbi Yosi broadens Rabbi Akiva’s position from the individual to the communal level. Failure to launder clothing endangers lives, and therefore hayekha kodmim dictates that the city with the water use it for laundering clothing, even if this decision endangers the lives in the adjacent city. Not laundering clothing creates a safek pikuah nefesh – uncertain danger. Tanna Kamma rules that one must place himself in safek pikuah nefesh to save another in certain danger, while Rabbi Yosi believes that one may not place himself in a possible danger to save those in definite danger. Although we might consider self-endangerment to save others midat hassidut – an act of piety – the people of the city with the spring may not endanger themselves to save the adjacent town.

Rabbi Yossi Sprung, Rosh Beit Medrash of the Beit Medrash Govoha for Medical Halacha, suggests that Rabbi Yosi attaches great significance to the danger posed to the community. Something that is considered a low level of danger for an individual might qualify as sakanat nefashot for a community. There is little danger if a few people cannot launder clothing, but much if everyone in the city cannot. For this reason, Rabbi Yosi ruled that the people of the first town may launder their clothes, as they face possible communal danger, safek pikuah nefesheven though their doing so places the adjacent city in definite pikuah nefesh.[42] Rabbi Moshe Tendler suggests that if two individuals were in the desert with enough water for both to drink, but if one used the water to launder clothing the other would die, Rabbi Akiva would rule that they must share the water for drinking.[43] However, regarding the spring, Rabbi Tendler continues, it is the responsibility of the city to consider unborn generations. The future and the present become one. Failure to launder clothing over the course of time will lead to certain pikuah nefesh, as the danger to the community is real, and not just potential.

From the Individual to the Community

Indeed, Halakhah defines pikuah nefesh more broadly for a community than for an individual. Shabbat 42a presents the opinion of Shmuel that on Shabbat one may violate a biblical prohibition and extinguish a lump of fiery metal in the public domain so that no one will be hurt. Ramban writes, “It is astonishing how we permit an absolutely forbidden labor because of potential injury where there is no danger to life. Perhaps according to Shmuel all potential injury to the public is considered like a danger to life.” Along these lines, Ran Shabbat 42a states that, “any danger to the public is like sakanat nefashot.”[44] Rav Shaul Yisraeli writes that, “whatever concerns public welfare or removal of hazards, it is all regarded as pikuah nefesh. For everything connected to public welfare has an indirect element of pikuah nefesh.”[45]

Poskim list several other factors to consider when prioritizing the allocation of limited resources on a communal level. These include A) special consideration for a pandemic or during a war; B) the special status of children; and C) the unique obligation of a Jewish government to its citizens. In the midst of a pandemic, halakhic decisors allow leniencies that might otherwise not apply. For example, although Tzitz Eliezer 9:17 rules that a physician should not endanger his life to save patients, he may do so during a pandemic.

Rabbi Shabtai Rappaport, head of the Beit Midrash in Bar-Ilan University and grandson-in-law of Rabbi Moshe Feinstein,  believes that the government must prioritize pikuah nefesh regarding its citizens over that of other countries, especially during a pandemic. He states that a community may redistribute resources when redistribution does not compromise the care of those currently in danger or need of those resources. He explains that before a pandemic starts, a country with more resources that is not yet suffering might be obligated to give resources to a country that is. However, once the pandemic has reached the country with resources, that country must give its citizens priority, even if the danger to them is remote.[46],[47] Citing this position, Dr. Dienstag states, “it seems based on the ruling of Rabbi Akiva in the Talmud Bava Metziah… that a country with medication must first worry about its own citizens before attempting to aid another country.”[48]

An unvaccinated healthcare worker in Africa exposed multiple times each day to COVID-19 faces greater danger of death from COVID-19 than a twice-vaccinated healthy thirty-year old vaccinated eight months ago in the US. His risk of infection might be comparable to that of a 65-year old or an immunocompromised individual vaccinated more than eight months ago. Regarding the question of which individual should receive the vaccine, Halakhah would likely favor the healthcare worker in Africa, because he faces a more certain danger. However, on a communal level, the authors believe that Halakhah would reach a different conclusion. For a community, Halakhah equates possible danger with certain pikuah nefesh. The US and Israel possess doses of COVID-19 vaccine, a limited, critical, life-sustaining resource similar to the city’s water in Nedarim 80b.[49] The Western countries that have the vaccine must first worry about their own citizens and not those of another city or continent. Although the risk of COVID-19 infection in the vaccinated is substantially lower than that of the unvaccinated, on a communal level it is certain that without a booster, six months after vaccination at least some individuals in Israel, the US, or another Western country will die or become severely ill with COVID-19. Because Halakhah defines pikuah nefesh broadly on the communal level, even a small risk of COVID-19 morbidity will become pikuah nefesh for a community or country. While wealthy countries might consider diverting vaccines to poorer countries when the level of COVID-19 infection reaches the influenza standard, in the midst of a pandemic with more than 100,000 new cases daily in the US, Halakhah leans toward offering booster shots to bolster citizens’ immunity over reappropriating doses to poor countries.

As broadly as Halakhah defines pikuah nefesh for issues of public safety, it expands it even further for issues overseen by a Jewish state. Rav Goren argues that the state of Israel, as the representative of the Jewish people, must consider even remote future pikuah nefesh concerns. A Jewish country has a unique responsibility to care for the needs of its citizens. “When we are dealing with an independent Jewish state… this national responsibility does not express itself in the daily individual planning of medical services in Israel, but rather in overall long-term responsibility.”[50]

Although several countries have authorized boosters, Halakhah offers an even stronger endorsement of Israel’s decision for two reasons. First, Israel has described itself as at war against COVID-19, with its healthcare system on the verge of collapse. Common sense dictates that a country at war cannot be expected to relinquish its ammunition to others, even if those other countries are also at war. Such a decision would be tantamount to national suicide. This wartime analogy is not merely rhetoric but has halakhic validity and implications. In a teshuvah addressing the halakhic permissibility of undergoing experimental medical therapy, Rav Shlomo Zalman Auerbach in Minhat Shlomo 2:82:12 broadens the halakhic definition of milhemet mitzvah – an obligatory war – beyond an existential battle against an invading army to a situation where wild animals and bears overrun the city. He writes that when this happens, it is a mitzvah for anyone to desecrate the Shabbat in order to save as many lives as possible. Life-threatening diseases are, as Rav Shlomo Zalman Auerbach describes, ke-ein milhemet mitzvah, essentially a milhemet mitzvah. If our society lived under Da’at Torah, the beit din would authorize medicines to help us battle disease. The contemporary equivalent of the beit din is our medical experts, who are invested with the halakhic authority to prescribe and treat, and to send us out to fight diseases. In the midst of the COVID-19 pandemic we are also engaged in ke-ein milhemet mitzvah, essentially a milhemet mitzvah, which allows Israel to give protecting her citizens special priority.

Second, as a Jewish State, Israel has an additional, unique obligation to protect its citizens. To this end, Prime Minister Bennett strongly defended Israel’s decision to offer boosters to all citizens over age 16, offering five reasons to support his decision. First, we are at war with COVID-19 and must adopt wartime strategies under which the elected leader, not health officials or generals who are often risk averse, makes the decisions. The pandemic affects every aspect of life, including the economy and mental health. The elected leader must balance these competing interests and act decisively in the best interests of his country. Second, both the efficacy of the vaccines and people’s vigilance in adhering to COVID-19 precautions have waned. Third, boosters are safe. Fourth, boosters could help the country avoid another lock-down; had the country waited three more weeks to authorize boosters, the healthcare system would have collapsed under the volume of patients with severe infection. Fifth, allowing vaccine efficacy to decline further would squander the gains made in the initial vaccination campaign, erode public trust in the vaccines, and feed the anti-vaxxer movement.

Is It Really a Zero Sum Game?

But ethically, how could Halakhah possibly favor keeping doses for one’s citizens when five billion people have not received a single dose of the vaccine? Let us return to Rabbi Oshry’s argument that Halakhah favors saving the greatest number of lives. Even Rabbi Kook, who rejects this principle under normal circumstances, suggests that saving the greatest number of lives applies during wartime.[51] Diverting vaccines to Africa would seem to be the most effective means to achieve this goal. However, vaccines are not entirely comparable to Jewish lives in the ghetto or redemption of captives. In the case brought before Rabbi Oshry, deporting some Jews would directly save the rest of the community. In contrast, diverting boosters from wealthy countries will not necessarily translate into lives saved in poor countries. Dr. Francis Collins, Director of the National Institute of Health, has pointed out that equating boosters with vaccines for poor countries creates a false equivalence. He does not find them mutually exclusive or comparable, stating “I don’t accept the idea that we have to do one or the other. We are, after all, sending out more doses to the rest of the world. In all the other countries combined, 115 million doses are already out there. Another 500 million are planned and already approved. We’ve given $4 billion to COVAX. We’re scaling up the manufacturing as fast as we can, so this doesn’t have to be a limited number of doses. It’ll be more about distribution.”[52],[53]

In addition, a booster program that would cover roughly 155,000,000 Americans would provide vaccine coverage for 77,500,000 worldwide if the US were to divert those boosters to poor countries. This amount would not go far to protect the nearly 5,000,000,000 unvaccinated people worldwide who require 10 billion doses to achieve immunity. In addition, there is a false dichotomy between offering boosters and sending vaccines to people in undeveloped countries. The booster vaccines will expire, and can’t be moved from place to place.[54] India has not approved the Pfizer vaccine, which would be used for boosters. Even if the vaccine were available, poorer countries lack the cold storage capability that it requires. The Lancet COVID-19 Commission India Task Force calls for 5,000,000 vaccinations per day for adults over age 45. India can achieve half this goal by manufacturing its own vaccines, and, with financial support and raw materials, could increase production even more.[55] Additionally, America has pledged to developing countries its 60,000,000 doses of the AstraZeneca vaccine, as the FDA is unlikely to approve its use in the US.[56],[57]

Are there limits to Halakhah’s requirement that governments protect their citizens even at the expense of other populations? Would Halakhah ever favor diverting boosters and vaccines to poorer countries in need? Does Halakhah apply differently to specific subpopulations?

Based on Rabbi Shabtai Rappaport’s position noted above, that during a pandemic, countries may not divert medicines from their citizens to other countries in need, we believe that when COVID-19 becomes a virus with a background level of risk comparable to influenza and the United States has sufficient doses of the vaccine to meet the demand of its citizens, the government may, and perhaps must, allocate doses to countries in need. Until that time, governments must retain doses to vaccinate their citizens and administer boosters to the already-vaccinated in order to guarantee continued vaccine efficacy.

Furthermore, we believe that Halakhah does not distinguish between subpopulations. Data from Israel indicate that vaccine efficacy declines across all age groups. It is clear that with time, the vaccine protects those over age 60, those between ages 50 and 59, and those between ages 40 and 49 less well. Although no one has yet demonstrated a similar decrease in protection for those under age 40, the absence of such an effect in this population is likely due to its more recent vaccination.[58] With time, the efficacy of the vaccine against severe disease will likely decline in the younger population as well.

Conclusion

As wealthy countries debate whether to administer COVID-19 boosters to the vaccinated or to distribute those doses to the five billion unvaccinated adults in poor countries worldwide, we believe that Halakhah rules in favor of countries holding on to doses for their citizens. Halakhah obligates governments to protect their citizens from even remote risk, safek pikuah nefesh. During a pandemic as in the midst of war, governments, especially a Jewish government, have an obligation to keep their medications, as they would their weapons, for their own citizens. All governments, and especially a Jewish State, must protect against even remote risks to their citizens, and prioritize the welfare of their citizens over the welfare of those in other countries.


[1] Barak Mizrahi, “Correlation of SARS-CoV-2 Breakthrough Infections to Time-from-vaccine; Preliminary Study,” medrxiv.org, July 31, 2021.

[2] “BNT162b2 [Comirnaty (COVID-19 Vaccine, mRNA)] Evaluation of a Booster Dose (Third Dose) Vaccines And Related Biological Products Advisory Committee Briefing Document,” Pfizer, September 17, 2021.

[3] Sharon Alroy-Preis & Ron Milo, “Booster Protection against Confirmed Infections and Severe Disease – Data from Israel,” Israel Ministry of Health, et al., September 17, 2021.

[4] Srinivas Nanduri, et al., “Effectiveness of Pfizer-BioNTech and Moderna Vaccines in Preventing SARS-CoV-2 Infection Among Nursing Home Residents Before and During Widespread Circulation of the SARS-CoV-2 B.1.617.2 (Delta) Variant,” Centers for Disease Control and Prevention, August 18, 2021. This study demonstrated that among nursing home residents, vaccine effectiveness diminished from 74% from March-May 2021 to 53% in June-July when the Delta variant predominated. The study did not report on the effectiveness of the vaccine in preventing severe infection .

[5] Eli S. Rosenberg, et al., “New COVID-19 Cases and Hospitalizations Among Adults, by Vaccination Status — New York, May 3–July 25, 2021,” Centers for Disease Control and Prevention, August 27, 2021. This study reported a decline from 91% to 79% in the vaccine’s ability to prevent infection in New York between May 2021 and July 2021. However, vaccine effectiveness at preventing severe disease did not change.

[6] Mark W. Tenforde, et al., “Sustained Effectiveness of Pfizer-BioNTech and Moderna Vaccines Against COVID-19 Associated Hospitalizations Among Adults — United States, March–July 2021,” Centers for Disease Control and Prevention, August 27, 2021.  This study showed that vaccine effectiveness against infection or COVID-19 hospitalization did not decrease up to 24 weeks after vaccination. These results extended to those at high risk of severe disease.

[7] Rosenberg, et al., “New COVID-19 Cases and Hospitalizations Among Adults.”

[8] Tenforde, et al., “Sustained Effectiveness of Pfizer-BioNTech and Moderna Vaccines.”

[9] Alroy-Preis & Milo, “Booster Protection – Data from Israel.”

[10] Ibid.

[11] Ibid.

[12] Berkeley Lovelace, Jr., “NIH Director Says New Israeli Covid Data is Building Case for Booster Shots in The U.S.,” CNBC., August 17, 2021.

[13] Sara Y. Tartof, et al., “Six-Month Effectiveness of BNT162B2 mRNA COVID-19 Vaccine in a Large US Integrated Health System: A Retrospective Cohort Study.” The Lancet, August 23, 2021. Available at SSRN: https://ssrn.com/abstract=3909743 or http://dx.doi.org/10.2139/ssrn.3909743.

[14] Dov Lieber, “In Israel, Being Fully Vaccinated Now Means Three Shots,” The Wall Street Journal, August 31, 2021.

[15] Meredith Wadman, “ A Grim Warning from Israel: Vaccination Blunts but Does Not Defeat Delta.” Science, August 16, 2021.

[16] Amy Spiro, “Nearly 200 Covid Deaths Reported in Past Week, but Booster Data Raises Hopes,” The Times of Israel, August 22, 2021.

[17] Isabel Kershner, “Israel, Once the Model for Beating Covid, Faces New Surge of Infections,” The New York Times, August 18, 2021.

[18] Ari Rabinovitch, “Israel Offers COVID-19 Booster to all Vaccinated People,” Reuters, August 29, 2021.

[19] Michael Erman and Julie Steehuysen, “Pfizer, BioNTech to Seek Authorization for COVID Booster Shots as Delta Variant Spreads,” Reuters, July 9, 2021.

[20] Yinon M. Bar-On, et al., “Protection of BNT162b2 Vaccine Booster against Covid-19 in Israel,” N Engl J Med 385: 1393-1400, 2021.

[21] G. Owen Schaefer, et al., “Making Vaccines Available to Other Countries Before Offering Domestic Booster Vaccinations.” JAMA. Published online August 12, 2021. doi:10.1001/jama.2021.13226.

[22] Lovelace, “Israeli COVID Data Building Case for Booster Shots.”

[23] “Who is Eligible for a COVID-19 Vaccine Booster Shot?” Centers for Disease Control and Prevention, October 22, 2021.

[24] Michael Erman, et al., “The Great Reboot: FDA Advisers Recommend Covid Boosters for 65 And Older, Reject Broad Approval,” Reuters, September 17, 2021.

[25] “Fauci Reacts to FDA Recommendation on Covid-19 Booster Shots,” CNN Health.

[26] Schaefer, et al., “Making Vaccines Available to Other Countries Before Offering Domestic Booster Vaccinations.”

[27] Anbarasan Ethirajan, “As India Halts Vaccine Exports, Nepal Faces Its Own Covid Crisis,” BBC News, 12 May, 2021.

[28] “Covid-19 Deaths in Africa Surge More than 40% over Previous Week,” World Health Organization, July 15, 2021.

[29] “Covid-19 Vaccine Tracker: The Global Race to Vaccinate,” Financial Times, 22 September, 2021.

[30] “WHO Director-General’s Opening Remarks at 148th Session of the Executive Board,” World Health Organization, 18 January, 2021.

[31] “COVID-19 Virtual Press Conference Transcript,” World Health Organization, August 18, 2021.

[32] Ewen Callaway, “Covid Vaccine Boosters: The Most Important Questions,” Nature, August 5, 2021.

[33]Amy Maxmen, “Covid Boosters for Wealthy Nations Spark Outrage,” Nature, July 30, 2021.

[34] “NIH Director Collins on Why the U.S. Reversed its Decision on Booster Shots,” NPR Morning Edition, August 19, 2021.

[35] Philip R. Krause, et al., “Considerations in Boosting Covid-19 Immune Responses,” The Lancet, September 13, 2021.

[36] Jamie Lopez Bernal,  et al.,  ”Effectiveness of COVID-19 Vaccines against the B.1.617.2 Variant,”  bioRxiv. Preprint posted online May 24, 2021. doi:10.1101/2021.05.22.21257658Google Scholar.

[37] Ezekiel J. Emanuel, et al., “How Many Vaccine Doses Can Nations Ethically Hoard? The Case for Sharing Supplies Prior to Reaching Herd Immunity,” Foreign Affairs. Published March 9, 2021. Accessed August 10, 2021.

[38] Minhat Shlomo Tanina 86:1.

[39] Aryeh Dienstag, “Rationing During a Pandemic Flu,” Verapo Yerapey.

[40] Iggerot Moshe Yoreh Deah 1:145.

[41] Translation by Avraham Steinberg, “Allocation of Scarce Resources,” Encyclopedia of Jewish Medical Ethics, 46 (Feldheim, 2003); Frontal lecture, Yeshiva University, Winter 2004.

[42] Rabbi Yossi Sprung, “Pikuach Nefesh of the Community and Individual,” Beit Medrash Govoha for Medical Halacha, September, 2018.

[43] Moshe Tendler, “Problems in Triage: Public Expenditures and Saving One Life versus Another,” Sefer ha-Yovel in Honor of Rabbi J.B. Soloveitchik [in Hebrew] (New York: S.O.Y., 1984).

[44] For a more detailed discussion regarding the definition of communal pikuah nefesh, please see Sharon Galper Grossman and Shamai Grossman, “Sharpening the Definition of Holeh Lefanenu: The Diamond Princess and the Limits of Quarantine,” The Lehrhaus, May 19, 2020.

[45] Rav Shaul Yisraeli, Amud ha-Yemini (Mekhon ha-Torah ve-haMedinah, 2000), 214-215.

[46] Shabtai Rappaport, “Priorities in Allocating Public Resources for Medicine,” Assia 49-50, Tamuz 1990, p17-5.

[47] Dienstag, “Rationing During a Pandemic Flu.”

[48] Ibid.

[49] The situation presented in Nedarim 80b assumes that the death of those in the adjacent town does not endanger the town that withholds the water in order to do laundry. For COVID-19 vaccines, withholding vaccines from poor countries to boost the vaccinated in wealthy countries could ultimately endanger the vaccinated by contributing to the development of variants. However, variants can develop in these wealthy countries even if they keep their vaccine doses and certainly if they earmark their vaccines for poor countries and leave their vaccinated with diminished immunity. In fact, modeling studies indicate that variants are most likely to develop in wealthy countries that have high levels of vaccination but have not achieved herd immunity. Nevertheless, countries do have the ability to control the spread of the pandemic and close their borders. This was the approach of New Zealand and Australia. See Simon A. Rella, et al., “Rates of SARS-CoV-2 Transmission and Vaccination Impact the Fate of Vaccine-Resistant Strains,” Sci Rep 11, 15729 (2021).

[50] Rav Shlomo Goren, Torat ha-Refuah, 80.

[51]Mishpat Cohen 143

[52] “NIH Director on Why the U.S. Reversed its Decision on Booster Shots.” NPR, August 19, 2021.

[53] Francis Collins adds, “And again, let’s be clear, the U.S. – if you look at Louisiana, Florida, Mississippi right now, if they were countries, they would lead the world in the number of per capita cases right now. We’ve got a big problem on our own hands, so it’s not as if we’ve got it all figured out and everybody’s got a life jacket. We’re still in trouble.”

[54] Tanya Lewis, “Should You Get a Booster Shot? Here’s What We Know,” Scientific American, August 20, 2021.

[55] “Managing India’s Second COVID-19 Wave: Urgent Steps,” The Lancet COVID-19 Commission India Task Force, April 2021.

[56] 3,000 children worldwide die of pneumonia and diarrhea daily, both easily preventable by vaccination. Yet no one argues that the US should divert pneumococcal and rotavirus vaccines from its children to poor countries. See “Pneumonia & Diarrhea Progress Report,” Johns Hopkins and the International Vaccine Access Center, 2020.

[57] Berkeley Lovelace Jr., “US to Share 60 Million Doses of AstraZeneca COVID Vaccine with Other Countries,” CNBC, April 26, 2021.

[58] Alroy-Preis & Milo, “Booster Protection – Data from Israel.”

 

Dr. Sharon Galper Grossman

Dr. Sharon Galper Grossman is a graduate of Matan’s Morot L’Halakha program. She is a radiation oncologist and former faculty member of Harvard Medical School where she also obtained a Masters in Public Health. Her current interests are in Women’s Health and Halakha, specifically issues related to preventing women’s cancers. She has recently published “The Angelina Jolie Effect in Jewish Law: Prophylactic Mastectomy and Oophorectomy in BRCA Carriers” in the Rambam Medical Journal. “Resolving the Debate Over Human Papilloma Virus (HPV) Vaccination for Cancer Prevention in the Religious World” has been accepted for publication in Tradition.