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April 21, 2021

Vaccine Passports Done Equitably

Author Affiliations
  • 1Faculty of Law, Common Law Section, University of Ottawa, Ottawa, Ontario, Canada
JAMA Health Forum. 2021;2(4):e210972. doi:10.1001/jamahealthforum.2021.0972

Around the world, governments and other organizations are developing COVID-19 vaccine passports—documentation to allow vaccinated people greater mobility and access to other services—to speed society’s reopening and a return to ordinary life. But vaccine passports are controversial: sources of opposition include scientific questions—for example, whether vaccinated people can still transmit the virus—and concerns about privacy, especially in connection with digital passports. Each of these are likely to be solvable problems. Evidence of vaccine effectiveness continues to accumulate1 and will eventually answer questions about lasting immunity and transmission. Privacy concerns could be mostly addressed by adopting passport alternatives that satisfactorily protect individual’s information, and such efforts could be advanced by government attention and regulation.

A deeper and more intractable concern is that any system of vaccine passports risks being discriminatory and inequitable. Consider the inequities we see already2 in the distribution of COVID-19 vaccines: supplies and distribution have predictably favored richer countries. Historically and socially marginalized groups are less likely to be vaccinated, often because of worse access, but also because of vaccine hesitancy based on intelligible mistrust of government and historical experiences of medical abuse. For people who are unable to be vaccinated because of their health status or religion, a vaccine passport regime could unfairly frustrate their return to normal life.

In general, the problem is that existing inequities threaten the future equitability of any vaccine passport scheme. However, achieving perfect equitability may be impossible. It would require going beyond improving access to vaccines and making sure people who cannot be vaccinated are not “damned for their disability”; it would also require us to resolve substantial social, economic, and health inequalities among nations and individuals. These may not be solvable problems, at least not in the short term.

Fortunately, good policy need not be flawless, and there are many ways for policy makers to promote equity in the context of vaccination and vaccine passports. For example, a community-led approach to promoting vaccine uptake executed by trusted community leaders, organizations, and local health care institutions could address the issue of mistrust.3 Such an approach is being used by some Indigenous health leaders in their work with Indigenous individuals who may be vaccine hesitant. In support of accessibility, mobile vaccination units and vaccination clinics in smaller communities should be deployed. It would also be advisable to implement systems to monitor the outcomes of vaccine passports themselves: monitoring brings accountability and transparency and provides information to guide future policy making.

To the extent that vaccine passports are useful, regulating against them makes sense only when they would create worse problems than they would solve. Disallowing vaccine passports will not fix our inequities, and there are obvious situations in which requiring proof of vaccination is appropriate and well advised. For example, there is a clear public health interest in tightly controlling international travel during a pandemic, and many governments, airlines, and others have been motivated to implement proof of vaccination as a condition for air travel. Vaccination requirements for travel are not new4 and can be implemented equitably as long as they respect human rights and are not too restrictive.5 With respect to people who cannot be vaccinated for health reasons, there is middle ground here: it is unnecessary to completely bar unvaccinated people from activities like air travel. Vaccine passports could facilitate a fast lane for travel without the extra testing, quarantines, or other measures that the pandemic has made necessary in many places. That such compromises could soften the differential impact of vaccination requirements on the vaccinated and unvaccinated often goes unnoticed.

Travel aside, some critics worry that vaccine passports will be deployed as “a passe-partout [for] spaces including the workplace, theaters, cinemas, sporting venues, and places of worship.” Again, in some of these contexts, vaccination requirements are justified from a public health perspective, for instance, requiring proof of vaccination from health care workers or from individuals applying for admission into long-term care. However, going forward, if we take seriously the idea that we should use only the least restrictive measures, it is hard to see why people who are vaccinated should continue to be subject to restrictions when there is little public health rationale for it. This does illustrate an important prima facie dimension of unfairness in implementing vaccine passports: people who are not vaccinated will experience restrictions (somewhat) longer than people who are vaccinated. However, the unfairness can be mitigated if governments undertake the regulatory actions and sensible interventions like those discussed earlier. Trying to bolster equitability by maintaining otherwise unnecessary restrictions is simply a type of leveling down.

Remember also that the pandemic and the measures taken to prevent the spread of COVID-19 disproportionately affect certain groups, including those with lower income and older adults, and if passports can encourage vaccination and speed up a return to normalcy,6 then these groups will benefit as well. It is also reasonable to think that many of the fairness issues related to vaccine distribution will be temporary, especially in high-income countries. For instance, in most countries young people have not been prioritized for vaccination, which puts them at some disadvantage. However, this is a short-term concern: eventually, the vast majority of those who are able and willing to be vaccinated will be, especially if we proceed with serious efforts to make vaccines as widely available as possible and work to promote uptake.

As one writer recently put it, vaccine equity is “much more important than vaccine passports,” but they are not incompatible. It is imperative that vaccine distribution and access be as equitable as possible, but disallowing vaccine passports will not secure vaccine equity. Requiring proof of vaccination in some contexts is not an intrinsic threat to equality, but it is an inevitability: governments must be willing to set rules for vaccine passports, as some already are, and take initiatives to ensure that these systems are as fair and unoppressive as possible.7 The conversation we should be having is not about whether or not vaccine passports should be adopted but rather about what rules should be set to make sure any passport regime advances the goals of supporting public health, reopening society, and advancing a return to ordinary life for everyone in manner that is as equitable as possible.

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Article Information

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Tanner R et al. JAMA Health Forum.

Corresponding Author: Ryan Tanner, PhD, JD, Faculty of Law, Common Law Section, University of Ottawa, Fauteux Hall, 57 Louis Pasteur St, Ottawa, ON K1N 6N5 Canada (ryanmjt@gmail.com).

Funding/Support: This research was funded in part by the COVID-19 Immunity Task Force, launched by the Government of Canada in collaboration with Canadian Institutes of Health Research.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Acknowledgments: We would like to thank Bryan Thomas, Kumanan Wilson, and especially Jennifer Gibson for their comments as well as all the members of the Bruyere-uOttawa Research Group on Immunization Passports for their support.

References
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Phelan  AL.  COVID-19 immunity passports and vaccination certificates: scientific, equitable, and legal challenges.   Lancet. 2020;395(10237):1595-1598. doi:10.1016/S0140-6736(20)31034-5PubMedGoogle ScholarCrossref
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Hall  MA, Studdert  DM.  “Vaccine Passport” Certification - Policy and Ethical Considerations.   N Engl J Med. 2021. doi:10.1056/NEJMp2104289PubMedGoogle Scholar
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