Bioethics Forum Essay

Covid-19 Vaccination Certificates: Prospects and Problems

In the early days of the pandemic, Covid-19 immunity passports were proposed as a useful tool to allow some individuals to return to work, shopping, cultural events, and travel. These passports were to be issued to those presumed immune to Covid-19 because they had either recovered from the disease or could prove they had previously been infected by testing for circulating antibodies.

Immunity passports were to help reopen economies and allow individuals to resume normal activities under the presumption that those with a passport were no longer a threat to others and could therefore be exempt from Covid-19 public health measures.

From the beginning we argued that immunity passports were scientifically unsound and ethically perilous. We noted a lack of robust scientific evidence about how Covid-19 immunity worked, and drew attention to serious ethical concerns about privacy, the potential for discrimination, and the risk of exacerbating existing social inequities.

Now, with limited distribution of vaccines with varying degrees of efficacy there is renewed interest in immunity passports; more accurately described as vaccination certificates.  Israel is leading the pack. With more than 40% of its population fully vaccinated, it has started to reopen its economy, relying on its self-styled Green Pass. Those who have been fully inoculated with a vaccine or who can prove they have recovered from an infection with SARS-CoV2 are free to return to movie theatres, gyms, and their vacations in Greece. Those without government-validated certification cannot. Other countries, including the United States, China, Canada, and the United Kingdom, and the European Union are now considering some kind of similar program.

With Covid-19 vaccines now in the arms of some but not others, it’s as if everything and nothing has changed. Indeed, there is a growing chorus of people suggesting that vaccination certificates are inevitable.

This suggestion is accurate insofar as anyone who receives a vaccine must be given relevant documentation.  What remains to be determined is who may use this documentation for what purpose. In high risk settings, such as long-term care homes and health care centers, vaccination records will be an important tool to protect those most vulnerable, and by extension, public health. However, broad application of vaccination certificates risks prolonging the pandemic and increasing harm. Governments must act quickly to develop effective and just policy to protect the interests of “all” citizens before private companies implement ad hoc mandates for proof of vaccination.

1. The policy should be evidence informed.

All authorized vaccines are known to be safe and effective at protecting against severe disease and death from Covid-19.  Missing, however, is robust vaccine-specific data about transmissibility. Preprint data suggest that both the Pfizer-BioNTech and AstraZeneca Covid-19 vaccines provide some level of protection from transmission of SARS-CoV-2, but by how much and for which variants remains to be determined.

Uncertainty about viral transmission is compounded by the emergence of new SARS-CoV-2 variants, for which available vaccines are already demonstrating varying degrees of efficacy at preventing disease.

Data about the level and duration of transmissibility should inform vaccination certification policy, for example by delineating vaccine specific expiration dates. Furthermore, vaccination certificates cannot be used to guarantee safe international travel until transmission data, specific to each vaccine and for each variant, is in hand. If a vaccine fails to prevent transmission, travelers to countries with low vaccination rates could put the health of entire nations at risk and thereby prolong the pandemic.

2. The policy should not further entrench inequity.

The World Health Organization is developing key specifications and standards for digital vaccination certificates. It nonetheless explicitly warns against the use of these certificates for international travel owing to limited information about the impact of vaccines on transmission and limited supply of vaccine.

As many predicted, inequitable access to Covid-19 vaccines is pervasive. For example, Kenya (a country of nearly 53 million) has only just received its first shipment of 1 million vaccines, and it’s predicted that the vast majority of lower-income countries won’t have national vaccine roll-out until 2022. This inequity is fueled by a complex interplay between histories of colonization, imperialism, economic disadvantage, systemic racism, and discrimination on the basis of race, ethnicity, and religion, among other factors. Dismantling these systems of oppression during a global pandemic is nearly impossible. However, policies that entrench existing oppression and inequity are indefensible.

Inequity in access to vaccines is not just a problem between borders, but also within borders. One need look no further than Israel, where residents of the West Bank and the Gaza Strip, predominantly Palestinians, have been systematically left out of vaccination efforts. A recent report out of the U.S. documented vaccines earmarked for predominantly African American communities being diverted to the wealthy, predominantly white, elite.

Vaccination certification mandates must not be layered on top of these existing inequities.

3. The policy should not exacerbate mistrust.

There are individuals who are vaccine resistant (who reject vaccination for religious or personal reasons) and others who are vaccine hesitant (who are unsure about being vaccinated). For many in this second group there are concerns about the novelty of Covid-19 vaccines, the speed by which they were developed, and distrust in the institutions that produce and distribute vaccines. Some people who are vaccine hesitant come from communities that have experienced considerable racism and have long histories of mistreatment by the medical profession and the government – Indigenous and First Nations peoples, Blacks, communities of color, immigrants and refugees.

Using vaccination certificates to discriminate against those who choose not to be vaccinated or effectively coercing or rushing people into vaccination, by restricting activities of daily living to those who have been vaccinated, will only create more distrust in public health institutions. Initiatives that build trust in the public, with specific attention given to increasing access to marginalized communities should instead be prioritized (see Black Doctors Covid-19 Consortium for an example of success).  

Vaccination certification policy must make fair and just provisions for those who are not vaccinated.  It is not only those who “can’t be vaccinated” for medical reasons who need protection from discrimination.

4. The policy should be aligned with public health objectives.

Various ethical concerns with vaccination certification policies have been raised concerning privacy, risks of forgery and corruption, and the potential to increase discrimination and create new platforms for discrimination on the basis of immunity and vaccine status. These are valid concerns that should be addressed by any such policy. However, we have deeper concerns about the motivations and ethical underpinnings that steer such policies. 

In public debates about the merits of vaccination certification, at least three discrete rationale have been advanced: 1) to jump-start flailing economies, 2) to return to some semblance of a “normal” pre-Covid- life which includes international travel, and 3) to assist public health with the overarching goal of reducing viral transmission.  Arguably only the last of these goals fits squarely within a public health ethics.

It’s been a long year, and we empathize with the desire to return to social and leisure activities, but nevertheless, the global pandemic persists. A failure to undergird policy with a public health ethic–centered on the common good and protecting the most vulnerable–could prolong the pandemic and exacerbate harm.

It is imperative that governments are explicit about the ethical commitments that support any vaccination certification policy. Motivations rooted in neocapitalism and individual liberalism are at odds with public health ethics. They put citizens at risk and imperil the global community.

Natalie Kofler is the founder of Editing Nature, leads curriculum development for the Scientific Citizenship Initiative at Harvard Medical School, and is a visiting fellow at the E.J. Safra Center for Ethics at Harvard University. Twitter: @NatalieKofler. Françoise Baylis is University Research Professor at Dalhousie University in Halifax, Canada. Twitter: @FrancoiseBaylis