Certifying a person’s immunity to COVID-19 is inevitable to get life back to normal in the United States, according to a growing number of public health experts. But how to do that, considering the need to protect personal privacy and avoid exacerbating existing inequities, has become an increasing area of debate as more vaccines become available to the public, experts said.
As countries around the world become more eager to reduce public health risks and jumpstart their own economies, vaccine passports are becoming a focus of discussion, and in some cases a reality. The European Union, China, and Japan are working to launch their own digital programs, while Israel recently unveiled its “Green Passport”. These programs are being used to gradually — and safely — reopen the world by allowing people to dine or exercise indoors or cross borders with neighboring countries while not exposing communities to further coronavirus outbreaks.
On Monday, Andy Slavitt, senior adviser for the White House COVID-19 Task Force, said that the U.S. does not plan to create such a passport. Instead, Slavitt said that states can develop their own and the federal government is helping to develop standards for equity and privacy that these programs need to uphold. New York has begun developing its own digital certification, known as the Excelsior Pass, which could allow residents into public establishments.
Because the virus cratered the travel and hospitality industries, closing borders and requiring stay-at-home orders to prevent the virus from spreading, both sectors have been among the loudest advocates for such a system. They argue the need is becoming more urgent as travel ramps up and passengers are confused and concerned about other people’s vaccine status. Airlines have also said they want their staff to be able to authenticate COVID-19 test results and vaccination status.
In a report last year before coronavirus vaccines were authorized for use, the World Health Organization said the idea of “immunity passports” carried several ethical and logistical factors to weigh. “Governments should seek to prevent immunity certification policies – public and private – from making disadvantages worse in terms of opportunities for health care, employment, housing and so forth for particular populations,” it said.
Some critics have echoed similar concerns vaccine passports could perpetuate inequities, particularly among communities that have faced problems accessing the vaccine. And others say these documents could jeopardize personal freedoms and private health data.
“They’re coming whether we like it or not,” said Dr. Saad Omer, director of the Yale Institute for Global Health, referring to programs that verify a person’s vaccination status. But he said the conversations policymakers and private businesses have right now could help depoliticize this public health tool and maintain public trust.
What is the precedent?
For centuries, yellow fever haunted the world’s port cities. The highly infectious mosquito-borne disease spread easily and often was deadly, especially in warmer climates, sickening an estimated 200,000 and killing 30,000 people each year among unvaccinated populations, according to the CDC. To this day, there is no cure for yellow fever.
But in 1937, virologist and physician Max Theiler developed an effective vaccine to thwart the disease. Two decades later, the World Health Organization issued the International Certification for Vaccination or Prophylaxis, a yellow-colored paper also known as a Yellow Card. These certificates served as proof that the bearer had been vaccinated and did not pose a risk of carrying yellow fever or causing a potential outbreak. It remains a standard document for U.S. travelers to parts of South America and Africa, according to the CDC.
A similar idea has been floated for the current pandemic. The International Air Transport Association, an aviation industry lobbying group, has rallied for a digital travel pass app that yields a “global and standardized solution to validate and authenticate all country regulations regarding COVID-19 passenger travel requirements” — one the industry says could restore people’s confidence in the safety of air travel. The app would synch health regulations, testing and vaccination centers and laboratory results in a “digital passport.” So far, about two dozen international airlines have experimented with these travel passes.
Some countries already are putting this verification tool to work. To ease hesitancy and incentivize vaccination, Israel’s Ministry of Health chose not to mandate vaccines and instead launched the Green Pass, a six-month pass to enter gyms, hotels and restaurants after one has either recovered from a COVID-19 infection or has been fully vaccinated against the virus. The passes could also be used as a way of verifying a person’s vaccination status while traveling.
When health care workers who chose not to be vaccinated were forbidden from entering clinics or hospitals in Israel, public attitudes bristled, according to a March 15 JAMA opinion piece. The Green Pass was seen as a way to encourage people to get vaccinated, but public health officials will need to do more than grant access to social settings in order to boost more widespread confidence in coronavirus vaccines, according to the authors.
“To build trust,” Israeli public health experts Rachel Wilf-Miron, Vicki Myers and Mor Saban wrote, officials “need to understand these concerns and provide appropriate, transparent, and easily accessible information.” That includes data about vaccine effectiveness, side effects and information that weighs the risks of catching COVID-19 versus getting vaccinated, the authors said.
“Creative use of incentives is likely to boost vaccination rates in some groups, whereas other groups will need more to allay their concerns, which should not be dismissed,” the authors said.
This month, the European Union considered launching a so-called “digital green pass.” But no European country has mandated vaccines, and many have struggled to get enough people vaccinated. For now, the Civil Liberties Union for Europe said any European country’s willingness to mandate COVID-19 vaccines seems “very unlikely” in the coming months.
Unlike the physical Yellow Cards, there are growing concerns about data privacy as documents verifying COVID-19 vaccination would exist and generally be accessed digitally. These digital health records would operate outside of the Health Insurance Portability and Accountability Act of 1996, or HIPAA, which protects people’s private medical information from being disclosed by health care providers,health plans, or businesses. And there are instances when HIPAA allows that information to be released, such as when it is in the public interest. More broadly, some people are concerned that their data could be used against them by law enforcement, accessed by hackers or sold to third-party vendors if regulators fail to offer appropriate oversight.
“Governments shouldn’t rush it. I think it’s a Pandora’s box and think it’s a slippery slope into having life being governed by your health status,” Clare Wenham, an assistant professor of global health policy at the London School of Economics, said in an interview with CBS News.
In addition to privacy concerns, some Americans have expressed opposition to vaccine passports because of their resistance to getting a COVID-19 vaccine.
Some of this resistance emerges from a health freedom movement that rose long before the pandemic among conservatives after anti-vaccination messaging was combined with Tea Party ideology, said Dr. Peter Hotez, who directs the Center for Vaccine Development at Texas Children’s Hospital and serves as dean of the National School of Tropical Medicine at Baylor College of Medicine. More needs to be done to defuse anti-vaccination attitudes in the U.S., he said.
Some U.S. conservatives already question the threat posed by COVID-19 itself and steps to bring the virus under control. Throughout much of the pandemic, misinformation about the virus has circulated widely on social media and in some cases from public officials or media outlets, and has conditioned many people to be suspicious of what experts regard as standard protocols for public health. Former President Donald Trump was one public figure who elevated misinformation, making unsubstantiated claims about the virus on multiple occasions, downplaying its deadliness and injecting politics into his administration’s coronavirus response.
While Trump’s time in office is over, the impact of his statements continue to have lingering effects. In a March 11 PBS NewsHour/NPR/Marist poll, 49 percent of Republican men said they did not want to get vaccinated for coronavirus, compared to 30 percent of Americans overall.
Loyal Trump supporter and Republican Florida Gov. Ron DeSantis called vaccine passports “completely unacceptable” and said he would forbid businesses from refusing to serve patrons who could not supply proof of vaccination, the Associated Press reported.
This week, a video surfaced of Rep. Marjorie Taylor Greene, R-Ga., claiming, without any evidence, that a vaccine passport is “Biden’s mark of the beast,” a reference to the Bible’s Book of Revelations and Christian prophecy about the end of the world. The Biden administration said that the pandemic is affecting “all parts of society,” but it is not pursuing a vaccine passport, according to Slavitt during a briefing Monday.
“Unlike other parts of the world, the government here is not viewing its role as the place to create a passport, nor a place to hold the data of citizens,” Slavitt said. “We view this as something that the private sector is doing and will do.”
Given how many Americans still do not want to get vaccinated, even if it is available to them, Hotez said policymakers would be wrong to simply dismiss opposition to vaccine passports as conspiracy theories. People are still struggling to get appointments to get vaccinated, he said, adding that he expects “fierce resistance from the political right” if vaccine passports were implemented.
“It doesn’t get much more dystopian than being required to show your ‘health papers’ wherever you go,” Justin Amash, a former representative from Michigan who switched from the Republican Party to the Libertarian Party in April 2020, said in a tweet expressing disdain for a vaccine passport.
With the nation’s vaccine rollout still underway and largely unfinished, Hotez said launching a vaccine passport is premature.
“Let’s just focus on getting vaccinated,” he said. “I think it could be counterproductive and turn into a barrier to vaccination.”
Incentivizing good public health
With COVID-19 mutating into more transmissible variants and new infections, hospitalizations and deaths starting to rise, Dr. Leana Wen said accelerating vaccinations while continuing to follow public health guidance is more important than ever. Even though people are fatigued with the pandemic, the debate about vaccine passports is concerning to Wen, a visiting public health professor at the George Washington University and former Baltimore city public health commissioner.
“I worry that we’re letting perfect be the enemy of the good,” she said. “I think many people will feel more comfortable in engaging in activities where they’re assured that people around them are fully vaccinated too.”
Vaccine passports could be a valuable tool to help people feel safe about once again boarding cruise ships and airplanes or packing into restaurants and theaters, she said. Activities that were once commonplace are now shrouded with dread about airborne illness, outbreaks and a pandemic without end. With a vaccine passport system in place, Wen said, “many people will feel more comfortable in engaging in activities where they’re assured that people around them are fully vaccinated, too.”
While private industry is already looking at ways to develop such a system, Wen said the federal government needs to establish minimum standards, to protect people’s private health information and to monitor for forged vaccination cards already selling for hundreds of dollars on the black market.
But vaccine passports aren’t enough to end the pandemic, said Dr. Eric Topol, a cardiologist who founded and directs Scripps Research Translational Institute in La Jolla, California. While they have been implemented in other countries, he said political divisions in the U.S. require a more holistic approach. To gain control over the coronavirus, Topol said the U.S. needs to get creative to get people vaccinated.
“We need to work along all fronts,” he said. “It’s not just a singular strategy.”