With increasing numbers of people being fully vaccinated against SARS-CoV-2 worldwide, governments have been considering the implementation of vaccine passports. Vaccine passports (VP), also known as digital health passes or immunity passports, are certificates that provide details of vaccination against a pathogen. The main rationale for these passports is to return to pre-COVID times, allowing safe return to work, activities, travel, and access to healthcare without increasing viral spread. Lockdown is a one-size-fits-all method to restricting movement and contact between individuals. While this measure has proven to be effective in preventing viral spread, it can be detrimental in other aspects such as financial stability, mental health, and economic growth. VP would minimize the number of restricted individuals and maximize freedom of those with negligible risk of spreading disease. The requirement may also incentivize vaccination and support the development of herd immunity.
However, there are some ethical considerations. VP could potentially exacerbate existing inequities and create hierarchies in immune status, as evidenced by the history of yellow fever in the Southern United States in 1800s. Survival from yellow fever became associated with virtue, heavily impacting employment, housing, and even eligibility for marriage. For the enslaved, this new hierarchy of health was bad news. Some pro-slavery advocates claimed black people were born with immunity. Others justified that slavery maintains safety of white people. Moreover, enslaved individuals that survived yellow fever were appraised at higher values, benefiting their wealthy owners. Vast disparities in equity have become apparent as the pandemic has raged on. For example, while many people had to adjust to working remotely, the truth is that this option is a luxury primarily available to higher income workers. Not only are lower income workers less likely to have the option of working from home, they are also more likely to work under conditions that have higher risk of exposure to the virus and to live in crowded or high density housing. Another key ethical consideration of VP is universal vaccine access. It’s been shown that communities that experience the highest levels of economic difficulties and barriers to healthcare access, including vaccines, are the same communities which have been hit hardest by the pandemic. Less than 1% of people in low-income countries have received their first vaccine dose. In contrast, over 80% of the vaccines produced have been distributed to high income nations, highlighting the gap in equity across the globe. Implementation of VP could drive further structural inequities. Moreover, a return to normalcy may result in decreased pressure to support marginalized communities in vaccine access. Besides availability of vaccines, vaccine hesitancy is prevalent amongst marginalized communities. There is deep-rooted mistrust in government and medical institutions due to history of racism, medical abuse, and human experimentation. Thus, it is critical to support vaccine awareness and healthcare access amongst these communities, especially with the immense amount of misinformation being shared. Furthermore, vaccines are contraindicated in people with allergies, serious health conditions, and pregnant women while children under the age of 12 are not yet eligible for vaccination. Restricting those who are unable to be vaccinated has ethical implications. Any implementation of VP must accommodate medical contraindications and religious beliefs, as well as prevent discrimination, whether for travel, in the workplace, or even in daily life.
Despite the ongoing debate, local governments and corporations, such as airlines and cruises, are rushing to develop systems for VP. Health data is sensitive information; thus, privacy and authentication of the records must be of utmost priority. Issues of forgery or fraudulent vaccine passports could arise. Moreover, this data could be subject to hacking or used to benefit large corporations for marketing purposes, rather than public health. To circumvent some of these issues, roll out of VP should be standardized and implemented on an international level. However, initial responses from governments to this divisive matter already suggests that this will not be the case.
Beyond ethical and legal considerations, there are also scientific challenges to the use of VP. Vaccination does not always translate to immunity. Responses to vaccines are dependent on many factors such as the individual’s immune system, health conditions, and medical history. The efficacy of available vaccines differ as well. It is important to identify an accurate measurement of immunity post-vaccination. Moreover, the durability of the immune response to the vaccines is still uncertain. How long are you protected for after vaccination? Does protection wane over time? Are these vaccines protective against the emerging variants of concern?
There are numerous benefits to vaccine passports, on the individual level as well as the community, enabling reduced restrictions, increased assurance of safety, and incentivizing vaccination. Implementation will need to address data privacy, standardization, scientific limitations, and, most importantly, global vaccine equity. We should leverage our current understanding to address local and global structural issues to avoid perpetuating the already massive disparities in equity. Vaccine passports have the potential to do a lot of good as long as we don’t turn them into yet another barrier.
Citations
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2. Padma, T.V. Nature (2021).doi:10.1038/d41586-021-01762-w
3. Phelan, A.L. The Lancet 395, 1595–1598 (2020).
4. Osama, T., Razai, M.S. & Majeed, A. BMJ 373, n861 (2021).
5. Reichel, C. Bill of Health (2021).at <http://blog.petrieflom.law.harvard.edu/2021/04/07/vaccine-passports-covid-ethics-law/>
6. WHO (2021).at <https://www.who.int/news-room/commentaries/detail/immunity-passports-in-the-context-of-covid-19>
7. Williams, M. The Conversation (2021).at <http://theconversation.com/the-ethical-questions-raised-by-covid-19-vaccines-5-essential-reads-163604>
8. Robinson, K. Biopharma from Technology Networks (2021).at <https://www.technologynetworks.com/biopharma/articles/the-ethics-and-safety-of-covid-19-vaccine-passports-349233>
9. Chang, A. NPR.org (2021).at <https://www.npr.org/2021/04/06/984829952/the-ethics-of-vaccine-passports>
10. Brown, R.C.H., Kelly, D., Wilkinson, D. & Savulescu, J. The Lancet Infectious Diseases 21, e58–e63 (2021).
Ling Ling Tai
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