Obligations in a global health emergency.

Ezekiel Emanuel and colleagues emphasise the ethical obligations of pharmaceutical companies to combat the COVID-19 pandemic on the basis of four ethical principles: optimising vaccine production; fair distribution; sustainability; and accountability.

We here add a fifth principle that arises from ethical considerations enshrined in the Helsinki Declaration, which requires that vulnerable groups participating in medical research benefit from resulting interventions. Populations in low-income and middle-income countries (LMICs) can be considered particularly vulnerable during the COVID-19 pandemic due to weak health systems, few possibilities to self-isolate in manual and informal labour markets, and insufficient social protection mechanisms.

LMICs have nonetheless contributed substantially to the research on COVID-19 vaccines: of 199 country locations for 145 registered trials for the seven vaccines currently recommended by WHO, 2% were in low-income, 9% in lower-middle-income, 28% in upper-middle-income, and 62% in high-income countries (appendix). The considerable share of country locations in LMICs (39%) stands in stark contrast to the fragile access to vaccines in these regions. As of July, 2021, the share of the population that had received at least one dose of a COVID-19 vaccine was 1% in low-income, 8% in lower-middle-income, and 19% in upper-middle-income countries.

By September, 2021, the share had increased in lower-middle-income and upper-middle-income countries, but the pace has been painstakingly slow, and low-income countries have barely made any progress. It is unacceptable that COVID-19 vaccine access in LMICs is based on voluntary international initiatives (eg, COVAX) or donations alone. Instead, the aforementioned ethical principle should be translated into binding legal mechanisms obliging pharmaceutical companies to guarantee access to the fruits of medical research for vulnerable populations who participated in human experiments.

We declare no competing interests.