By Mahlon Meyer
Northwest Asian Weekly
When Nancy Jecker was doing research as a visiting professor at the National University of Singapore on older adults needing care, she got to know migrant caregivers—young women who had traveled from the Philippines, Sri Lanka, and India. Now a professor at the University of Washington (UW) School of Medicine, she recently published a paper arguing that vaccine passports raise health equity objections both domestically and internationally, at a time when humanity needs to come together. She was thinking, in part, of those migrant caregivers she had met in Singapore.
“They were coming to live in homes and care for older Singaporeans. They had family sponsors, but now they can’t travel there because they don’t have access to vaccines in the countries they come from. Rather than requiring a vaccine, why not just offer a flexible tool like a negative test 72 hours before travel?” Jecker said.
Eighty-five percent of vaccines against the SARS-CoV-2 virus have gone into the arms of people living in rich countries, a statistic Jecker cites in her paper, “Vaccine passports and health disparities: a perilous journey,” published in the Journal of Medical Ethics.
“What message does that send to migrant workers who need to travel for work, but can’t access vaccines?” she asked.
Such concerns reflect a struggle on the part of policy makers and their advisers, between the desire to roll out initiatives—such as vaccine passports—as quickly as possible in the face of the pandemic and the understanding that until the most vulnerable are cared for, such measures could be ultimately ineffective.
“I just take an alternate view that equity concerns don’t inherently disqualify a policy. At different times since the beginning of the pandemic, there have been concerns about equity in lockdowns, vaccine rollouts, and covid relief. But should those concerns have stopped us from implementing those policies at all?” said Josh Liao, a physician and director of the Value and Systems Science Lab at the UW.
Liao contends that a multi-pronged approach can also be more pragmatic. Different countries can implement different measures—and do so already. Some, with full access to vaccines, might use vaccine passports. Those, such as countries from which caregivers that need to fly for work like the women Jecker interviewed, could be subject to less intrusive measures, such as COVID testing and a masking mandate.
“What we’ve seen in the last year is that different countries, either in concert with each other or alone, will implement their own measures about how to protect the public, their populations,” said Liao.
In one sense, the approaches are not too dissimilar. Jecker calls for “flex passes” instead of vaccine passports—these could be the masking and testing that Liao calls for. But for Liao, vaccine passports are simply another tool that should be implemented along with others.
“Even if you are vaccinated and get a passport, does that mean the end of masking? Does that mean the end of testing? Does that mean the end of quarantine if you or a close contact develops symptoms? If you believe in variants, breakthrough cases, and the need to adjust policy to both, then you would use vaccine passports alongside other measures,” he said. “It’s not an either-or situation.”
Jecker bases her argument on health equity, applying it both globally and domestically.
Domestically, vaccine passports should not be used until vaccines are widely available and equitably distributed, she said. Even then, Jecker worries about policing and the possibility of racial profiling. In her article, Jecker points to China’s practice of forced testing of African nationals as an ominous sign.
“It’s easy to think this wouldn’t happen here. But the Black Lives Matter protests remind us how entrenched and widespread racism is, especially in the area of policing, so I worry about who’s going to be charged with enforcement and what impact this might have in the long run on societal trust,” she said.
Equity ought to be a concern before policy makers and experts even begin to focus on any specific policy, agreed Dr. Tracy M. Hilliard, director of the Center for Culturally Responsive Engagement at Michigan Public Health Institute (MPHI), a nonprofit. Hilliard is also a clinical assistant professor of Child, Family, and Population Health in the UW School of Nursing.
“It’s important for the people with power and decision-making authority to not only ask experts, so to speak, in medicine, in policy, or in public health, but to ask those folks that are furthest from justice and most impacted by inequities in our country, to ask them what their perspectives are, ask them what they feel should happen,” she said.
“That way we can ensure that those who are most impacted, that their needs and perspectives are considered and prioritized.”
One area of agreement is that the pandemic creates a “moving target” with changing messaging from the government and scientific uncertainty about mutations and the efficacy of the vaccines.
For Jecker, this is all the more reason to disavow vaccine passports. In fact, Jecker argues that a vaccine passport could lead people to let down their guard and mingle, leading to more viral spread. She cited the fact that vaccinated people can transmit the Delta variant.
The contrast between the pandemic in the U.S. and poorer parts of the world underscores catastrophic differences in equity, said Dr. Stella Gran-O’Donnell, associate director of the Center for Culturally Responsive Engagement at MPHI. Gran-O’Donnell is also a lecturer and field instructor in the UW School of Social Work.
“Here, getting a vaccine is a choice. In comparison, developing countries such as the Philippines, Sri Lanka, and India with limited or no access to vaccines, hospitals, and medical infrastructure continue to be plagued with the surging tide of new cases and deaths,” said Gran-O’Donnell. “While the U.S. remains well-resourced with a surplus of vaccinations in some locales, India broke the world record of over 400,000 new cases in early May, along with an increase of over 3,500 deaths.”
As a result of such disparities, said Gran-O’Donnell, vaccine passports will serve as a disincentive to vaccination, both domestically and globally.
“The issue of vaccine passports will disproportionately burden those who have been most vulnerable to contracting and dying from COVID-19, Black and brown individuals, and communities of color in the U.S., along with their counterparts of those living in poverty and oppressed individuals and groups around the world,” she said. “Eligibility for these types of passports and fear of government by communities of color, along with deportation most common among Mexican and other Latino immigrants, contributes to lower vaccination rates and ongoing disparities and inequities.”
Jecker, who is a Fulbright U.S. Scholar for South Africa, further argues that it is currently estimated that it won’t be until 2023 or 2024 that some low- and middle-income countries have vaccine access. Imposing a vaccine requirement for travel before being able to fly will create a “rich person’s club” and make the skies “unfriendly,” she contends.
“While the conversation in places like the U.S. is that vaccine passports are unfair to vaccine refusers, in poorer nations, the concern is that there is no vaccine access at all,” she said.
But Liao said that it makes sense to recognize the realities of different distributions of vaccines and for residents of countries that have access to vaccines to get vaccinated first. Such an approach will contribute to the global good, he said.
Still, said Jecker, vaccine passports could contribute to the hardening of divisions between the rich and poor.
Marginalized groups in the U.S., for instance, had less access to vaccinations when they were first rolled out, she said. More privileged counties—areas “with less social vulnerability”—received them first. Vaccine passports could further alienate groups already “cautious” about vaccines, she said, further dividing people.
Liao clarified that his argument was not contrary to Jecker’s position. If anything, he would only emphasize that policy makers have had to think about equity issues in every part of the pandemic, from lockdown regulations, to vaccine rollout, to COVID relief.
“The point is that many aspects of COVID policy have had equity concerns. But those concerns are not reasons not to implement policy at all—they are reasons to implement policy with equity front and center,” said Liao. “One of the abiding things we take away from the pandemic, when it comes to public health, is that our health is not fully in our own hands.”
This health series is made possible by funding from the Washington Department of Health, which has no editorial input or oversight of this content.