Q&A: The Human Rights Lessons from Bulgaria’s COVID-19 Failures

A woman receiving a shot in her arm.
A woman receives a COVID-19 vaccination shot in Sofia, Bulgaria, on February 2, 2021. © Georgi Paleykov/NurPhoto/AP

Throughout the COVID-19 pandemic, Bulgaria has had one of the highest rates of death from the virus in Europe, together with the lowest rate of vaccination. Many of these deaths likely could have been prevented if the Bulgarian government had prioritized effective access to vaccines for vulnerable groups, such as older people and people with existing health problems. The Justice Initiative has filed a human rights complaint before the European Committee on Social Rights (ECSR) against Bulgaria over its policies in a bid to learn lessons from the failures of the pandemic and to strengthen protections for the future under the European Social Charter.  

Doctors Ranit Mishori and Brianna da Silva Bhatia, from Physicians for Human Rights, submitted an expert opinion before the ECSR that highlighted how low vaccine uptake in Bulgaria was likely a significant contributing factor to the disproportionately high COVID-19 mortality rate in the country. Maïté De Rue of the Justice Initiative spoke to them about the case.

In disasters like the COVID-19 pandemic, what are the expectations for national authorities to foster regional and global collaboration, as well as to share information about the effectiveness and safety of the vaccines? 

First, we want to recognize that this many things were unknown in 2020. Governments made decisions with little information. However, research and data regarding high-risk groups and medical conditions, as well as expert advice, became available in early 2020. Vaccine clinical trial, safety, and efficacy data also became available in 2020. By the end of 2020, leading expert organizations endorsed COVID-19 vaccination and published guidelines on best-practices for their allocation.

So, governments had information and material to review to help guide vaccine rollouts. Further, a substantial body of research existed by the one-year mark of the pandemic. 

From the outset, there was a clear consensus from various international experts that older adults and people with medical conditions were at a significantly heightened risk of severe disease and death and should have been prioritized for vaccination. 

There was simply no good reason for any government or health authority to ignore these guidelines and recommendations. Bulgaria’s early vaccination plan and subsequent “green corridors,” which allowed any Bulgarian resident regardless of age or medical condition to receive the vaccine, were in stark contrast to global best practices and international consensus. Green corridors de-prioritized the most vulnerable and at-risk Bulgarians. 

The pandemic showed us the importance of prioritizing vulnerable groups for access to vaccines and therapeutics. Can you make the case for putting these individuals at the front of the line, before younger, healthy individuals?

Certain groups are “vulnerable” because they have conditions or situations that put them at higher risk for exposure, disease, or death. In the context of COVID-19, this included older age and having underlying health conditions. Further, as we have already seen, essential workers are likely to be repeatedly exposed to or spread COVID-19. 

When resources are limited, governments must step in and have a process to protect vulnerable groups by prioritizing the delivery of public health interventions to those who need them most. 

In Bulgaria, authorities prioritized essential workers, but not older people and those with underlying health conditions. Older people accounted for the vast majority of deaths in the country even after vaccine availability in 2021. By mid-2021, the uptake of two vaccine doses in vulnerable Bulgarian groups, including people in long-term care facilities and older people, was the lowest in the European region. 

In fact, even currently, Bulgaria compared to the European Union (EU) continues to have the lowest amount of vaccine doses administered, the lowest number of people fully vaccinated, and the lowest number of administered booster doses. Further, Bulgaria has the lowest cumulative uptake of a primary series of vaccines among people above the age of 60 years, compared to EU nations. 

Everyone has the right to health and to benefit from scientific progress. Governments have a responsibility to prioritize response based on the vulnerability of certain populations, including groups that might experience a health crisis more severely based on, for instance, their age, gender, or ethnicity, or because of their geographical settings or lack of accessibility.  

How should the authorities have informed and educated populations about the benefits of vaccines to tackle vaccine hesitancy and combat misinformation? 

Health crises are often accompanied by the rapid spread of false information and rumors, which is why best practice in health communication and infodemic management requires the delivery of accurate, timely, and linguistically and culturally appropriate messaging by trusted sources. 

During crises and health emergencies, governments have a responsibility to provide trustworthy information. When health communication is done well, it is tailored to different communities and delivered in channels and venues where people are likely to receive information. It helps individuals take evidence-based action, reduces fear and panic, as well as helps counter false or misleading information. 

In the case of COVID-19 vaccines, governments and health leaders have a responsibility to transparently convey the available scientific information in comprehensible terms, as it was emerging. 

In late 2020, as vaccines were being manufactured and prepared for delivery, data confirming their safety and efficacy was available. In both Bulgaria and globally, this data could and should have been better explained to the public. In 2021, Bulgarian authorities, such as the Council of Ministers, and especially the Ministry of Health, could have better shared emerging data, such as summaries of population data or health registries demonstrating vaccine safety and efficacy. Lastly, governments and health authorities in Bulgaria and globally needed to more vigorously combat pre-existing vaccine hesitancy and misinformation, far before the vaccine roll outs actually began.  

What are a few lessons learned from the COVID-19 pandemic when it comes to vaccine allocation/prioritization, and how can countries apply them to protecting and promoting human rights in a future health emergency? 

Global coordination and collaboration are essential to respond to the next health crisis. Global solidarity—particularly when it comes to sharing scientific advancements and resources like vaccines—would have saved lives and reduced suffering. Such collaboration and coordination would entail employing early and regular communication, coordination, knowledge and technology sharing, equitable funding, and infrastructure support with investment in public goods and public safety net services. Bulgaria’s failure to adhere to international norms that were developed and shared during 2020 and 2021 around vaccine prioritization and rollout led to tragic consequences for its population. 

A second lesson that we need to recognize is that inaction—such as decades of underinvestment in global health and health infrastructure—hinders an effective pandemic response. In the context of COVID-19, these failures have yet to be remedied—the public health emergency may be over, but the causes remain. Further, a “me first” approach allowed vaccine and supply hoarding in high-income countries, disrupted supply chains, and limited the right to health of people, particularly those in low- and middle-income countries. 

Third, multiple fundamental human rights such as the rights to equality and nondiscrimination, freedom of movement, the right to seek asylum, and others, are particularly fragile during emergencies and disasters. Governments and states have an obligation and duty to fulfill and protect human rights at all times, including during public health emergency preparedness, response, and recovery. Governments must work to ensure that non-state actors—such as actors from the pharmaceutical industry who are involved in emergency preparedness and response—also uphold, protect, and promote human rights, including the right to health. 

Lastly, while the world has rightly focused on the unequal distribution of COVID-19 vaccines and related technology globally, another type of vaccine injustice has been overlooked: discriminatory and inadequate domestic vaccination policies. These domestic plans left at-risk and marginalized groups behind, and undoubtedly contributed to avoidable and excess deaths. 

As part of pandemic and public health emergency preparedness, it is imperative that we reflect honestly on and scrutinize poorly executed domestic vaccine rollouts. Domestic vaccination policies must ensure that limited supplies of vaccines are distributed in an equitable, fair, and nondiscriminatory manner, and safeguard the most vulnerable groups. Compliance with human rights standards and scientific evidence should be central to any public health policy.

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