Is Vaccine Passport the COVID Endgame?
By Arunima Rajan
Healthcare activists, academics, lawyers share their views on trade-offs, advantages, legal and ethical issues of vaccine passports.
Yohan Tengra is a 24-year-old Mumbaikar works with a healthcare start-up called iThrive; he works as the Chief Knowledge Custodian. He runs the Instagram page Anarchy for Freedom India and is also part of the anti-mask movement in Mumbai. "The efficacy claims of COVID vaccine are dubious. They use relative risk analysis instead of using absolute risk. Vaccine passports shouldn't be mandated, especially since efficacy isn't completely proven. We are planning to organise a protest on the 24th of July to protest against vaccine passports, vaccines as well as mask use," says Tengra, who hasn't taken the vaccine yet.
COVID-19 immunity passport has been embroiled in polemics ever since discussions started about its implementation.
What is a Vaccine Passport?
"Vaccine passports are mainly digital documents with information about your vaccination status. Platforms may be different from each other. Some apps or platforms may have your testing results, and others may have your vaccination records or both. In the US, the CDC has issued paper-based certificates for those who have taken the vaccine. States such as California and New York have started to roll out digital portals, either through a website or an app, for their residence to verify their vaccination status. Not all certificates are called passports. In the EU, these are Digital Green Certificates," says Soumitra Bhuyan, Assistant Professor, Edward J. Bloustein School of Planning and Public Policy, Rutgers University-The State University of New Jersey.
Amid arguments, there is a broad consensus that these portals or vaccine passports have important implications for travel, specifically for international travellers, as each country has different requirements. "However, how different jurisdictions within a country will use these portals or vaccine passports is still not clear. For example, some states in the US, including Arizona, Florida, and Texas, actually banned these vaccine passports or requirements for any COVID-19 vaccine documentation for the business. States like California require a business to verify the negative COVID status or vaccination status in mass events," Bhuyan adds.
These digital certificates also have implications for workplaces. "I believe, in the future, and depending on the natures of future mutations of the virus and prevalence, some digital documentation for the positivity or vaccine status may be a requirement in workplaces on an ongoing basis. More true if we need to get a booster dose at a specific interval after the initial shots of the vaccine. These changes are happening so fast that we are still struggling to implement laws to safeguard healthcare data privacy and security in our workplaces. There is evidence of a gross violation of patient privacy during the initial stages and even committed by governments worldwide," Bhuyan explains.
Is it a polarising concept in the US?
"Vaccination is still a polarising concept in the US. In the last few weeks, the rate of vaccinations has slowed down. And, with the new surge of the Delta variant among all the new cases, this is a significant concern. As I said earlier, states have different laws and regulations about these vaccine passports or any web portals and apps and how these can be used. The US lawmakers are still debating some of the privacy laws about the use of these vaccine passports. It is essential to protect the fundamental rights of the citizens without proof of vaccinations. As of last week, only four states (California, Hawaii, Louisiana, and New York) are actively using vaccine passports. As many as 19 states have some ban on vaccine passports," he adds.
Who are the key stakeholders in developing these apps?
"In the US, different states usually have different programs so far. For example, New York has an app, Excelsior app. The state of California is introducing a web portal to verify the vaccination status. The Excelsior app uses the state vaccination record and verifies the status. However, there have been issues with a technical glitch in the system, and many could not use the app. Data quality is critical for such systems to work. The vaccine passports are not HIPPA violations, as patients can self-disclose their information. Moreover, HIPPA laws are limited to healthcare organisations and business associates," he explains.
Benefits of Digital Health Passes
Happymon Jacob, Associate professor of Diplomacy and Disarmament at JNU, has a different take. "I agree that the concept of vaccine passports is elitist and tend to contribute to inequities. And yet, there seems to be no alternative or way around it. The world can't come to a hard stop until all citizens are vaccinated. People have to travel; students need to get to their universities, businesses have to reopen etc.; so there has to be some way of deciding who can be allowed to travel. Vaccine passport seems to be the only available option at this point for want of a better alternative," he explains.
Prasanth Sugathan, Legal Director, SFLC.in, argues that vaccine passports are credentials that one has been vaccinated, and they act as proof of the same. "Several countries do require mandatory vaccination shots for diseases like Yellow Fever for international passengers. These health passes have been in place for a while but have been popularised by the COVID-19 pandemic. One of the biggest benefits of these passports is that it works as proof that one has been vaccinated against a certain disease and that one does not pose a high risk of spreading the disease to others," says Sugathan
He highlights two significant vaccine disadvantages passports. "It unfairly punishes those who have not been vaccinated against such disease due to the lack of vaccines in their region or country. Then, similar to the current EU situation wherein Covishield and Covaxin are not featured in the list of approved vaccines, citizens of such countries who received these vaccinations would be barred from travelling to other countries. Another challenge could be compulsory e-passes. One of the biggest challenges in implementing a digital health pass is the smartphone/ smart device penetration. Several countries, including India, have less than 50% smartphone penetration. The second issue is accessibility and digital literacy- a large section of India's population, for instance, is not digitally literate and, therefore, will find it challenging to access digital certificates," says Sugathan.
What about privacy issues?
The deepest concern of experts has been about privacy. Vaccine certificates include personal information such as one's address, ID card number, contact details, health ID number. This information is sufficient to trace a person. Besides, sharing certificates virtually makes it easier for malicious parties to forge certificates leading to identity theft. This means that a malicious person can modify someone else's certificate and pass it as their own.
"Gavi and its COVAX partners call on all countries contemplating using vaccination status as a prerequisite for travel not to widen further today's already glaring global vaccine inequity and accept all vaccines validated by WHO Emergency Use Listing (EUL) or approved by Stringent Regulatory Authorities (SRAs)," says Thabani Maphosa, Managing Director for Country Programmes at Gavi, the Vaccine Alliance.
Vaccine Passports versus Vaccine Scarcity
Dr Swapneil Parikh, author of the book, The Coronavirus warns that in the current context of vaccine scarcity and global vaccine inequity, creating one set of rules for vaccinated individuals and another for unvaccinated individuals will perpetuate inequity. "If the COVID-19 vaccines were available to everyone who wanted them, like the yellow fever vaccine or the polio vaccine, that would be a very different scenario. Currently, the vast majority of COVID-19 vaccinations have occurred in just a handful of countries. Many low and middle-income countries in Africa, Asia and South America do not have adequate vaccines. The very countries that have suffered high infection and high mortalities due to lack of access to vaccines will now face discrimination issues to vaccine passports," he explains.
He admits that massive inequities in vaccine access cost lives. "It seems ethically and morally incorrect to roll out a vaccine passport system that creates an immunity-based class system when most low-and middle-income countries can't access vaccines. If such a system does go into effect, many western countries would essentially have restrictions for most people from Africa, Asia and South America. How do we reconcile such a system with values of equity, justice and fairness?" he asks.
There are ethical and moral objections to such a system, but there are scientific concerns. Many vaccines reduce asymptomatic infections and reduce onward transmission, but not all vaccines have been studied for this purpose. "Not all individuals respond to vaccination in the same way. While it does appear that some vaccines significantly reduce transmission, this may not hold true for all vaccines and all subsets of people. How would vaccine passports work for immune-compromised individuals? Some such individuals may not be adequately protected by vaccination, will there be a different set of rules for them?" Parikh asks.
What does a vaccine passport fetch vulnerable communities?
Oommen John, Senior Research Fellow, George Institute India, thinks that vaccine passports in India and elsewhere perpetuates inequities. "The digital gatekeeping of access to COVID-19 vaccination combined with the preferential access to vaccines through the private sector pay for service model implemented by India during the initial phase of the vaccination programme restricted the opportunities for vaccination among those without access to the internet or those who could not afford to pay. In such a situation enforcing a vaccine passport to restrict travel or mobility for economic activity, education or recreation would adversely impact individuals and add further to the sluggish economic outlook. Vaccine passports will further and amplify existing inequities. Marginalised and vulnerable communities who do not have access to routine health services are the ones who need the vaccines most. They are the ones who are unlikely to get a vaccine, and the linked vaccine passport, thereby excluding them from participating in economic activities, might even deny them their basic rights should the vaccine passports evolve into the bedrock for a digital surveillance led capitalistic economy" he explains.
EU Green Pass
John also talks about how Indians till recently had access to only two vaccines Covaxin and Covishield. "A large majority of those who have been vaccinated have got Covishield. If a country or group of countries deny entry into their territories based on the type of vaccine, it is essentially building a wall of vaccine apartheid. One needs to keep in mind that in the middle of the pandemic, most vaccines have been licensed under EUA. In this context, as countries do not have full visibility into the comprehensive safety profile of the vaccines, their choice of vaccine is based on availability and affordability. For example, the cold chain capacity in India is not capable of mRNA based vaccines when the vaccination strategy was being developed, India had to rely on vaccines that its health systems could deliver, how can the citizens of a country be penalised with such restrictions in effect this will amount to forcing citizens to wait for other vaccines which make them eligible for the Green Pass and in the process of such a wait face eventualities should they get infected," explains John.
Do private businesses have the right to impose vaccine passports?
But can companies ask for vaccine certificates as a precondition for employees to return to work?
"I agree that mandating or requiring individuals in India to show proof of vaccination (especially digital proof) will perpetuate inequities. Internet access in India is only at 57.29% and is further fragmented due to the divide between urban and rural India, and the division also cuts across class and gender. Also, initially, the vaccines were not free for the 18-45 year age group (or were free only at government centres), and therefore, people could not access the vaccines. Vaccination is optional in India, and the government has stated that it is not looking at making it mandatory. No law at present makes vaccines compulsory. So I don't believe companies can require proof of vaccination as a precondition for employees to return to work," says Pallavi Bedi, Senior Policy Officer at The Centre for Internet and Society.
Proof of Immunity= False Assurance?
Dr. Bharesh Dedhia, Consultant, Critical Care at P.D.Hinduja. Hospital and Medical Research Centre, Khar, argues that a vaccine passport is nothing but a document that establishes whether you are eligible to travel and indeed enter jurisdictions where the vaccine passport is necessary for entry. "The Aarogya Setu is nothing but the same concept at work and has been actively used for domestic travel since the first wave. However, when this is expanded to the international space, it is likely to be problematic to a large country like India, where the huge population, many of whom are not tech-savvy, may find it difficult to fulfil the international criteria for travel if a "Vaccine Passport" becomes mandatory, explains Dedhia.
Would a Vaccine Passport lead to a false assurance among people and lead to the spread of the pandemic? "Indeed, having a "Vaccine Passport" would like to give the bearer a false sense of security and assurance that they can now travel with impunity and therefore may travel with a lowered sense of safeguard measures, like wearing masks, hand hygiene and ensuring proper social distancing. Therefore theoretically, this behaviour may lead to the spread of the pandemic. WHO has also suggested that vaccine passports may prompt people to lower their guard. Also, it is known that while vaccines may prevent the person from getting a severe disease, it will not necessarily prevent a mild infection which could be transmissible and infect others," he explains.
The Balancing Act
The question now is what could be sufficient alternatives for the indigent. Part of the answer may lie in a gradual implementation of vaccine passports. These are questions for which many policymakers don't have answers. Chandrakant Lahariya is a public policy, vaccines and health systems expert based in New Delhi. "The value of COVID vaccination is relatively shorter, might be a year or two. Once the disease becomes endemic, there won't be any value for these passports," says Lahariya.