The scientific community has succeeded in producing coronavirus disease 2019 (COVID-19) vaccines in record time; however, some countries are just receiving their first doses while others, such as the United States of America, have had vaccines since December 2020. Te gap between available vaccines and vaccinated people raises concerns around production of vaccines, rates of vaccination, coordination between agencies, vaccine hesitancy and global health equity. We propose that the approach to COVID-19 vaccination needs to address key ethical and social justice concerns. We believe that four issues are key to understanding current challenges to COVID-19 vaccination. First, vaccines have historically led to positive outcomes for the poor, but not without good stewardship. Vaccines have health and economic effects that help the poor, such as improving productivity, reducing severity of disease and costs, and promoting physical and mental health.1,2 However, the global uptake of vaccines has often been higher in richer segments of society compared to the poor, especially in the initial stages of rollout. National governments and international actors need good stewardship to monitor and course correct such differential uptake to ensure equity in delivery.3 COVID-19 vaccination programmes need to be pro-poor from the beginning to reduce economic vulnerability of those at higher risk.1,4 Second, COVID-19 has affected some groups more than others, and COVID-19 vaccines should not do the same. Te incidence of COVID-19 has been higher, and its severity more acute, in economically disadvantaged, minority and vulnerable populations.5 Widespread racial and ethnic disparities in COVID-19 infection and mortality is seen with disproportionately higher impact in vulnerable populations…more