Annals of African Medicine
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Table of Contents
Year : 2021  |  Volume : 20  |  Issue : 3  |  Page : 157-163  

Public health ethics and the COVID-19 pandemic

Department of Community Medicine, Faculty of Clinical Sciences, College of Medical Sciences, Ahmadu Bello University, Zaria, Nigeria

Date of Submission28-Aug-2020
Date of Acceptance05-Aug-2021
Date of Web Publication17-Sep-2021

Correspondence Address:
Prof. Alhaji A Aliyu
Department of Community Medicine, Faculty of Clinical Sciences, College of Medical Sciences, Ahmadu Bello University, Zaria
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aam.aam_80_20

Rights and Permissions

Health is a human right anchored in values as a basic necessity of life. It promotes the well-being of persons, communities, economic prosperity, and national development. The coronavirus disease-2019 (COVID-19) pandemic caught the world unaware and unprepared. It presented a huge challenge to the health and economic systems of every country. Across the spectrum of human endeavor and liberty, several ethical questions have been raised with regard to its management, particularly the public health control measures. Decisions for pandemic control measures are made under difficult circumstances driven by urgency and panic, with uncertainties and complexities for public goods over individual rights. Global solidarity in controlling the pandemic is being tested. National governments have the responsibility to protect public health on the grounds of common good. Political considerations should not be the basis for decision-making against the best available epidemiological data from pandemic disease dynamics. Hence, the need to adhere to the values of honesty, trust, human dignity, solidarity, reciprocity, accountability, transparency, and justice are major considerations. A literature search was conducted for the publications from academic databases and websites of health-relevant organizations. I discuss the ethical questions and challenges of the COVID-19 pandemic in the context of public health control measures using the standard ethical principles of respect for autonomy, beneficence, nonmaleficence, and social (distributive) justice. It is observed that, at the country level, the World Health Organization (WHO) guidelines are used to control the pandemic. As WHO through the COVAX strategy distributes the vaccines to less developed countries, a lot still needs to be done to address the complex bottlenecks of allocation and distribution. There is a need to ensure acceptable and transparent system that promotes cooperation, equitable access, and fair distribution of vaccines on a global scale.

   Abstract in French 

La santé est un droit humain ancré dans des valeurs en tant que nécessité fondamentale de la vie. Elle favorise le bien-être des personnes, des collectivités, la prospérité économique et le développement national. La pandémie de COVID-19 a pris le monde au dépourvu et au dépourvu. Cela représente un énorme défi pour les systèmes de santé et économiques de chaque pays. Dans tout le spectre de l'activité humaine et de la liberté, plusieurs questions éthiques ont été soulevées concernant sa gestion, en particulier les mesures de contrôle de la santé publique. Les décisions concernant les mesures de lutte contre la pandémie sont prises dans des circonstances difficiles motivées par l'urgence et la panique, avec des incertitudes et des complexités pour les biens publics plutôt que les droits individuels. La solidarité mondiale dans la lutte contre la pandémie est mise à l'épreuve. Les gouvernements nationaux ont la responsabilité de protéger la santé publique au nom du bien commun. Les considérations politiques ne devraient pas être la base de la prise de décision par rapport aux meilleures données épidémiologiques disponibles sur la dynamique des maladies pandémiques. Ainsi, la nécessité d'adhérer aux valeurs d'honnêteté, de confiance, de dignité humaine, de solidarité, de réciprocité, de responsabilité, de transparence et de justice sont des considérations majeures. Une recherche documentaire a été menée pour les publications des bases de données universitaires et des sites Web d'organisations liées à la santé. Je discute des questions éthiques et des défis de la pandémie de COVID-19 dans le contexte des mesures de contrôle de la santé publique en utilisant les principes éthiques standard de respect de l'autonomie, de la bienfaisance, de la non-malfaisance et de la justice sociale (distributive). On constate qu'au niveau des pays, les directives de l'OMS sont utilisées pour contrôler la pandémie. Alors que l'OMS, via la stratégie COVAX, distribue les vaccins aux pays moins développés, il reste encore beaucoup à faire pour remédier aux goulots d'étranglement complexes de l'allocation et de la distribution. Il est nécessaire de garantir un système acceptable et transparent qui favorise la coopération, l'accès équitable et la distribution équitable des vaccins à l'échelle mondiale. critères d'attribution des vaccins COVID-19 dès qu'ils deviennent disponibles.

Keywords: Coronavirus disease-2019 pandemic, ethics, public health
Mots-clés: Santé publique, éthique, pandémie de COVID-19

How to cite this article:
Aliyu AA. Public health ethics and the COVID-19 pandemic. Ann Afr Med 2021;20:157-63

How to cite this URL:
Aliyu AA. Public health ethics and the COVID-19 pandemic. Ann Afr Med [serial online] 2021 [cited 2023 Oct 2];20:157-63. Available from:

   Introduction Top

The current severe acute respiratory syndrome (SARS)-like manifestations caused by coronavirus-2 (SARS–COV–2 [COVID-19]) pandemic is the third known spill over of an animal coronavirus to humans resulting in a major pandemic.[1] The COVID-19 pandemic has revealed the world's interconnectedness and interdependence and has exerted pressure on world leaders, policy-makers, and public health authorities to make ethically challenging decisions on public health containment measures. COVID-19 is both a matter of global and public health ethics. Under democratic norms, decision-making must be justified and communicated in a transparent manner against the background of diverse values and norms present in democratic societies. In this context, ethical accountability is also important. Thus, making difficult decisions including choices and trade-offs is inevitable. Public health ethics has a wider dimension of not only health and disease but also of social justice and public trust. Further, it considers duty to care, public goods, population health, freedom, justice, reciprocity, and solidarity as being central.[2],[3],[4] Pandemics, by their very nature, have a wider social and political dimension as well as being biological.[5]

The COVID-19 pandemic is not exempt from this, as one witnesses politics in open confrontation with science (epidemiology). Unfortunately, with the on-going pandemic, difficult ethical decisions and choices are inevitable. Here, out of necessity, politics must not only listen to but also respect science because the public health measures being instituted to counter the pandemic are for the common good. However, most importantly, value judgments are applied to science.[6] The principles of decision-making during pandemics such as duty to care, health, nondiscrimination, equity, severity, liberty, privacy, proportionality, public protection from harm, solidarity and reciprocity, and public trust must be given consideration. Against this background, as the COVID-19 pandemic progresses and more epidemiological facts become known, the need for well-justified, transparent and accountable decision-making and communication from public health authorities, and political decision-makers on the responses to the pandemic to the public becomes important.[7],[8],[9],[10] In order to promote compliance, governments worldwide need to be transparent, accessible, and accountable through mechanisms that facilitate two-way feedback on pandemic control measures, the lockdowns, and their impact on citizens.[2],[11],[12] This is crucial because the measures affect the different public sectors in a disproportionate manner.

The pandemic also has exposed our shared humanity (inter-connectedness) in a globalized world and exposed the weaknesses in human endeavor. No nation can single-handedly mount sufficient response to bring the pandemic under control. With an effective and timely notification of an epidemic to the international community, countries are ethically obliged to help prevent the spread of the disease.[13] Through reciprocity and solidarity, countries less affected have a responsibility to assist by providing less developed countries logistics to contain the pandemic.

As the world is coming to terms with the “new normal” situation created by COVID-19 pandemic, it is timely to make some observations on how ethics as a discipline or as a service within health care settings has fared. Public health ethics reflects not only on population health, but in a wider context considers health and other challenges against the backdrop of social, political, religious, legal, economic, and societal structures. Therefore, the importance of managing the pandemic in an organized internationally coordinated global response is an ethical duty.

   The Context Top

Ethical and legal issues will continue to surface as the world periodically faces or is affected by serious infectious diseases. With the human immunodeficiency virus/AIDS pandemic of the 1980s,[14] the alarm over multi-drug resistant tuberculosis in the 1990s,[15] and the SARS pandemic in 2003[16],[17] did it become obvious that there are issues bordering on the core ethical questions posed by public health that need to be addressed. Interestingly, COVID-19 when the outbreak started late in 2019, like SARS, took the world by surprise through a pretherapeutic era, initially no specific case definition, no diagnostic test kits and to date, no effective treatment.

According to the World Health Organization (WHO), the disease epicenters are in the Americas (USA and Brazil) and Asia pacific (India), with the three countries at time of writing all having passed the one million mark in the number of cases, with thousands of fatalities. Now that the first wave of the pandemic has “apparently” ended without flattening the epidemic curve, with some countries entering the second wave and yet others transiting to the third wave. It is pertinent to evaluate the global public health response to COVID-19 focusing on surveillance, isolation, quarantine, social distancing, travel restrictions, universal masking, and contact tracing (CT). This will provide the empirical basis for the ethical and legal principles that will guide future public health approaches or interventions as the world faces the second wave of the pandemic, and even possibly prepare for the future. The public health measures often raise difficult and intricate questions about the relationship between the state and its citizens and organizations that are affected by public policies.[8] Thus, paying attention to ethical issues in the outbreak and taking an ethical approach could be beneficial for maintaining public trust and confidence.[18]

   Ethical Principles Top

The cardinal four basic ethical principles of health care are as follows: Respect for autonomy, beneficence, nonmaleficence, and distributive justice.[19] The health-care provider's duty must be exhibited within the context of these ethical principles. There are other ethical principles of public health of import that come into play, especially during a pandemic: duty to protect public health, duty of care and public goods and individual rights of privacy and liberty.[2]

Even though during epidemics and pandemics, individual choice is, strictly speaking, legally limited on the basis of the harm principle,[20] it is important to ensure that human dignity is not eroded. This must be done with fairness and justice. Every member of the society must be treated fairly and with respect. In the process of implementing pandemic control interventions, risk should be minimized as much as practicable.

To gain public trust and confidence, the effective communication of risk and other critical information are central to the success of the response to the contagion. Transparent, honest,[21] and timely communications and dialogue are vital as citizens seek information to safely guide their lives. Active engagement of media to ensure that timely and accurate information, and technical explanations including justification for decisions taken, are available to support informed reporting.[2] It is emphasized that authorities neither downplay the risks which may lead to higher rates of preventable infections with consequent excess morbidity and mortality, nor overstate the risks leading to panic or a lack of public trust and its aftermath.

   Surveillance Top

In addition to existing public health laws of any country, once the government has declared the presence of an infectious disease (COVID-19) to be serious and a threat to public health, this declaration in itself gives the government more legal powers to control the disease.[22] The state has responsibility to promote and protect the health of its populations and needs to undertake public health measures that include restricting movements, forced quarantine, and isolation, if the infected member of the community poses a threat to public health. These measures, short-term in their implementation, can infringe on liberty, but the measures are justified.

Epidemiologic data are important for planning public health interventions. This requires collecting information that does not reveal the identity of the person (anonymized data) and is generally not regarded as intrusive. Nonanonymized data interferes with the individual's right to privacy. However, against this backdrop, it must be emphasized that it may be ethically justified to collect nonanonymized data of individuals even without consent if significant harm to others can be avoided. Health-care providers, under “duty to care” and “common good” can pass on reports of cases of notifiable diseases (COVID-19) to authorities for the purposes of control and disease prevention. Consent from those infected is not required in this regard and the data can include information that identifies the person. This has raised concerns about surveillance as an important public health tool and claims for privacy.[23],[24] The use of pandemic surveillance data for research may pose ethical challenges, particularly data ownership and copyright.[25],[26]

Contact tracing (CT) is a key to effective control of any infectious contagion. This has been very problematic with the current COVID-19 pandemic due to a lack of preparedness and adequate information leading to the inability to trace exposed/suspected cases. These problems include people not willing to provide correct contacts on arrival in the country and the sensitive nature of providing personal data that may infringe on an individual's right to privacy, fear of stigma, and forced isolation or quarantine sometimes in unsanitary facilities. Asymptomatic individuals may find this difficult to accept. To ease this process, digital technology has given us an enabling environment to develop CT apps. These apps can serve many functions: provide COVID-19 related information, monitor those in quarantine, trace movements, and give users rapid warning of their potential for having recently been exposed to SARS-COV-2[24],[27] and also to assess the transmission dynamics of the virus. However, the use of these apps has raised ethical and moral questions such as a lack of data security.

As part of the COVID-19 pandemic response, advisory bodies and experts have considered the ethical aspects of digital surveillance technologies including CT apps.[28] Balancing individual autonomy and the public good needs important consideration. Finally, as with SARS surveillance, the publication of surveillance data needlessly called unwelcome and even injurious attention to people of a particular racial or national background.[29] The origin of the disease from China unfortunately fueled negative Chinese stereotypes. There was also evidence of overt discrimination, stigma, and racism toward Chinese citizens in America. There is a need for sound political judgment based on scientific evidence to address stigma, group prejudice, restriction of movement, universal masking (wearing a mask in public places), and other activities as the world experiences continued surge in the number of cases from the pandemic.

   Isolation and Quarantine Top

The use of these two preventive measures is not new in public health practice. The approach to control different infectious diseases in the past has involved a range of interventions. These must depend on a variety of factors related to the pathogen's (i.e., the virus) mode of transmission, infectiousness, infectivity (virulence), incubation period, and susceptible risk groups.

Seven hundred years ago, the city of Venice, Italy, made history when it created a vast public health response and laid the modern foundation for coping with pandemics.[30] The Black Death (Bubonic plague) that killed about 25 million people in Europe and subsequent implementation of quarantine strategy by the Republic of Venice to contain the scourge are the examples of good public health practice.[30],[31] The Venetian Islands of Lazzaretto Vecchio and Nuovo, respectively, became isolation and quarantine centers. Thus, it is not surprising that the terms are used interchangeably. Isolation refers to restrictions on the activities of a person who is known to be infected. Initially, those with COVID-19 were being treated at specialist isolation units. However, as the number of cases increased, people were advised to self-isolate at home and only serious cases were taken to the hospital for monitoring and treatment. While quarantine (Italian word-quaranta, means “40 days”) is the restrictions on the activities of a healthy person or groups suspected of having been exposed to an infectious disease (COVID-19)[20],[32] and possibly go on to develop the disease.

In US law, quarantine often refers to both types of intervention, as well as to limits on travel. Isolation and quarantine can be either voluntary or enforced by laws.[32] In 2000–2003 during the SARS epidemic, the WHO instituted public health measures of isolation, quarantine, surveillance, CT and restrictions, and/or advisory warnings on travel. These rigorous measures were judged to be responsible for the quick interruption of transmission. However, the measures raised ethical questions, especially about the acceptability of interventions that infringe on personal liberties for the sake of reducing the risk of disease to others.[20]

It is quite disturbing that globally, the current practice of isolation and then quarantine has caused problems. Even though voluntary restriction of movement is preferred to forced restriction,[33],[34] human nature, and or behavior has made inevitable the need for forced restrictions in some situations. During a pandemic, when the state has declared a threat to public health, does an individual have any say in such a decision? Does an infected person or (suspected asymptomatic) groups have a right to decide where and even how to be isolated or quarantined? How much support do these individuals receive during the period of isolation?

In this context, the ethics of restricting social contacts or freedom of interaction need consideration. In this situation, it is the health authorities of the government that decides what constitutes a legitimate and fair process. However, the key elements of fair process will involve transparency about the grounds for decisions, appeals to rationales that are acceptable for meeting the health needs fairly and procedures for revising decisions in the light of challenges to them.[35]

A fair process requires publicity about the reasons and rationales that play a part in decisions. There must be no secrets where justice is involved. People will more likely accept and comply with decisions if they are aware of the grounds for these decisions.[36] In order to prevent stigmatization and harassment of those under isolation and quarantine, public education is needed to correct misconceptions.[37]

   Social Distancing Top

This is one of the cardinal public health (nonpharmaceutical) preventive measures in controlling the spread of COVID-19, but it has its own problems in the context of the environment in which it is implemented. Lockdowns and social-distancing measures have profoundly altered our social interactions. No more face-to-face interactions, handshakes, and hugging. With different measures of social distancing worldwide, the age-old societal norms which were part of humanity have all gone.

Although the WHO has recommended a distance of 2 m, in practice compliance has been between 1 and 2 m worldwide. It is not autocratic to demand that people maintain physical distance to save lives, but it is autocratic to demand it without giving people in different situations the means to do it. A lancet report showed a reduction in risk of 82% with a physical distance of 1 m in both health care and community settings. For every additional 1 m of separation, more than double the relative protection is achieved.[38]

Identifying the physical space is a major problem in highly congested and over-crowded communities in countries with emerging economies (or developing countries). In many situations, people especially in commercial centers, malls, and markets have chosen to exempt themselves from the measure based on their own understanding of the risk. Is it justified and right to open markets and malls while places of worship and schools remain closed? Does an individual have a right of choice in this context when the order has been enforced and predetermined? For those affected by man-made and natural disasters in internally displaced persons' camps (IDPs), can they be rightly penalized for flaunting these measures? Is it fair and justified to apply common sanction to those who did not adhere to social distancing due to lack of proper education and information? These are some of the ethical questions arising from the COVID-19 pandemic.

   Testing for Coronavirus Disease-2019 Top

This can be stand-alone for symptomatic cases, or as part of CT for suspected cases. Globally, since the WHO declared the pandemic public health emergency of international concern in January 30, 2020, the lack of preparedness for testing was evident and reported from designated centers both from developing and developed countries. The rigor, anxiety, and mental stress, together with the stigma associated with testing, can be agonizing to affected individuals.

For a disease with no known cure, what benefit or incentive awaits those who test positive? As people flaunt travel bans, how do you trace secondary contacts of a positive patient that has travelled hundreds of kilometers in a country that lacks even basic data on its citizens? Without being at risk of any force or coercion, what incentive is available to volunteers (akin to whistle blowers) for providing information about their contact with known positive cases? Is the testing voluntary or compulsory? Does an individual have the right to decline testing especially if s/he is asymptomatic? Is it fair and justified to conduct mass testing as public goods? With a mass shortage of testing kits, coupled with the current strategy of testing, it is going to be extremely difficult to have an effective well-coordinated CT programme to contain the pandemic now that we have gone far into community transmission? This is going to be even more challenging as lockdown restrictions are been relaxed.

   Vaccination for Coronavirus Disease-2019 Top

The development of COVID-19 vaccines (COVAX) can be seen to be fundamentally a confrontation between humanity and the virus. The race has been won by humanity and vaccinating the world is a moral and ethical obligation to produce herd immunity that will ensure everyone is protected. During these critical moments, the world needs to see itself as one global village that is united against the COVID-19 pandemic and regard the vaccines as global public health goods. Throughout this pandemic, the world has not much attention to the shared mission, shared vision, and shared sacrifice to contain COVID-19 virus. While discovering the vaccines was a test of science, making them available, accessible and affordable is going to be a test of our humanity.[39] Getting the world vaccinated may well be a litmus test.

There were initial concerns about the future COVID-19 vaccines[40] and a recent report from the US revealed that only 49% of Americans planned to get vaccinated against SARS-COV-2.[41] These fears enameted as a result of misinformation, misconception, and mistrust.[42],[43] Vaccine hesitancy remains a huge barrier to a successful full population vaccination against highly infectious diseases such as COVID-19. However, the urgency and pace with which Covid-19 vaccines were developed raises guanine concerns about safety of such vaccines that contributed to vaccine hesitancy. The WHO has considered it as one of the top-ten threats to global health.[43],[44] Getting vaccinated depends on many factors including individual responsibility for population and the common sense about the value of civic life and social solidarity.[45]

As countries role out their plans on vaccine procurement, distribution, and vaccination process, there is the need to focus on the pertinent ethical principles in population health maximization, justice, autonomy, the do no harm principle (nonmaleficence), public trust, and reciprocity and solidarity.[46] The field of public health ethics discusses different normative principles to guide good public health actions.[47] These principles are of particular importance to the current pandemic[46] and are summarized in [Table 1].[48],[49]
Table 1: Overview of ethical principles

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Unfortunately, the global demand for SARS-COVID-19 vaccines has already outstripped supply as many countries in the global north have placed orders. These countries are already in the forefront of supply queue which obviously will delay access to COVID-19 vaccines to a large majority of the global population. Recently, some countries in Europe and India are even holding on to delay supply until their own citizens have been vaccinated. This gives rise to the salient question of not who must get the vaccines, but who will be granted equitable access to the vaccines? It is important that the following safeguards be given consideration as COVID-19 vaccine development and supply continues to meet global demand:

  • First, evidence that the pandemic is still a public health threat and has not been adequately controlled by current preventive measures (testing, CT, isolation and quarantine) evidenced by rising cases and increased mortality. This is the current situation in the USA, some Latin American countries, and India
  • Second, strong evidence of vaccine safety and effectiveness among target populations. Even during pandemics, when large populations are at risk, vaccination is carried out among large numbers of healthy people. Because of this, vaccine safety must be ensured.[12] This has become both a moral and ethical necessity to guarantee public trust and acceptance
  • Third, evidence of effectiveness among target population or groups. Here, the ethical dilemma of who should receive priority (target population) need to be urgently resolved. Will it be vulnerable population such health-care professionals working in high risk settings, or working with high risk patients (nursing home residents) or elderly that are to be targeted? Despite its been available, coverage rates worldwide have so far been unimpressive
  • Fourth, adequate supply of vaccines to cover target populations or group. All logistic and financial barriers must be reduced to the barest minimum to guarantee access by all. Supply must be ensured at all points of care and equity must not be compromised. There are logistical problems both on demand and supply sides. As the WHO tries to make the vaccines available to developing countries through global access program of COVAX, all these issues need to be urgently addressed to ensure smooth delivery. Even in developed countries, arrangement for vaccination has not been straightforward and this can even exacerbate major heath disparities[50]
  • Fifth, informed consent, every individual receiving the vaccine must be well-informed about the benefits (public good) including the side effects of any SARS-COV-2 vaccines. There should be open and transparent communication on the best available evidence about the vaccines to guide against distrust, misconceptions, and vaccine refusal.
  • Finally, the conduct of challenge vaccine trials poses serious ethical considerations. Live pathogen challenge studies have been, in the past, for diseases where the pathogens and risks are reasonably well characterized and/or effective, safe treatments are available. In the case of SARS-COV-2, this is not the case. Thus, communicating about and assessing potential risks and benefits of participating in a challenge study and ensuring informed consent may be impossible.

Now that the vaccines are eventually available, how will they be equitably distributed? Is it ethically (and morally) right to start booking for a product (COVID-19 vaccines) that is still at the preliminary (clinical trial) stage? Will it be justified to give priority to countries with the highest number of cases - USA, Brazil, and India? The importance of public health programs being sensitive toward health inequalities and the implications of allocation strategies require careful consideration. Global solidarity might be tested even in a relatively straight forward situation, the international context of COVID-19 pandemic raises particular issues around equity, and these should be given due consideration in relation to vaccine distribution.[20],[51]

Recently, news that Russia hacked into SARS-COV-2 vaccine research in the US, UK, and Canada is disturbing and worrisome. At a time when global solidarity is needed among scientists/researchers to end the COVID-19 pandemic, this is a distraction. The ethical and moral dimensions of this incident are multi-faceted: It erodes ethical etiquette of scientific research, and undermines trust among researchers and collaboration between countries or continents.

Finally, to conduct research during a pandemic requires prompt ethical approval. It must be emphasized that all ethical standards for research must be respected in investigations carried out on all aspects of the COVID-19 pandemic.[52],[53],[54]

   Conclusions Top

The on-going COVID-19 pandemic has shown how globalized a society we live in, and it is testing our global interconnectedness and solidarity in terms of how governments around the world are responding to this health crisis. The pandemic has challenged our core public health ethics, individual rights, liberty, and human rights. To ensure respect for these ethical values and principles, soundness, transparency, and responsiveness must be evident in the process of adopting and implementing pandemic response policies.[55] Scientific evidence available has shown that better economic and health outcomes by adopting a cooperative, equitable, and fair distribution of COVID-19 vaccines on a global scale.[56]

During health crises, the need for ethical standards and accountability becomes imperative. Health-care providers, governments worldwide, and policy-makers have a responsibility, a duty of care to safeguard public health. Hence, all the public health preventive measures instituted play a crucial role in controlling the COVID-19 pandemic.

Placing importance on the common good is ethically justified. The pandemic requires difficult, but inevitable political and social decisions with ethical importance and complexity. It is the responsibility of governments to ensure public trust through transparent and timely communication and dialogue on all decisions taken.

Finally, governments must make sure that those affected by restriction orders are taken care of through the provision of basic needs without discrimination in an equitable manner. Even though, it may not be a one-size fits all model, the WHO guidelines should be followed based on each country's context.

Regarding vaccines, the WHO COVAX program is a step in the right direction to ensure transparent and equitable access to the vaccines, especially in less developed countries. The world has done it before COVID-19 pandemic can be controlled justly through our shared human values, responsibilities, equitable, and cooperative strategies by all the nations of the world to promote sustainable livelihoods and development.

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Conflicts of interest

There are no conflicts of interest.

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