Abstract
Determining whether an allocation is equitable requires ethical and empirical analyses, specifically answers to 3 questions: (1) What is the ethical standard for fair allocation? (2) What is the quantitative equity metric for this standard? and (3) What do the empirical data demonstrate? Two ethical standards for assessing the fair allocation of scarce medical resources have been delineated: the COVID-19 Vaccines Global Access initiative's population-based standard and the COVID-19 health-burden standard. The equity metric for the population-based standard is vaccine per person in each country, and for the health-burden standard it is vaccine per excess deaths per country. When using excess deaths data from the World Health Organization and vaccine data from the United Nations Children's Fund, the health-burden standard showed that middle-income countries with high excess deaths (e.g., Indonesia, Peru, Mexico, Egypt, South Africa) were treated inequitably: not provided enough vaccines given their high excess deaths. The right standard to assess fair and equitable allocation is a health-burden assessment. According to this standard, contrary to assumptions and initial claims, low-income countries were not treated inequitably in COVID-19 vaccine allocation, and middle-income countries with high excess deaths were treated inequitably. (Am J Public Health. 2025;115(7):1085-1094. https://doi.org/10.2105/AJPH.2025.308077).
