The Ethics of Relying on Vaccine Certifications for International Travel during times of Vaccine Inequity

Do no harm.  This is a well-recognised principle of ethics.  While societies have to make choices where a mix of harms and benefits can result, this principle offers some guidance in navigating such decision-making.  As part of cost-benefit assessments, not underestimating the potential for harm in a given situation can assist in bringing about mutually beneficial outcomes.  This line of thinking brings plenty to unpack onto the mounting debate surrounding COVID-19 vaccine certifications, in particular with respect to recognising the risks of complacency during this pandemic and acting out of due concern for fellow human beings.  Unpacking in the literal sense is also partly behind the reason why countries are deciding on whether and how vaccines certifications should become part of societies.  There are industries and livelihoods that depend on people packing up, moving about, and then unpacking somewhere else.  While COVID-19 vaccine certifications may be used for other purposes, such as attending sporting events, the pub, or the gym, which concern their use domestically and thus raise additional questions, the focus here is on their proposed use for international travel.  Before attempts are made to rekindle what was to some the normal toing and froing across borders, people, companies and governments have the opportunity to carefully consider what this practice will mean if international travel becomes contingent upon the use of COVID-19 vaccine certifications, specifically with respect to travel from a High Income Country (HIC) to a comparatively Low Income Country (LIC) while there are disparities in access to vaccines.

Vaccination efforts in HICs

Whether digital, non-digital or both, the idea of vaccine certificates being used during the COVID-19 pandemic has become part of public discourse in some HICs because these places have managed, for the time being at least, to tame the ongoing pandemic to levels that perhaps justify seeking out new policies aimed at 'getting things back to normal'.  Some governments and companies appear to consider that vaccine certifications will be a measure that can achieve such a version of normality, despite the irony that more people being vaccinated against COVID-19 means the point behind any use of vaccine certifications becomes more questionable.  In the words of the Ada Lovelace Institute:

There will be opportunity costs to focusing on vaccine passports rather than other interventions. There may be a comparatively narrow window where there is scientific confidence about the impact of vaccines on transmission, and enough of a vaccinated population that it is worth segregating rights and freedoms. Once there is population-level herd immunity it will not make sense to differentiate, and passports would be unnecessary.

While any benefits of introducing vaccine certifications for the purpose of protecting public health reduce the further a population within a country is vaccinated, not all countries are vaccinating their populations at the same rate, with HICs outpacing LICs.  What does this mean in the context of potentially introducing vaccine certifications for the purposes of international travel?  Many things, but here the focus remains on one that could transpire: giving the green light to vaccinated people in HICs for travel abroad to LICs where people have not been vaccinated. This matter brings with it some hefty ethical considerations.

Vaccination efforts in LICs

The US recently announced  that it supports the waiver of intellectual property protections on COVID-19 vaccines.  Whether this is the best course of action to get as many people as possible safely and swiftly vaccinated has been debated in light of several factors.  First, in the short-term, even if intellectual property protections are waived for COVID-19 vaccines, additional steps will be needed in order for LICs to benefit from doing so.  This in part rests on current manufacturers sharing knowledge surrounding the technology that is needed to develop these vaccines, as not doing so means that many LICs 'may not yet have the means or know-how to produce them domestically'.  Second, another factor is whether LICs have the facilities and infrastructure to produce and distribute the COVID-19 vaccines that they need, even if they are provided the knowledge to do so.  Assisting LICs in enhancing their domestic manufacturing capacities is particularly important  both now, and in the future, especially considering  that a small number of suppliers provide a large number of vaccines.  Third, in the long-term, although the profits of pharmaceutical companies and their executives  may seem shocking to some, particularly if the marginal cost of production of a new product is minimal (see Milanovic, p. 107), should intellectual property protections be waived in the face of this public health emergency, 'even as a one-off, will firms invest next time there is a similar emergency?'   Providing incentives is a part of fostering innovation.  Fourth, HICs could pay for  all the vaccines that LICs need. Individually, and even more so collectively, HICs have extensive economic capabilities that could allow them to bear the costs of getting most of the globe vaccinated.

HICs are making efforts  to support solutions to the COVID-19 pandemic beyond their own borders.  The US statement is an element of this effort.  However, at this time, regardless of where arguments come down on the most effective, efficient and ethical means of getting as many people as possible safely and swiftly vaccinated against COVID-19 (for more on this debate see here, here  and here), LICs have vaccinated comparatively fewer people within their borders than HICs.  According to Oxfam, HICs are 'vaccinating one person every second while [the] majority of the poorest nations are yet to give a single dose'. Research from the Brookings Institution also shows a 'disconnect between vaccine distribution and global needs'. This inequality between countries is one reason why the current position  of the World Health Organization is that countries 'should not introduce requirements of proof of COVID-19 vaccination for international travel as a condition for departure or entry'.  There is ground that remains to be covered in ensuring that everyone throughout this world that needs, and wants, a vaccine can get one.  In light of what remains to be done  in terms of vaccination efforts, until sufficient ground is covered on a global scale, there will exist a concern with respect to issuing COVID-19 vaccine certifications to residents of HICs who in turn travel abroad to LICs.

Travel from HICs to LICs and back during times of vaccine inequity

Considering the context discussed above, is it ethical to provide vaccine certifications to residents in HICs so that those who can afford to do so, can travel to LICs where swathes of their populations have yet to be vaccinated?  Although other forms of vaccine certifications have existed for years, and biometric passports already contain data on holders' physiological characteristics, a certificate attesting to a holder having been vaccinated against COVID-19 raises different issues at present if they were to be used for international travel during this time of vaccine inequity.  How so?

First, there is the possibility of transmitting the virus post-vaccination.  Even if people in HICs are fully vaccinated so that they are unlikely to suffer the worst of the consequences that the disease can cause, these people may pass on the virus that causes the disease.  An editorial in The Lancet  points to this exact problem, stating that until data on the effect of vaccination on the transmission of the virus has been 'reliably elucidated', 'peer-reviewed and their validity confirmed, uncertainty will remain around the epidemiological utility of relying on vaccine certificates to re-open economies'.   What this means in the context of travel from HICs to LICs is something along the lines of the following: vaccinated travellers from HICs go to LICs and interact with people who have not been vaccinated, putting these people, and anyone they come into contact with, at risk.  To make this clear, let's take an example.  Some tourists from a HIC, all of whom are vaccinated, get together and throw a party whilst on holiday in a LIC.  The people working at the party are bartenders, caterers and cleaners, none of whom are vaccinated.  These workers get infected by the partygoers, and then, via packed public transport, head on home.  And they happen to live in communities where social distancing, and perhaps even handwashing, is not possible.  All it takes is one vaccinated person from a HIC to pass on the virus to one non-vaccinated person in a LIC that lives in such circumstances to result in an entire community being infected.  And because none of that community is vaccinated, they are more likely to get severely sick and die.  Countries need solutions to this pandemic that can guard against more dire prospects for their economies and hence the health and livelihoods of their residents.  Invigorating international travel, especially for countries with tourist-dependent economies, is one means of doing so.  Yet it is hard to envisage how vaccine certifications stating something along the lines that their holders are 'safe to travel because they have been vaccinated' will minimise the risks associated with COVID-19 for those in LICs that have not been vaccinated.

Second, there is the matter of variants circulating across the globe.  It is encouraging that the currently available COVID-19 vaccines appear to  be effective against currently identified variants.  Mutations or variants can occur  each time the virus comes into contact with a person.  Professor Devi Sridhar at Edinburgh University has stated, that as more variants emerge it is going to be 'a bit like Pokémon:  we've just gotta catch them all!'  Until 'caught', these variants could 'undermine our natural immunity to Covid-19 or partially evade our vaccines'.  The use of vaccine certifications for international travel could contribute to this problem in two ways.  First, those that travel from HICs to LICs and back could bring with them variants that are more resistant to the vaccines available at present.  Although data suggests it is unlikely, people that are fully vaccinated can still  get severely sick and die from COVID-19, meaning people that travel abroad under any 'green light' provided by a vaccine certification could be putting themselves and others at risk upon return.  Second, and relatedly, there are people living in HICs that are not vaccinated.  Those that travel abroad, including to where there are variants, could put these people at risk when they return.  A measure that countries could adopt to counterbalance this concern and alleviate some of their economic strains, is agreeing on travel bubbles between each other, in which travel would be contingent upon a satisfactory proportion of the respective populations being vaccinated, and low (or no) case numbers.   This policy could take the form of a traffic light scale, in that countries could decide between themselves whether travel to and from them, without the need to test and quarantine should happen (green), or should be prohibited, with limited exceptions, such as allowing residents to return home (red).  The amber level in such settings could be for places in which travel is not prohibited, but testing before departure and quarantining on arrival would be mandatory because an insufficient proportion of the population in both countries has yet to be vaccinated, and case rates are not low enough.  This approach could provide a further incentive for countries to vaccinate populations beyond their own borders, as the more travel bubbles that were designated as green, the more safe and smooth international travel could occur between more countries, meaning more sectors that are travel-dependent could be invigorated across more countries.  No vaccine certifications would be needed in order for such a policy to be put into practice, as its efficacy would rely on robust testing, which is an essential component  of successfully responding to the COVID-19 pandemic.

Third, there is a psychological aspect to issuing vaccine certifications that could lead to the promotion of behaviour that could in turn worsen the pandemic.  It is worth noting that these behaviours could also come about once people have been fully vaccinated, regardless of whether they have a certification or not.  That said, the existence of an official document stating that a holder is fully vaccinated, legitimises this outcome and could lead to assumptions that holders are immune from COVID-19.  It could also lead to holders assuming that other people are immune, which is problematic when someone travelling from a HIC assumes that people in the LIC they are travelling to, will also be immune.  And before anyone can say 'who would assume that?', it is worth reflecting on what has already occurred throughout this pandemic in terms of human behaviour.  People occupy (sometimes strikingly ) different realities to others.  Obtaining official documentation attesting to holders being vaccinated against COVID-19 could lead to the continuance, or increase, of behaviours that appear to be wilfully blind to the pandemic.  Travel from HICs to LICs based on vaccine certification could lead to more of these behaviours that have made this pandemic worse than it needed to be (i.e. no handwashing, no mask-wearing and no social distancing).  COVID-19 vaccine certifications could thus promote a form of moral hazard, which occurs when people or other entities have an incentive to increase their exposure to risk because they do not bear the full, or any, costs of that risk.  Feelings of greater safety post-vaccination, plus the legitimisation of being vaccinated that would be provided by an official document attesting to such a fact, could result in behavioural changes in people whereby it becomes more likely that they will contract the virus and pass it on.

Towards a common ethic of responsibility

There are many matters  that are raised by the idea of COVID-19 vaccine certifications being used for international travel, some of which have not been addressed here, such as the supply chains upon which vaccine distribution depends, or the possible correlation  between vaccine certifications, and vaccine hesitancy or uptake.  While rights are often used  to frame the ongoing pandemic, which in part may well be due to 'conceptual overreach', it is questionable whose rights certain societies are really concerned about.  Would countries be implementing the same policies they have been, such as nationwide lockdowns, if COVID-19 was only killing homeless people?  When people tout terms such as the right to freedom of movement, are they thinking about those that do not have the prospect of exercising such rights?  It is not often mentioned that rights should be exercised with responsibility.  Companies and countries may have the right to develop COVID-19 vaccine certifications, but whether doing so is responsible requires reflecting on what added value such documentation would bring, and weighing that up against the potential repercussions of introduction.

Instead of rushing around in perhaps futile attempts to 'get things back to normal' in HICs, perhaps more attention should be placed on what can be learnt from LICs in dealing with risk.  If COVID-19 is going to be kicking around for the foreseeable future and becomes endemic to life on planet Earth, people may end up having to live with elevated levels of risk that many in HICs will not be accustomed to because of their privilege.  Yet many people in LICs will be familiar with having to get on with life with risks all around, due to situations such as conflict, famine and the spread of disease.  It is understandable that vaccine certifications are perceived by some living in HICs as a route towards returning to the lives they once knew.  Yet whether international travel should become contingent upon such documentation is ethically dubious during times of vaccine inequity.  Ultimately, any rollout of COVID-19 vaccine certifications and related laws and policies should not be rushed, but instead given the proper scrutiny demanded by democratic governance.

 Author: Dr Richard Mackenzie-Gray Scott is Research Fellow in Public Health Emergencies and the Rule of Law